INTRODUCTION: Skin cancer is the most common cancer in the United States and melanoma is the fifth most common kind of cancer. The incidence of melanoma has been increasing over the past thirty years. This type of cancer can be detected using a visual skin examination. Survival is related to the thinness and stage at the time of diagnosis. Clinicians find thinner, earlier stage melanomas compared to those found by patients and significant others. REVIEW OF THE LITERATURE: The average American visits their primary care provider twice annually and skin conditions are the number one reason Americans younger than sixty-five visit their primary care physician. However, the majority of residents in the United States are not comfortable with performing the full body skin examination required to screen for melanoma. Medical schools in the United States spend one percent of the curriculum on dermatologic conditions. In fact, the United States Preventative Services Task Force does not support regular skin cancer screening by primary care providers since there is limited evidence that primary care physicians perform adequate skin examinations. METHODS: This curriculum is aimed at teaching internal medicine and family medicine interns and primary care physician assistants and nurse practitioners the full body skin cancer screening examination as well as the ability to differentiate between benign and malignant skin lesions. A pre- and post-course examination of benign versus malignant lesions will be distributed and the scores will be analyzed using a paired T-test. A pre- and post-course Likert scale will be dispersed to evaluate how clinical practice changes based on this course. Mean and standard deviation for the overall Likert scale as well as individual parts of the scale will be calculated and a paired T-test will be used to analyze how the course changed clinical practice of the clinicians. Additionally, standardized patients will be provided for the participants to practice the full body skin examination. CONCLUSION: This study is unique in that it is teaching primary care medical interns as well as physician assistants and nurse practitioners the full body skin examination. Limitations include a small sample size, voluntary participation in the setting of a busy work schedule, and pushback from clinicians since performing full body skin exams are not recommended at this time.

AN ABSTRACT OF THE DISSERTATION OF DIANE M. LAND, for the Doctor of Philosophy degree in Health Education, presented on December 3, 2014, at Southern Illinois University Carbondale. TITLE: PSYCHOSOCIAL PREDICTORS OF HIGH SCHOOL ADOLESCENTS' SUN-TANNING AND SUN-PROTECTIVE BEHAVIORS MAJOR PROFESSOR: Dr. Roberta Ogletree Background: The incidence of skin cancer among adolescents and young adults is increasing in the United States (American Cancer Society, 2014). Ultraviolet radiation (UVR) exposure via sun-tanning is considered an important risk factor for development of melanoma. Sun-induced skin damage and sun-tanning habits are initiated in early life and promoted through later sun exposure patterns. Social norms, appearance attitudes, and perceptions of fitness and health attributed to sun-tanned skin and tanning bed usage have been established. The primary aim of this study was to investigate high school adolescents' sun-related attitudes and behaviors through a theoretical framework of psychosocial constructs grounded primarily in Bandura's (1986) Social Cognitive Theory. Assessing the differences in predictors of adolescents' UVR sun-tanning and sun-protective behaviors (including sunless tanning) has the potential to aid in developing age-appropriate strategies to prevent the adoption of sun-tanning habits and reinforce more health enhancing behaviors. Methods: This research study utilized a quantitative, cross-sectional, descriptive research design to assess the attitudes, motivations, and behaviors regarding sun-tanning and sun-protective practices of high school adolescents in rural Southern Illinois. A purposeful sample of 9 - 12th grade students (n = 900) enrolled in physical education class during the fall 2014 semester were invited to complete a self-report paper and pencil survey consisting of 56 Likert-type items and five demographic variables. Results: A total of 156 adolescents received parental permission and completed the survey, providing a 17.3% response rate. Intentional sun-tanning (UVR exposure) continues to be prevalent. Study participants reported sun-tanning more often and had a higher number of sunburns within the past twelve months that in previous national studies. Participants from low socio-economic status (SES) were more likely to outdoor suntan and use sunless tanning lotions, gels or creams than their not low SES counterparts. For sun-tanning behaviors, a significant amount of the variance in mean sun-risk behavior score was explained by the constructs situation, outcome expectations, and value expectancies. Situation, outcome expectations, value expectancies, and self-efficacy were all predictive of outdoor sun-tanning; whereas only outcome expectations were predictive of indoor sun-tanning. Self-efficacy explained a significant proportion of variance in sun-protective behavior mean score. Outcome expectations were predictive of both sunless tanning with lotions, creams or gels and spray tanning product use. Sunless tanning appears to be used as both an additive behavior for those reporting the highest frequency of indoor tanning and a substitution behavior for adolescents who reported never indoor tanning.

