Skin cancer is the most commonly occurring secondary neoplasm observed among survivors of childhood cancer, representing a prominent late effect of cancer treatment and an important public health concern for this population [6
]. Risk for skin cancer among survivors of childhood cancer is likely exacerbated by the fact that survivors tend to report low rates of sun safety behaviors that are proven to reduce risk for skin cancer, such as wearing sunscreen with an appropriate SPF and limiting sun exposure [8
]. Yet, evidence for effective behavioral interventions to encourage sun safety practices and reduce risk of secondary skin cancer among adolescent survivors of childhood cancer remains scarce [9
]. Given that risk for skin cancer is increased by greater exposure to UV radiation at a young age and greater cumulative UV radiation exposure over time [11
], interventions to encourage sun safety practices among adolescent survivors of childhood cancer are especially critical to reduce the risk for skin cancer that may accumulate as these youth grow older.
In light of this, our finding that the SHARE Program intervention was efficacious in producing short-term improvements in self-reported sun safety practices among adolescent survivors of childhood cancer is encouraging. To our knowledge, this is among the first studies to report on a behavioral intervention designed to increase sun safety practices within this special population. One earlier study, the Protect Study, tested whether a multi-component behavioral intervention improved health-related perceptions, knowledge, and behaviors among adolescent survivors of childhood cancer [9
]. In the Protect Study, participants chose from one of three priority health behavior goals established in consultation with their health care provider, which included improving sun safety practices for some participants. At baseline, more than one third of participants (36%) did not regularly practice sun safety behaviors, and over half (52%) were unaware of potential risks for secondary cancers. However, only 12% of participants set goals to improve sun safety behaviors, and sun safety practices did not significantly improve from baseline to 1-year follow-up as a result the intervention [9
Our findings indicate SHARE resulted in modest changes in self-reported sun safety behaviors at 1-month follow-up. Though short-term, these findings highlight important directions for future research to strengthen the evidence-base for sun safety behavior change interventions among adolescent survivors of childhood cancer. Similar to prior studies examining this outcome [19
], our investigation relied on self-report. Self-reported assessments of sun safety behaviors, including sun exposure [25
], sun screen use [27
], and wearing protective clothing [26
], appear to be valid when compared with objective measurement methods (e.g., direct observation, UV radiation dosimeters). Nevertheless, self-report behavioral assessments are inherently subject to biases such as inaccurate recall and social desirability [19
Despite this limitation, self-reported sun protection is by far the most widely used assessment modality in behavioral intervention research [19
]. There is an important need to bring to bear more objective methods of sun safety measurement, such as direct observation of sun protective behaviors, personal dosimetry, and skin swabbing to verify sunscreen use in future studies [19
]. Using a combination of self-reported and objective methods of sun protection practices will enable researchers to triangulate data collected via multiple sources, and more accurately determine intervention effects on behavioral outcomes [19
Another important step to build on the promising results of the SHARE Program will be investigations of the durability of these intervention effects over time. Furthermore, the clinical significance of these findings remains unclear beyond the measured changes noted herein. Indeed, an important limitation of sun safety intervention research in general is that few studies utilize clinical outcome measures, such as the occurrence of skin cancer and precancerous lesions [19
]. This likely stems from the fact that most intervention studies have been conducted with relatively short-term (i.e., ≤ 12 month) follow-up periods, limiting the ability to detect changes that may not accrue until a decade or later for young people [19
]. Preliminary evidence examining clinical skin cancer outcomes over prolonged follow-up periods is promising. Findings from one trial evaluating the long-term impact of consistent sunscreen use among adults on clinically-verified skin cancer outcomes [30
] suggest that regular sunscreen use significantly reduces the occurrence of squamous cell carcinomas [31
] and melanomas [32
]. Linking these findings with the long-term clinical impact of sun safety behavioral interventions remains important [19
]. Such studies are especially needed among populations at high risk for skin cancer, such as young survivors of pediatric malignancies.
Our multivariate model of sun safety behaviors accounted for important covariates, including seasonal influences and participant gender, and explained a robust proportion of outcome variance (59%). However, aggregate sun safety measures do not provide specific information regarding which sun safety behaviors responded to the intervention [19
]. While they should be interpreted as preliminary, our bivariate findings () may be useful to inform optimization of behavioral outcome assessments and intervention strategies in future studies. For example, the lack of observed change for some behavioral outcomes (e.g., using sunscreen with SPF ≥ 15) may be due to measurement limitations, and these behaviors could be assessed using more sophisticated objective outcome measures in future studies. Additionally, various intervention modalities, such as print materials, video, and counseling by healthcare providers, may differentially affect certain skin cancer prevention behaviors [19
]. Future studies should explore how these and other educational strategies can be adapted and integrated into the SHARE Program model to target specific behavioral outcomes that appear to be more difficult to change.
An interim evaluation of the SHARE Program intervention indicated that participants found the in-person, group-based format to be relevant, understandable, beneficial, and acceptable [13
], supporting the use of this intervention approach within this population. Recent research also suggests that cancer survivors tend to prefer distance-based approaches to behavioral intervention, which may be a result of specific barriers to engaging in in-person intervention programs within this population (e.g., distance, travel restrictions, lack of time) [34
]. Future studies can improve upon this work by investigating intervention strategies designed to reduce barriers to participation, such as those using distance-based communication technologies as well as other practical strategies (e.g., interventions at multiple locations within the community) to extend the reach of behavioral intervention programs [13
As the number of survivors of pediatric cancer continues to grow, encouraging healthy lifestyles among survivors of pediatric cancer has become essential to optimum risk-based care and the prevention and management of cancer late effects [3
], including secondary skin cancer [6
]. Optimum risk-based care entails systematic planning for lifelong screening, surveillance, and prevention of cancer late effects among young survivors [3
]. This includes devoting specific attention to risks that may be influenced by factors such as cancer type, therapy received, genetic predisposition, lifestyle behaviors, and co-morbid health conditions [3
]. It is also important that risk-based care addresses individual-level survivor-related factors that likely influence lifestyle and behavioral choices, such as knowledge, self-efficacy, and motivation necessary to engage in a healthy lifestyle and address behavioral factors contributing to cancer late-effects [3
]. These individual-level factors are central to the SHARE Program intervention approach, which is a health behavior change intervention model that could be integrated into young cancer survivors’ risk-based care. Nevertheless, additional research is needed to understand important methodological issues surrounding intervention implementation, such as the optimal time at which to deliver health behavior interventions among pediatric cancer survivors relative to cancer diagnosis and treatment [3
The findings of this study should be interpreted in light of important limitations, including the homogenous sample and our sample size, and reliance on self-report measures to assess sun safety behaviors. While we used a measure of sun safety behaviors that had previously been demonstrated as psychometrically sound, the internal consistency of the scale was limited at baseline and improved at follow-up. In addition, this work could be improved by employing more objective assessments of sun safety behaviors in future studies. Finally, the short-term follow-up does not enable us to draw conclusions regarding sustained effects of the intervention on sun safety behaviors.
Despite these limitations, our findings are promising, suggesting that the SHARE Program intervention led to modest improvements in short-term self-reported sun safety practices among adolescent survivors of childhood cancer. Future studies can build from this work by incorporating objective measures of sun safety practices (e.g., direct observation, UV dosimetry) and examining the durability of the intervention in larger, more diverse samples over longer follow-up periods. Additional research is also needed to investigate the long-term clinical impact of sun safety behavioral interventions among pediatric cancer survivors over long-term follow-up periods. This study lays the groundwork for understanding how health behavior interventions addressing sun safety and other health behaviors can be integrated into optimal risk-based cancer care for this special population.