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Journal of Behavioral Medicine, Vol. 29, No. 5, October 2006 (
C
2006)
DOI: 10.1007/s10865-006-9064-5
Prevalence and Correlates of Sun Protection and Skin
Self-Examination Practices Among Cutaneous Malignant
Melanoma Survivors
Sharon Manne
1,2
and Stuart Lessin
1
Accepted for publication: June 14, 2006
Published online: July 20, 2006
Little is known about the level of engagement and correlates of sun protection and skin self-
exam among individuals diagnosed with melanoma. Participants (N = 229) completed mea-
sures of skin self-exam and sun protection practice and knowledge and attitudes. Approx-
imately eighty-four percent of patients reported engaging in skin self-examination at least
once in the past year. Engagement in sun protection practices was moderate. Self-exam prac-
tice was associated with gender, physician recommendation about self-exam, and perceived
benefits and barriers of self-exam. Sun protection was associated with gender, age, medical
status and health care access, physician recommendation, knowledge, and a number of psy-
chological factors. Behavioral interventions to improve skin surveillance and sun protection
may benefit from an emphasis on physician education regarding self-exam and sun protec-
tion, education regarding the efficacy of sunscreen and the risks associated with sunbathing,
reducing perceived barriers to self-exam and sun protection, and reducing reliance on social
influences on sun protection practices.
KEY WORDS: psychological factors; sun protection; skin self-examination; cancer survivorship.
INTRODUCTION
Cutaneous malignant melanoma incidence and
mortality rates are increasing in White popula-
tions worldwide more rapidly than any other can-
cer site (American Cancer Society, 2006). There
are several strategies individuals can utilize that
are thought to reduce melanoma risk. Regular skin
surveillance by total cutaneous examination and
skin self-examination (SSE) are believed to in-
crease the chances of detecting thinner, more cur-
able melanoma lesions. In addition, individuals can
engage in regular sun protection and sun avoidance
during peak ultraviolet light hours (American Can-
cer Society, 2006; American Academy of Derma-
tology, 2006; Skin Cancer Foundation, 2006). Rec-
1
Fox Chase Cancer Center, Philadelphia, PA.
2
To whom correspondence should be addressed at Fox Chase
Cancer Center, P1100, 333 Cottman Ave., Philadelphia, PA
19111; e-mail: Sharon.Manne@fccc.edu.
ommendations regarding performance of total cuta-
neous exam and SSE have been the subject of sci-
entific disagreement. There have been no controlled
trials evaluating the impact of total cutaneous exam
on melanoma mortality, and there has been only one
study supporting the link between SSE and reduced
melanoma mortality (Berwick et al., 1996). Because
of this lack of mortality reduction data, some scien-
tific groups do not recommend routine skin cancer
surveillance (e.g., United States Preventive Services
Task Force, 2001).
Because epidemiological evidence has not been
gathered it may be premature to target average risk
populations for interventions to improve skin can-
cer surveillance practices. However, a strong case
can be made for focusing prevention and surveil-
lance efforts on subgroups of individuals at in-
creased melanoma risk. Individuals who have been
diagnosed with melanoma are a subgroup of in-
dividuals who are at increased risk for devel-
oping a second primary melanoma or melanoma
419
0160-7715/06/1000-0419/0
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2006 Springer Science+Business Media, Inc.
420 Manne and Lessin
recurrence (American Academy of Dermatology,
2006; Brobeil et al., 1997; Garbe et al., 2003; Rhodes
et al., 1987). Although there is no evidence proving
a link between skin surveillance and sun protection
and risk for melanoma recurrence or a second pri-
mary melanoma, recent guidelines published by task
forces suggest that survivors be counseled about this
risk, taught how to perform SSE, instructed to con-
duct regular SSE, and instructed to bring new or
changing skin lesions to the attention of a physician
(Roberts et al., 2002). There are no special guide-
lines for melanoma survivors regarding sun protec-
tion. However, sun protection would be considered
particularly important for those who are at increased
risk for a second melanoma due to a prior history.