With a view to establishing a model system for examining toxicity in skin, primary lingual keratinocyte cultures , a keratinocyte cell line and freshly isolated keratinocytes all derived from rat sub-lingual epithelium, were partially characterized both morphologically and enzymically and the toxicity and metabolism of the mycotoxin T-2, studied therein. A number of techniques for obtaining pure suspensions of sublingual keratinocytes (NCK) were examined and dispase is recommended for completely separating the epithelium from its dermis prior to trypsinization. Existing methods for the culture of PLK cells were improved to reduce the number of rats used and minimize the fibroblast contamination and a technique for culturing the epithelium associated with human hair follicles was also examined. The follicle technique was found to produce primary cultures which were 100% epithelial but considerable time and resources were required to generate relatively few cells. The keratinocyte cultures, PLK and RTE5, were shown to produce keratin and undergo stratification like the epithelium in vivo, Using a series of specific enzyme inhibitors, both the cultured and non-cultured epithelial cells were found to possess the same characteristic forms of acetylcholinesterase, butyrylcholinesterase and carboxylesterase. The effect of T-2 on protein synthesis in the keratinocyte cells was examined and a dose-related inhibition was evident. The primary and freshly isolated cells appeared to be the most resistant to synthesis inhibition. The rate of recovery from this inhibition was greatest in the cell line which also lost T-2 at the fastest rate. The uptake into and loss of T-2 from the keratinocyte cells was chiefly by simple diffusion, but studies using rotenone demonstrated that an active process may have been involved in reducing the rates of uptake and loss. The total amount of T-2 absorbed was likely to be dependent on the number of binding sites while the overall rate of loss was dependent on the strength of that binding. The possible nature of these binding sites is discussed. T-2 was metabolized in all the keratinocyte preparations to the same products found in mammalian skin, in vivo, and studies with specific enzyme inhibitors showed that a carboxylesterase was most likely to be involved in its hydrolysis. The greater metabolism of T-2 in the primary cells, which contained the most carboxylesterase, is likely to have been one of the factors involved in reducing the levels of protein synthesis inhibition in these cells. Rat sublingual epithelium and the cultures derived from it have a similar morphology and esterolytic capability to that of skin in viva. The PLK cells were most similar to NCK cells in terms of protein synthesis and esterolytic capability, so if it is assumed that NCK cells are representative of the sublingual epithelial cells in viva and hence skin, then the primary cultures might prove to be the best model culture system for studying toxicity in skin. Nevertheless, the RTE5 cell line was most similar to the NCK cells in respect of T-2 metabolism, and if it shown to have other characteristic skin metabolism systems then it too might prove useful for studying skin toxicity. In addition, the cell line would probably prove to be a more convenient, simpler, reproducible and cheaper means of examining skin toxicity on a large scale.

Class of 2015 Abstact / Objectives: The purpose of this study was to describe differences in pharmacists' children and personal skin cancer prevention strategies, clinical outcomes, knowledge and to determine if there were differences based on attending pharmacy school in Arizona or other states. The skin cancer prevention behaviours of pharmacists were also compared to the general public. Methods: Pharmacists registered and living in Arizona with an email address with the State Board of Pharmacy were eligible for the study. A questionnaire was developed based on questions from the NHIS survey. The questionnaire was administered by using an electronic, on-line survey form. Results: Graduates of non-Arizona schools were significantly more likely to have completed a CE course on skin cancer prevention than the Arizona group (16% vs. 6%). Both groups were not significantly different in gender and work sites. The knowledge of pharmacists in both groups were very similar (p > 0.1) except for knowledge of photosensitivity for certain drug classes (p = 0.043).Pharmacists were most knowledgeable on risk factors for melanoma (97%) Pharmacists were least knowledgeable on when sunscreen should be applied (20%) responded correctly and the minimum age for using sunscreen in children (26%) responded correctly. Pharmacists were more than twice as likely to use sunscreen as the general population (72% vs. 31%). Conclusions: Pharmacist graduates of non-Arizona schools (Non-Arizona group) used a similar number of skin cancer prevention strategies as graduates of Arizona schools (Arizona group). Sun protective measures utilized by parents for their children were superior to parents' own self-care sun protection measures.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Background: One out of every three cancer diagnoses is a skin cancer, and the incidence of both melanoma and non‐melanoma type skin cancers is increasing. Skin cancers, including melanoma, are typically treatable if detected early. However, there is insufficient evidence to support recommendations to establish population based skin cancer screening programs. The specific aims of this study are 1) to evaluate characteristics of participants who attend a community skin cancer screening event and who are referred for follow up due to suspicious lesions, 2) to determine the proportion of participants with suspicious lesions identified at a community skin cancer screening event who complied with a request to visit a dermatologist or primary care physician, and 3) to evaluate attitudes toward sun protection practices, and perceived risk of developing skin cancer among participants who attend a community skin cancer screening and have a suspicious skin lesion. Methods: The Skin Cancer Institute sponsored a series of community skin cancer screening events in Tucson, Arizona from 2006 to 2013. Participants completed an American Academy of Dermatology screening form prior to a skin examination by a dermatologist. Participants with suspicious lesions identified at the examination who agreed to be contacted again received questionnaires 4 months after the initial screening to assess compliance with follow‐up recommendations, and their sun protection practices and risk perceptions. Results: 1979 community members attended the skin cancer screenings. The majority of the participants were Caucasian, females, had blue eyes and brown hair, were college educated, had no prior personal or family history of skin cancer, had health insurance but did not have a regular dermatologist, reported that they had never been to a skin cancer screening before, and stated that without this screening that they would not have their skin examined. 748 (37.8%) of community members were referred and instructed to see a dermatologist for further evaluation of a skin lesion. Of the 441 participants with a suspicious lesion who consented to participate in the follow‐up study, 120 returned a questionnaire; 90 (75%) reported that they followed up with a dermatologist or physician, and 30 (25%) did not. Of the 90 participants who followed up, 53% received a skin biopsy. The self reported diagnoses from the biopsies of the suspicious skin lesions were the following: 1% atypical or dysplastic nevus, 21% actinic keratosis, 16% basal cell carcinoma, 8% squamous cell carcinoma, 2% melanoma, and 38% did not have skin cancer. Conclusions/Impact: This study demonstrated that 38% of community skin cancer screening participants were referred for follow up due to a suspicious skin lesion being identified during a skin cancer screening event. It also appeared that 75% of those who responded to the follow‐up questionnaire complied with the request within four months, although the response rate for the follow‐up questionnaire was low. Therefore, implementing a formal reminder system following the skin cancer screenings may increase the percentage of participants who follow up with a primary care physician or dermatologist after the screening for further evaluation of their suspicious skin lesion.

