On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.79 no.1 Rio de Janeiro Jan./Feb. 2004
CLINICAL, LABORATORY AND THERAPEUTIC INVESTIGATION
Frequency of counseling for skin cancer prevention by the various specialties in Caxias do Sul*
Adelar Bocchese NoraI; Daniel PanarottoII; Louise LovattoIII; Márcio Manozzo BoniattiIII
Dermatologist, Professor of Ambulatory Dermatology, Medicine Course, Universidade
de Caxias do Sul
IIPh.D. in Endocrinology, Professor of Medical Physiology and Initiation in Research, Medicine Course, Universidade de Caxias do Sul
IIITenth-semester medical students, Universidade de Caxias do Sul
Nowadays, skin cancer is the most common form of cancer, in spite of being one
of the most preventable forms of cancer. We did not find national data about
the frequency of counseling for skin cancer prevention according to the various
OBJECTIVE: The objective of this study was to verify the frequency of counseling for skin cancer prevention by the various specialties in a sample of the population of Caxias do Sul.
METHODS: A transversal study was performed on 499 people who sought medical care in the dermatology sector of the community programs, each was interviewed and examined. The community programs took place in Caxias do Sul between January and July 2002.
RESULTS: Only 31.9% (n = 159; CI 27.8 - 36.2) of the individuals who were interviewed had already received counseling for skin cancer prevention by physicians. The high-risk patients with the greatest potential for intervention (patients under 20 years of age) received such counseling at a lower frequency than patients aged 20 years or older (26.5% versus 42.5%, respectively; p = 0.03). The specialty of dermatology was responsible for the majority of counseling on skin cancer prevention in this population.
CONCLUSION: The frequency of counseling for skin cancer prevention by physicians is low, even for high-risk patients. The counseling also varies according to the attending specialty; only the specialty of dermatology presented a high frequency of counseling.
Key-words: counseling; carcinoma, basal cell; carcinoma, squamous cell; specialties, medical; melanoma; skin neoplasms.
Skin cancer is the most common form of preventable cancer at the present time.1 Yet its incidence has been increasing in the last three decades,2 approaching epidemic proportions. This type of cancer today represents about a third of all the forms of cancer diagnosed.3 It is estimated that more than a million new cases are recognized per year in the United States and that one in five Americans will develop some type of skin cancer during his/her lifetime.4 In some countries, such as Australia, where the rates of incidence are the highest in the world,5 skin cancer has become an important problem of public health, especially because of the preventable nature of the disease and its morbidity and mortality.6 The incidence of melanoma, still the most lethal form of skin cancer,7 is proportionally greater than all other forms of cancer in the United States.4 It is the fourth most common form of cancer in Australia and in New Zealand, and the seventh most common in the United States and in Canada.8 In Brazil, according to data of the Estimates of Incidence and Mortality of the Instituto Nacional do Cancer, it was predicted that melanoma will affect, by the end of 2002, 3,050 individuals and be responsible for 1,085 deaths. As for non-melanocytic skin cancer, which is the most frequent type of cancer in the Brazilian population, there have been forecasts of the diagnoses of 62,190 new cases, among the 337,535 new cases of cancer predicted for the year 2002.
It is believed that 90% of non-melanocytic skin cancers and 65% of the incidence of melanomas may be attributed to solar exposure.7 The former is associated with a cumulative exposure to ultraviolet rays, while the latter is associated with intense episodes of solar exposure resulting in sunburns.1 Besides solar exposure, other risk factors for the development of skin cancer have been described, such as phenotypical factors (skin type, color of eyes and hair, tendency to tan or burn and freckles) and a personal and/or family history of skin cancer.1 Of these, it is known that exposure to ultraviolet radiation is more strongly associated with the risk of developing skin cancer.9,10 The focus of prevention is, therefore, solar protection.11 Primary prevention includes guidance as to the relationship between the sun and skin cancer, recommending the application of a sunscreen lotion, the use of appropriate clothes, the use of hats and sun glasses, remaining in the shade as much as possible, limiting the length of time of exposure to the sun and the avoidance of artificial sources of ultraviolet radiation (such as artificial tanning).1 Secondary prevention includes screening and early diagnosis in combination with counseling to put into practice the recommendations for primary prevention.1
In spite of its high prevalence and the fact that it can be avoided with simple methods, only a minority of the population adopts appropriate preventive measures against contracting skin cancer. In a research done on 32,440 individuals in the United States, only 23% affirmed they were in the habit of using appropriate clothing to protect themselves from the sun, 27% reported that they remained in the shade, and only 30%, used suntan lotion.10 In another study, done in Ireland in 2001, most of those interviewed knew that solar exposure can cause skin cancer, however less than half used suntan lotion and an even smaller number adopted some other measure of protection.12 The authors believe that adequate counseling of patients by professionals in health care could increase the frequency of the adoption of preventive measures.
