Problem Addressed

• A common, sometimes deadly form of cancer: Several million individuals are diagnosed and treated for skin cancer each year, making it the most common form of cancer.¹ Whereas the vast majority of these cases are curable basal or squamous cell carcinomas, more than 75,000 people will be diagnosed with melanomas of the skin, a dangerous form of skin cancer often caused by overexposure to ultraviolet (UV) rays, typically from the sun.¹ Incidence of melanoma has grown markedly over the past several decades, having risen 3.8 percent a year since 1995 among those age 15 to 34, and 8.8 percent a year among those 65 and older since 2003.² Skin cancers kill nearly 12,000 Americans each year, with more than two-thirds of these individuals dying from melanoma.³ Melanoma accounts for more deaths than any other form of cancer in women ages 25 to 30 and is second only to breast cancer in women ages 30 to 35.²
• Especially in New Jersey: With good summer weather and many beaches, pools, and other outdoor venues, New Jersey has a higher incidence of skin cancer (including melanoma) and skin cancer deaths than do most states.^2,3
• Failure to take proper precautions: Individuals who spend a lot of time in the sun often fail to take basic precautions to reduce the risk of melanoma and other forms of skin cancer, such as avoiding the sun at peak UV hours, wearing protective clothing in sunlight, and using sunscreen with a sun protective factor (SPF) of 15 or higher. In 2009, fewer than 10 percent of high school students reported using sunscreen routinely when out in the sun for prolonged periods of time. That same year, only about a third of adults reported always or often using sunscreen or seeking shade when outside for an hour or more on a warm, sunny day, and only 13 percent reported wearing a hat.¹ In addition, teenagers and adults often fail to take the steps needed to identify skin cancer as early as possible, such as conducting periodic self–skin examinations and getting screened regularly by a health professional. Late detection due to lack of screening is a particularly large problem among men (especially older Caucasian males), who are twice as likely as women to die from melanoma due to late detection.⁴ For their part, primary care physicians and other health professionals often fail to advise patients about the dangers of UV exposure and how to take appropriate precautions to reduce the risk of skin cancer.¹

Description of the Innovative Activity

• Locally led planning, with support from Health Alliance: Leaders in local communities learn about the program from Health Alliance staff and from the attention generated at events in other areas. (See the Planning and Development Process section for more details.) With support from the Health Alliance, these champions organize local events, including recruitment of volunteer health professionals (typically primary care physicians, nurse practitioners, physician assistants, and/or nurses) to conduct skin cancer education and screenings. They also work with mayors and other local officials to secure necessary approvals, permits, and other support from local government agencies, such as the county or city recreation department that runs the beach or pool site.
• Event planning and volunteer training: Using materials and templates provided by the Health Alliance, local champions work to secure donations of food and drink for volunteers and sun-related items to be given away to patrons (see below for more details). They also train volunteers to ensure they present consistent educational messages to those being screened.
• Marketing before and during event: Marketing occurs before and during the event, as outlined below:
  • Pre-event marketing: People learn about upcoming events through press releases and the Choose Your Cover Web site, which provides dates, times, and locations for each event. (During some years, the Health Alliance has worked with local sites to ensure that most or all participating communities hold events on the same day; in other years, events have occurred on different dates.) In some areas, local radio, electronic community message boards, and street signs also publicize the event.
  • Day-of-event marketing: Those at the venue learn about it from announcements via loud speaker (e.g., by lifeguards) and signs. Many also are drawn to the tents by a large UV index sign used at some venues. Some venues invite local radio personalities to conduct live interviews with those being screened, with the goal of encouraging listeners in the area to stop by the site to be screened.
• Event setup and logistics: Volunteers arrive before the scheduled start time to set up for the event, including the tent(s) where education and screening will be conducted, displays of educational materials, and in some cases a UV index sign. Most events held at beaches and pools run for 4 hours, from 10 a.m. to 2 p.m. (when UV levels peak); events at other locations may run for less time. Once the event begins, people line up to be screened on a first-come, first-served basis. Lifeguards and other venue staff are generally allowed to cut in line; volunteers explain to those behind them that these staff must be screened quickly during their breaks so they can get back to work.
• Skin cancer education and screening: The education and screening process consists of several steps, as outlined below:
  • Education during registration process: During the registration process, volunteers educate individuals about skin cancer prevention, ask them about their skin and sun safety habits, and remind them of the importance of regular screenings by a health professional. As appropriate, they suggest changes in habits to reduce the individual’s risk, such as using sunscreen more regularly, wearing protective clothing and/or going inside during peak UV hours, and wearing a hat. Most sites also have an education board that reinforces the key strategies for reducing the risk of skin cancer.
  • Free samples of related products: Volunteers distribute educational materials and sun-related giveaways, such as a small bottle of sunscreen, lip balm with SPF protection, and UV cards and bracelets that change color depending on the strength of the sun. (These cards and bracelets tend to be popular with children and teens.)
  • Screening and reinforcement: Once registration is complete, a qualified, volunteer health professional conducts a skin check and reinforces the same educational messages.
  • Referrals for followup care: If the screener identifies something suspicious, he or she emphasizes the need for followup care and provides the individual with a list of local dermatologists and community health centers (including federally qualified health centers) that can provide these services.
• Followup reminder after event: Some sites send a letter after the event to remind those receiving referrals about the importance of accessing followup care in a timely manner. The letter does not ask the individual to respond in any way or report whether they have received additional screening and/or treatment.