Despite the potential importance of regular
skin surveillance and protection among melanoma
survivors, little is known about the prevalence of
these practices in this population. The few studies
that have been conducted suggest that engagement
in skin surveillance is variable, with figures rang-
ing from 13.2% to 70% of patients reporting ever
performing SSE (American Cancer Society, 2006;
Robinson et al., 2002). There have been no studies
evaluating sun protection practices among melanoma
survivors, although one study has evaluated sun pro-
tection among non-melanoma skin cancer survivors
and reported between 44% and 79% reported vari-
ous sun protection habits after surgery (Rhee et al.,
2004).
There is also little known about factors con-
tributing to engagement in skin cancer surveillance
and prevention practices among melanoma sur-
vivors. A greater understanding of these factors may
provide information to guide intervention efforts
to improve acceptance of both behaviors. We se-
lected a comprehensive set of psychological and non-
psychological factors that we believed contribute to
skin surveillance and protection behaviors. The set
of psychological variables were drawn primarily from
the concept of the teachable moment and from the
Health Belief Model (Rosenstock, 1974). The teach-
able moment refers to a life event or transition that
inspires a person to make significant health behav-
ior change(s) that improve their health. These events
or transitions are often related to one’s personal
health. Among melanoma survivors, the event would
be the cancer diagnosis. According to McBride and
colleagues (2003), the degree to which a cueing event
such as a cancer diagnosis is significant enough to
be a teachable moment for behavior change depends
upon whether it increases perceptions of personal
risk and prompts a strong distress reaction. Based
on the teachable moment premise, perceived risk for
melanoma recurrence and distress associated with
melanoma were selected as two key constructs to in-
clude. Perceived skin cancer risk has been associated
with higher frequency of SSE (Robinson et al., 1998,
2002) and greater sun protection (Azzarello et al.,
2006) among persons at increased risk, and perceived
risk for skin cancer has been associated with sun pro-
tection among average risk individuals (e.g., Aiken
et al., 1994). Distress has not been studied as a cor-
relate of SSE or sun protective behavior among indi-
viduals at increased risk for melanoma due to a fam-
ily history (Manne et al., 2004). However, distress has
been associated with other cancer screening and de-
tection practices such as mammography (Kash et al.,
1992
).
The Health Belief Model predicts that indi-
viduals will undertake a health behavior change if
they perceive themselves to be at risk for a health
problem, perceive the consequences of the health
problem to be severe, perceive many benefits of
undertaking the preventive health behavior, and per-
ceive few barriers to undertaking the preventive
health behavior. Perceived severity of skin cancer
and photoaging with has been associated with sun
protection practices among average risk individu-
als (Jackson and Aiken, 2000). This construct has
not been evaluated as a correlate of SSE. Prior
studies have suggested that perceived benefits and
barriers are associated with less SSE among individ-
uals at increased risk (Manne et al., 2004; Robinson
et al., 2002). Benefits of sun protection, advantages
of sunbathing and sunscreen barriers are known cor-
relates of sun protection behaviors among average
risk persons (Carmel et al., 1994; Cokkinides et al.,
2001; Jackson and Aiken, 2000; Jones et al., 2000;
Lescano and Rodrigue, 1997; Mahler et al., 1997)
and sunscreen barriers have been associated with less
sun protection among individuals at increased risk
(Manne et al., 2004).
Studies of sun protection behavior suggest two
additional constructs may play a role in sun protec-
tion. Self-efficacy for sun protection predicts both
sun exposure (Reynolds et al., 1996) and intentions
to use sun protection (Jackson and Aiken, 2000;
Mahler et al., 1997). Self-efficacy for performing a
health behavior is a construct incorporated from the
Social Cognitive Theory (Bandura, 1986) and is nec-
essary for sustained performance of a habitual be-
havior such as sun protection. Prior studies have
also indicated that norms or beliefs of others are
Sun Protection and SSE Among Melanoma Survivors 421
influential in sun protection behaviors. Having
friends who use sunscreen is associated with sun-
screen use (Wichstrom, 1994) and having friends
who sunbathe is associated with sunbathing (Arthey
and Clarke, 1995). The modeling of high-status per-
sons such as movie stars and sports figures has also
been shown to influence sun protection (Jackson and
Aiken, 2000). Normative influences are a key compo-
nent of the Theory of Reasoned Action (Azjen and
Fishbein, 1980). Based on this literature, we evalu-
ated sun protection norms, sunbathing norms and im-
age norms for tanness as correlates of sun protection.