This study aimed, therefore, to ascertain the frequency of counseling for the prevention of skin cancer among the various medical specialties in a sampling of the population of the city of Caxias do Sul, in Brazil.
PATIENTS AND METHODS
A transversal study, consisting of interviews and examinations of individuals that sought help in the area of dermatology at community services provided in six different neighborhoods of Caxias do Sul from January to July of 2002. The community services were part of an interdisciplinary project developed by the University of Caxias do Sul to provide the communities of the neighborhoods of Caxias do Sul and neighboring municipal districts a multiplicity of activities and services in the areas of medicine, nursing, social services, biology, legal aid, physical education and artistic education. In these events students and teachers as well as employees of the institution participate in courses in their various areas of interest and expertise, all on a voluntary basis. In the interviews, information was obtained on sex, age, personal and/or family history of skin cancer, skin type (reaction of the skin to solar exposure), and as to what advices they had already received from a doctor or specialist about the prevention of skin cancer. The physical examinations supplied information as to the skin type and presence of actinic keratosis.
High-risk patients for developing skin cancer were considered to be those that presented at least one of the following factors: the presence of actinic keratosis, skin type I (the skin always burns and never pigments when exposed to the sun)13 or skin type II (the skin always burns and only slightly pigments when exposed to the sun)13 or a family and/or personal history of skin cancer.
These data were grouped and analyzed according to the Chi-square test, by the Epi Info program. The confidence interval in the statistical analyses was 95%.
Of the 499 individuals interviewed, 351 (70.3%) were female, and 148 (29.7%) male. The prevalence of those considered to be at high risk for skin cancer was 57.9% (n = 289; CI 53.4 - 62.3) (Table 1).
Only 31.9% (n = 159; CI 27.8 - 36.2) of the interviewed individuals, these being 27.7% (n = 41; CI 20.7 - 35.7) of the men and 33.6% (n = 118; CI 28.7 - 38.9) of the women, had ever received counseling by a member of the medical profession about the prevention of skin cancer. The frequency of the fact of having received counseling presented a significant difference (p = 0.000008) when comparing the individuals with a high risk and those with a low risk: 39.8% (n = 115; CI 34.1 - 45.7) and 21.0% (n = 44; CI 15.7 - 27.1) respectively had received counseling. For the high-risk patients, 38.8% (n = 31; CI 28.1 - 50.3) of the men and 40.2% (n = 84; CI 33.5 - 47.2) of the women had received counseling. Only 26.5% (n = 13, CI 14.9 - 41.1) of those 20 years old or less at high risk had received guidance.
Of the 159 persons that had received counseling, most, 65.4% (n = 104), had received it from a dermatologist, followed in frequency by general practitioners, 23.9% (n = 38). Considering the proportion of guidance according to the medical specialty consulted, of the patients that had consulted a dermatologist, 57.4% (n = 104) had received guidance. But the percentage was only 11.3% (n = 38) for the patients that had been seen by a general practitioner (Table 2).
Of the patients that had not received guidance, 65.6% (n = 223) had consulted with a general practitioner, and 53.2% (n = 181) with physicians specialized in gynecology and obstetrics. Considering only the high-risk patients that did not receive counseling, general practice, 70.1% (n = 122), and gynecology and obstetrics, 55.7% (n = 97), were the specialties most consulted. Of the high-risk patients and less than 20 years old that did not receive guidance, 80.5% (n = 29) had previously consulted with a pediatrician, while 63.8% (n = 23) had consulted physicians of other specialties.
Furthermore, among those at high risk that did not receive guidance, the average number of specialists consulted was 2.6 (SD 1.0) specialists per patient.
