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Didactic Coursework

Public Health Program

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5 years ago

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Public Health Program Development and Evaluation: Skin Cancer Prevention in the Upper East Side, NYC

Scope of the Problem

In the United States, 5.4 million people are diagnosed with nonmelanoma skin cancer per year, greater than the incidences of lung, breast, colon, and prostate cancers combined. Over the course of a lifetime, 1 in 5 Americans will develop some type of skin cancer. The most common types are derived from the epidermis: basal cell carcinoma, squamous carcinoma, and melanoma. Basal cell carcinomas account for 80% of skin cancers (4 million cases annually), squamous carcinomas account for about 20% (1 million cases annually), and melanomas account for about 2% of all skin cancers. In 2017, 87,100 cases of invasive melanoma were diagnosed and over 9,000 patients died from it. In 2018, the American Cancer Society projects that there will be 91,270 new cases of melanoma with 55,150 of the cases in men and 36,120 of the cases in women. Melanoma has been on the rise for the past 30 years. This rise in the incidence of skin cancer is due to increased exposure to UV light, increased usage of tanning beds, and our aging Baby Boomer population. Risk factors for skin cancer include having fair skin, being male, being older in age, having more sensitive skin towards sunlight, and personal or family history of skin cancer.

In New York State (NYS), skin cancer is the 8th most common form of cancer in both men and women. Annually, more than 3,700 residents of NYS are diagnosed with melanoma and of those residents, 500 die from it. There are currently two laws that prohibit anyone under the age of 17 from using devices with UV radiation. Those who are 17 must present a consent form that is signed by a parent or legal guardian prior to using UV radiation devices. Tanning facilities are mandated to post information about the maximum exposure time for each device. They must also provide adequate protective eyewear in addition to documenting user visits, the date, the duration of exposure, and type of device used. In 2012, the State Education Department (SED) allowed students to carry sunscreen in school as opposed to requiring an order from medical providers to do so. Yet, there has been no consistent effort to raise awareness of behaviors that mitigate UV exposure to ultimately lower the risk of getting skin cancer. Of all New York City neighborhoods, the Upper East Side has the highest incidence of skin cancer with 11% of all cases of skin cancer in NYC, but they only account for 2.7% of NYC’s population. Skin cancer prevention needs to start early on in life, allowing children and adolescents to protect their skin, even though incidence rates are highest among those aged 65 and over. However, people of all ages will benefit from these interventions, as skin protection is a lifelong and continuous process.

 

Planning

For this program, it would be more feasible to make behavioral changes rather than environmental changes, as it is difficult to control UV exposure onto the earth. The FDA already has in place strict regulations for tanning booths in terms of the type of equipment used, the duration, and providing protective eyewear. More must be done on the individual level in terms of educating children, adolescents, and adults about the risks of prolonged UV exposure and the benefits of sun protection. This will be executed mostly by teachers and healthcare providers. Health teachers or gym instructors will teach students about sun exposure as it relates to skin cancer, ensuring that students understand the importance of limiting sun exposure in addition to using sunscreen. Students no longer need a medical note to use sunscreen while in school. In terms of healthcare providers, not all primary care providers and others are trained to detect melanoma or other skin cancers. Routine skin cancer screenings should be performed more often and if they feel uncomfortable doing so, they could always refer patients to a dermatologist. It is recommended that patients receive skin cancer screenings at least once per year in addition to self-monitoring.

Stakeholders include and are not limited to federal, state, and local legislators, public and private school educators, students, providers, dermatologists, and dermatology specialty groups. Currently, the United States spends $4.8 billion dollars treating nonmelanoma skin cancers and $3.3 billion dollars treating melanoma. Since this program will not be launched on a national scale, we will first start by targeting the Upper East Side. Skin cancer screening is low-cost compared to other types of screening, as it does not require much technology. A shave or punch biopsy is usually covered under insurance. These preventative measures will ultimately reduce costs spent in treating skin cancer as opposed to preventing skin cancer. Health teachers or gym instructors could incorporate skin cancer prevention and the risks of using tanning booths in a lesson every semester or year to reinforce the idea of skin protection. Students and other adults benefit since they are learning about methods to protect their skin that will affect them in the long run. Healthcare providers will be able to bill and be reimbursed for these skin cancer screenings as part of the annual physical or other office visits. Additional information will be mainly obtained through surveying students and provider offices to see if this program has the desired effect on skin cancer prevention. If those surveys indicate a certain population that requires more intervention, we can then consider focus groups.

