Skin cancer is the most common cancer in the United States. It has been estimated that one in five Americans will develop the disease at some point during their lifetime.1 Skin cancer incidence in the United States has increased significantly over the past several decades.2,3 Melanoma, the deadliest form of skin cancer, has increased particularly rapidly; between 1982 and 2011, the incidence of melanoma in the US doubled from 11.3 to 23.7 cases per 100,000 people.4,5 Recent studies have estimated that in the year 2019 alone, 192,310 cases of melanoma will be diagnosed, with twenty individuals dying of the disease on average each day.2 Total lifetime sun exposure and tanning bed use, particularly during childhood and adolescence, is directly associated with increased risk of skin cancer.4 In the United States, tanning bed use is widespread among Caucasians, particularly women ages 18-30. In this age group, up to 30% admit to using tanning beds at least once per year; half of these women (15%) use indoor tanning ten or more times per year.6 Tanning bed avoidance is extremely important in reducing the risk of skin cancer, as more than 400,000 cases of skin cancer per year in the United States can be attributed to tanning bed use alone.7 Consistent protection against natural ultraviolet radiation from the sun has also been shown to directly decrease incidence of skin cancer; one study evaluating daily sunscreen use revealed that patients who used sunscreen had half the melanoma risk compared with those who did not.8
Counseling patients regarding sun protection and tanning bed avoidance in order to prevent skin cancer is an important responsibility of healthcare providers. This is especially relevant for primary care physicians, as patients visit these providers on a regular basis and often develop close therapeutic relationships.7 The United State Preventative Services Task Force (USPSTF) currently recommends counseling all parents of children ages 6 months through 24 years about the importance of sun protection (Level B recommendation).10 Such counseling has been shown to lead to an increase in sun protective behaviors, which in turn lower the future risk of skin cancer. Despite this recommendation, one report noted that only 34% of pediatricians counseled patients on sun protection during well-child exams in the summer months.11 The USPSTF also recommends that providers counsel adults older than 24 years with fair skin about using sun protection; however, the evidence is not as strong as in younger individuals (Level C recommendation).10 While it is still relevant to counsel older patients about sun protection, the correlation between sun exposure in adults and skin cancer development is weaker than that involving sun exposure during childhood. However, the potential drawbacks of counseling adult patients on sun protection are minimal, and counseling is therefore appropriate in many cases.8
Despite the likely benefit of regularly counseling patients about sun protection, rates of discussions about sunscreen use at outpatient visits are surprisingly low. In the National Ambulatory Medical Care Survey (NAMCS) of a database of all outpatient clinic visits from 1989 to 2010 (18.30 billion visits), sunscreen use was only mentioned 0.07% of the time.12 Sunscreen use is not relevant to all outpatient office visits, which may account for this staggeringly low statistic; however, this is still concerning given the direct benefit of sun protection in preventing skin cancer. Another NAMCS survey of 7.9 million high-risk patients (i.e. those with a prior history of skin cancer) revealed that dermatologists only counseled patients about sun protection 41% of the time, while family physicians did so 24% of the time.13 Likewise, another report from this past year also highlighted the fact that a majority of a group of 294 patients who regularly visited dermatologists did not receive adequate sun protection counseling, and as a result were unclear about current recommendations when queried.14
To date, few studies have investigated sun protection awareness and personal sun protection patterns among healthcare providers. One study reported that physicians who perceive this topic as important and use adequate personal sun protection tend to counsel significantly more patients in their practice.15 This study suggested that improving education among providers about sun protection in general will in turn lead to increased awareness among both patients and providers. However, few reports have investigated education patterns among physician-trainees regarding sun protection. One study revealed that less than 40% of primary care pediatricians received formal education regarding sun protection counseling during their medical training.16 Another report surveying French medical students also revealed a general lack of education and understanding about the importance of sun protection. 17
Inadequate education of medical trainees regarding sun protection appears to be common. It is therefore important that healthcare providers receive formal education on this topic, as this could improve patient education and counseling by physicians. Productive discussions about sun protection between patients and providers has the potential to improve sun protective habits among patients, which can in turn decrease the incidence of skin cancer. In our report, we discuss a survey study conducted among family medicine faculty and residents aiming to ascertain the frequency of personal sun protection use and patient counseling among providers.