Skin cancer is the most commonly diagnosed cancer in the United States; it is estimated that the number of Americans who have had a skin cancer in the last three decades is higher than the number for all other cancers combined. Fortunately, there are known prevention methods, effective treatments available for early-stage cases, and behavioral practices that can reduce the risk of secondary and recurrent cancer. However, in spite of these, skin cancer incidence continues to increase and mortality still exists, making skin cancer prevention of the utmost importance. Outlined in this dissertation are factors identify as associated with the development, diagnosis, and prognosis of skin cancer that could be targeted during primary, secondary, and tertiary skin cancer control and prevention interventions in Arizona. Utilizing the 2013 Arizona Behavior Risk Factor Surveillance System survey, aim one of this dissertation investigates factors associated with UVR exposure (as measured by sun protection use and sunburn history) that could be targeted during primary prevention efforts in order to reduce the disease burden. The results of this research are that approximately 20% of Arizona adults are protecting their skin with sunscreen or protective clothing every time they go outdoors and 28% of Arizona adults experienced one or more sunburns in the past 12 months. Compared with males, females were more likely to report that they protect their skin. Other factors associated with use of sun protection were higher education, higher income, good general health, and living in a more urban area. A recent history of sunburns was associated with being non-Hispanic white and a history of indoor tanning. Given that melanoma diagnosed in the earlier progression of the disease is associated with improved prognosis and significantly higher survival rates, secondary prevention interventions are essential to skin cancer control efforts. The second aim of this dissertation was to gain a better understanding of patient and community factors associated with late-stage melanoma diagnosis in Arizona. Based on Arizona Cancer Registry and community-level data, among melanoma patients there is evidence for significant associations between late-stage of diagnosis and being male (OR 1.22 [95%CI1.09-1.37]), non-white (OR 3.15 [95%CI 2.01-4.95]), and Hispanic (OR 2.13 [95%CI 1.61-2.81]). Additionally, access to care was found to influence stage of diagnosis. Residence in a rural area, compared to an urban area, was associated with late-stage melanoma diagnosis. Similarly, zip codes with a dermatologist density of less than 6 dermatologists per 100,000 persons, when compared to zip codes with greater than 12 dermatologists per 100,000 persons, were associated with late-stage melanoma diagnosis. A travel distance to the reporting hospital or clinic of over 40 miles, as compared to travel distance of 20 miles or less, was also associated with melanoma cases being diagnosed at a late-stage. Even after the progression of the disease, skin cancer survivors' prognosis and quality of life can be improved by following healthy lifestyle recommendations. The final aim of this study was to examine at what levels skin cancer survivors are meeting the recommended healthy lifestyle behaviors. Skin cancer survivors' behaviors were similar, with the exception of increased sun protection use, to behaviors among survivors of other non-skin forms of cancer. However, skin cancer survivors were more likely to practice healthy lifestyle behaviors than individuals without a reported history of cancer. Although skin cancer survivor did report better behaviors than non-cancer controls, there was still a considerable amount of survivors not practicing the recommended behaviors. Over 25% of skin cancer survivors only protected their skin during the summer or not at all. Additionally, low levels of other healthy lifestyle behaviors were noted among skin cancer survivors: slightly over half of skin cancer survivors met the physical activity recommendations, approximately half reported receiving their annual influenza vaccination, and less than 20% consumed 5 fruit or vegetable servings daily. This research suggests that there are opportunities for improved clinical and public health interventions targeted at increasing sun protection use, preventing sunburns, reducing disparities associated with late-stage melanoma, and improving healthy lifestyle behaviors among skin cancer survivors.

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