Funding will be provided by the state and local public health funds. This prevention program overall, should not be very expensive as compared to other intervention programs to combat obesity or diabetes. In general, the Upper East Side is one of the wealthier neighborhoods in NYC. The education system is already in place and teachers or gym instructors simply have to add additional lessons into their teaching plans. Providers will spend a brief amount of time teaching patients the characteristics of skin cancer and how to monitor their skin between annual visits. This program should be feasible in the long run since the tools needed are mainly education and awareness about skin cancer. Providers essentially need to invest in a dermatoscope that costs a few hundred dollars and biopsies are usually covered by insurance. These preventative habits should stay with students and patients and carry on later in life.

 

Development & Dissemination of the Interventions

The goal of this program is to decrease the amount of undetected skin cancers by increasing the number of skincare screenings and by raising awareness of protective habits that will mitigate harmful UV exposure. Since the incidence of skin cancer is highest in the Upper East Side as compared to any other neighborhood in NYC, we would want to monitor incidence rates in the subsequent years and look for a decrease in the number of skin cancer reports. This may take some time since skin cancer does not develop overnight and can appear later on in life. We can also measure awareness about skin cancer and look to see if skin cancer screenings have increased in that area. The incentives for providers and school educators should not cost much and the physical space required, such as schools and other medical facilities are already established.

Health teachers or gym instructors will conduct one lesson every semester or biannually throughout the academic year to educate students about skin cancer prevention, the risk of using tanning booths, the importance of sunscreen, the importance of reapplying sunscreen, and the characteristics of skin cancer. Schools may also hold special assembly meetings and invite dermatologists or other providers as a more interactive method.

Primary care providers should spend at least five minutes discussing skin cancer prevention and how to look for it during an annual visit. Patients should have their skin screened by PCPs, dermatologists, or other providers in dermatology at least once a year since it is difficult to monitor all parts of the body, especially on the back. A pamphlet describing the ABCDEs of skin cancer with pictures would be most useful for patients to take home:

  • A: asymmetry, one half of the mole does not match the other half
  • B: border, the border is irregular and not round
  • C: color, the color is not uniform and consists of several different colors
  • D: diameter, greater than 6mm (pencil eraser) is concerning
  • E: evolving size, shape, or color

 

Evaluation & Maintenance

To evaluate whether this skin cancer prevention program is working as planned, we would conduct two main surveys. One would be distributed to students in school and the other would be distributed to patients after their PCP visits. In the beginning, we would want to evaluate this program three months after implementation, six months after implementation, then annually afterwards. As mentioned before, if we find evidence of a group that requires more intervention after the initial surveys, we will make the necessary modifications. It would be useful to survey educators to see if they have suggestions for improvements. We would also want to see if there is an increase in skin care screenings in medical facilities as this may be associated with increased awareness. Possible survey questions may include:

  • What is skin cancer?
  • What are the common types of skin cancer?
  • What are the risks of using tanning devices?
  • What are the ABCDEs of skin cancer screening?
  • Have you gotten a skin cancer screening before?
  • How often do you get your skin checked by a doctor?
  • What SPF sunscreen should you apply before going outside?
  • How often should you reapply sunscreen?

If the intervention is unsuccessful, changes will be made after evaluating what went wrong and what needs improvement. There should not be many issues with skin care education in schools. Some problems may arise when getting the necessary referral to see a dermatologist or even finding a dermatologist. In terms of maintaining this program over five to ten years, sources of funding will continue from mainly the state and local public health funds. However, if dermatology specialty groups and wealthy residents of the Upper East Side want to contribute to the program’s efforts, their help would be greatly appreciated.

 

Sources:

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