References/Related Articles

Contact the Innovator

Innovator Disclosures

Results

• Enhanced access to education and screening: During the first 5 summers (2008 through 2012), the program held 70 screening events that collectively educated and screened 6,604 individuals (an average of 94 per event), many of whom had not been screened before. In the absence of this program, many of these individuals likely would not have sought screening on their own, or would have done so at a later date.
• Identification of many with suspected cancer: Among those screened, more than one in five received a referral for some type of followup care. Overall, 12.3 percent of those screened received a referral for a biopsy, just under half of whom (5.6 percent of all those screened) had a presumptive diagnosis of cancer. Whereas most of those with suspected cancer had a presumptive diagnosis of basal cell cancer (3.1 percent of all those screened) or squamous cell cancer (1.3 percent), 1.1 percent of all those screened had a presumptive diagnosis of melanoma. (These figures are likely conservative, as some sites did not report total referrals or those with a presumptive diagnosis in 2010, 2011, and 2012.)
• Increased knowledge about protective strategies: A comparison of the results from tests administered to attendees before and after receiving education and screening at one site in 2008 and 2009 found that the program led to a statistically significant increase in knowledge about appropriate use of sunscreen, protecting clothing, and hats. A more comprehensive analysis of the program’s impact on skin cancer knowledge is currently under way.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Developing initial version: Led by Dr. Baskies, a small group of individuals met over a several-month period beginning in October 2007 to develop the initial program. The group included representatives from the New Jersey Office of Cancer Control, Long Beach Island Health Department, Southern Ocean Medical Center, and the American Cancer Society. The goal was to launch the program at a few local beachfront sites in the summer of 2008.
• Launching on a small scale: On August 2 and 3, 2008, the Ocean County Cancer Coalition conducted screenings and education at three beachfront sites.
• Refining program: Following the August 2008 event, the planning committee immediately evaluated what did and did not work well, using information from questionnaires filled out by volunteers and those screened. This process convinced the group of the need to bolster the educational component of the program (which was fairly minimal during the first year, consisting primarily of handing out brochures). The group decided to create the aforementioned education board and to ensure that volunteers received training on appropriate educational messages in advance of events. This evaluation process also convinced the group of the merits of expanding the program to other parts of the state.
• Preparing for broader rollout: To facilitate expansion, the planning committee created an implementation guide and assembled standardized screening forms to meet privacy requirements and other materials to allow local coalitions and volunteers to plan events as easily as possible. For the most part, the committee did not create new materials but rather assembled and refined existing ones from various sources, such as the American Cancer Society and American Academy of Dermatology. Committee representatives visited with local leaders to educate them about and elicit interest in the program. Meetings were held with mayors; public health and recreation department leaders; other public officials; and representatives from nursing societies, hospitals, physician groups, and other community-based organizations with an interest in reducing the risk of skin cancer.
• Expanding to additional counties: In 2009, events were held at 11 sites in 4 New Jersey counties, with screenings, education, and related activities performed by more than 100 volunteers, dozens of providers, and representatives from more than 40 organizations and foundations. The success of these events led to significant interest from other parts of New Jersey. By 2010, the program had expanded to 22 sites. Because some of these events drew relatively few customers, local leaders reconsidered the appropriate number of events and where they should be held, with a few being eliminated or replaced with new venues. During the summer of 2012, screening and education events were held at 17 sites.

Resources Used and Skills Needed

• Staffing: Members of the Ocean Monmouth Health Alliance staff perform program-related activities as a small part of their regular duties. At the local level, a large number of individuals volunteer their time at the events, as described earlier.
• Costs: Event costs tend to be minimal, as both staff time and materials are typically donated by local individuals and organizations. Leaders of the Ocean Monmouth Health Alliance estimate that event-related materials, including giveaways, food and water for volunteers, and other items, would cost approximately $1,500 per event if purchased.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Do not reinvent the wheel: As noted, the Choose Your Cover Web site provides a wide array of materials designed to allow for easy, low-cost implementation of this program.
• Start small: Even if the ultimate aim is to disseminate the program throughout a wide area, start in just one or a few locations and then let the success of the event serve as a catalyst for others to adopt it. This approach also provides an opportunity to evaluate and refine the program as necessary before it spreads.
• Identify and recruit local champions: Programs will never get off the ground at a local level without the dedication of one or two community-based champions. Dr. Baskies served as that champion in Ocean County, and equally passionate champions have surfaced in other areas that have been successful. One site did not hold an event in 2012 because the previous champion moved out of the area and no one took over the effort.
• Choose right locations: The best locations are generally those that attract many people who regularly engage in outdoor activities. Beaches often prove to be good sites, whereas other venues have yielded mixed results. Pools often (but do not always) draw large crowds, whereas other sites that have been used, including golf courses/outings, farmers’ markets, and one-time events (e.g., runs or walks), have been relatively less successful. However, though some venues may not draw large crowds, they can serve as a good way to bring screening and education to hard-to-reach populations. For example, a recent event held at a golf course attracted only seven individuals, but six ended up being referred for followup, including four with a presumptive diagnosis of skin cancer. (As noted earlier, older white men—who make up a large proportion of recreational golfers—tend not to get screened regularly.)
• Choose right time of year: Obviously, events should be scheduled to maximize attendance, which in most of the country means during good beach weather. Those in New Jersey have found that July and August represent the best times for events. Events held in late May and in June have not fared as well, since temperatures are often not warm enough to draw large crowds. In 2011, for example, most Choose Your Cover sites held screenings in June. The average event that year screened 78 individuals, well below the per-event average of 94 across the entire 5-year period.

Sustaining This Innovation

• Constantly evaluate and refine program: By debriefing after every event, those involved in planning can continually improve the program, making changes as necessary to venues, dates and times, recruiting and marketing strategies, educational messages, and other key components.
• Use initial success to expand over time: Once the program has been successfully implemented and needed refinements made, approach leaders in other communities to explain the program and elicit interest in it.

Additional Considerations and Lessons

Use By Other Organizations