Most of the individuals interviewed, even those considered to be at high risk, had not received counseling for the prevention of skin cancer in any consultation. In spite of the fact that the frequency of counseling presents a statistically significant difference when comparing the high-risk patients and those at low risk, less than half of the individuals in the first group had received guidance. This low frequency of guidance for the prevention of skin cancer has been verified in other studies. It is known that most patients do not receive an assessment regarding skin cancer in primary care consultations.3 Feldman et al.14 stated that, of 787 million ambulatory consultations in the United States during 1997, this kind of counseling was offered in only 1.5%. That study further stated that of the high-risk patients, identified by the doctor responsible for the consultation, only 35.4% received counseling. Oliveria et al.15 made a comparison of the frequency, of the guidance for the prevention of skin cancer as against other advices for promotion of better health in primary care. Counseling for the prevention of skin cancer was reported in only 2.3% of the consultations, while guidance regarding self-examination of the breast, diet and nutrition, smoking and the practice of exercise was reported to be 13%, 25.3%, 5.7% and 17.9%, respectively.15 The results of that study indicate that the proportion of counseling for the prevention of skin cancer compared to other medical advice in primary care is low.15 Also in corroboration with those data, the results of a study by Weinstein et al.16 showed that the main sources of information about solar protection for the public are television and magazines; while the sources from which people would prefer to obtain this information are their family doctors or dermatologists.
Among the patients at highest risk, those with the greatest potential for intervention, or in other words, persons less than 20 years of age, received guidance in lesser frequency than persons 20 years old or above (26.5% versus 42.5%, respectively; p = 0.03). These data agree with those of the study by Feldman et al.,14 in which it was verified that children receive such counseling with even less frequency than that offered to other patients. These are considerations of significant concern, because it is known that childhood is a period of high risk for the development of skin cancer in adult life:17 about 80% of the solar exposure to which a person is submitted during his/her lifetime occurs before 21 years of age,9 and there is a well established relationship between the exposure to ultraviolet light in childhood and an augmented risk of developing skin cancer in the adult life.18 It is estimated that the regular use of suntan lotion during childhood may reduce the incidence of skin cancer in approximately 78% of the population.19
The specialty of dermatology was responsible for more than half of the counselings for the prevention of skin cancer in the population that was studied. Moreover, more than 60% of the persons at high risk that had consulted a dermatologist had received such counseling (Table 2). Feldman et al.14 verified that the frequency of this counseling for high-risk patients depends on the consulted specialty, in the following decreasing order: dermatology, family practice and other specialties. In agreement with those data, the present study showed that dermatologists present a high rate of counseling regarding the prevention of skin cancer, the same does not occur with regard to doctors in primary care.3 Data as to the frequency of counseling by the various medical specialties in Brazil were not found.
Among the high-risk patients that did not receive counseling, the average number of consulted specialists was 2.6 for each person, the most consulted being general practice and gynecology and obstetrics. Emphasis should be placed on the pediatrics specialty, because, of the high-risk patients less than 20 years of age that did not receive guidance, most (80.5%) had previously consulted a pediatrician. These data display the importance of advising doctors, mainly those in the areas most sought and of those in the area of pediatrics. The latter because they are attending the majority of patients that are in the age group with the greatest potential for intervention, so that they can offer counseling about prevention of skin cancer to their patients. These data reveal that many opportunities are still being wasted to practice preventive medicine.
The frequency of counseling for the prevention of skin cancer by health professionals is low, even for high-risk patients. And when only the high-risk patients less than 20 years of age are considered, the frequency is still lower, the opposite of that which is recommended. The counseling also varies in accordance with the specialty consulted, only the specialty of dermatology presenting a high frequency of counseling. All of this contributes to a paradoxical situation: skin cancer is today the most common type of cancer in the world, in spite of being one of the most preventable. The data of this study suggest the need to convince health professionals and especially those that are not dermatologists, to offer their patients counseling regarding how to prevent skin cancer.
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Visconde de Pelotas, 1447 / 81
95020-183 Caxias do Sul RS
Tel/Fax: (54) 222-0396 / 223-0300
in October, 10th of 2002
Approved by the Consultive Council and accepted for publication in September, 10th of 2003
* Work done at the Department of Clinical Medicine, Universidade de Caxias do Sul.