The final psychological construct included in our
set of factors was the concept of stage of adoption
from the Transtheoretical model (Rakowski et al.,
1996). We evaluated stage of adoption because the
combination of past behavior and future intention to
engage in health practices is important when consid-
ering an ongoing behavior change such as SSE and
sun protection. This discrimination allows for an un-
derstanding of factors predicting failure to continue
surveillance as well as those who intend to continue
surveillance practices (Robinson et al., 1998). In ad-
dition, stage of adoption of sun protection has been
used to tailor behavioral interventions to increase
sun protection (Weinstock et al., 2002; Prochaska
et al., 2004, 2005).
Non-psychological factors have also been asso-
ciated with SSE and sun protection and should be
included in any attempt to understand these health
behaviors. Potential factors include demographic
variables, the survivor’s medical history and health
history (e.g., phenotypic risk factors), access to health
care, melanoma knowledge, and the physician’s rec-
ommendation and education about SSE and sun
protection. Among average risk individuals, women
and younger persons (Robinson et al., 2002; Olive-
ria et al., 1999) report engaging more in SSE, and
age, ethnicity, gender have been associated with sun
protection (Carmel et al., 1994; Cokkinides et al.,
2001;Hallet al., 1997). Higher education has been
associated with greater engagement in sun protec-
tion among family members of melanoma patients
(Azzarello et al., 2006) and average risk persons
(Purdue, 2002). Time since cancer diagnosis and the
number of malignancies predict survivor’s engage-
ment in SSE (Robinson et al., 2002). A personal
history of skin cancer has been associated with sun
protection (Hall et al., 1997). Family history of skin
cancer (Oliveria et al.,
1999) and phenotypic risk
characteristics (e.g., freckling) are associated with
SSE among individuals in the general population
(Oliveria et al., 1999; Robinson et al., 2002) and fam-
ily members of melanoma patients (Azzarello et al.,
2006; Manne et al., 2004). Greater access to health
care is associated with engagement in SSE (Oliveria
et al., 1999; Robinson et al., 2002). Knowledge is a
known correlate of both SSE (Robinson et al., 2002)
and sun protection (Keesling and Friedman, 1987).
Finally, physician recommendation (Robinson et al.,
1998) and physician education about SSE (Manne
et al., 2004) are strong correlates of SSE. Thus, these
variables were included in our set of contributing
factors.
The present study had three aims. The first aim
was to examine engagement in and stage of adoption
of sun protection behaviors and SSE practices among
individuals diagnosed with melanoma. The second
aim was to examine the associations of psychological
and non-psychological constructs with engagement in
SSE and sun protection behaviors. We evaluated the
two teachable moment constructs, risk and distress,
first. Other psychological constructs were evaluated
next: benefits and barriers, perceived severity, self-
efficacy, and norms. Teachable moment constructs
were evaluated first because these factors would con-
sidered most relevant among cancer survivors. The
third aim was to evaluate the contribution of the
proposed set of psychological factors after account-
ing for the contribution of non-psychological fac-
tors. We were interested in understanding whether
psychological factors contributed after taking non-
psychological factors into account because psycho-
logical factors could be targeted in behavioral inter-
ventions to improve practices. We did not evaluate
engagement in total cutaneous skin exam because
our sample was recruited from a cutaneous oncolo-
gist’s practice during a follow-up visit where total cu-
taneous skin exam was performed.
METHOD
Participants and Procedures
229 patients seen at a large comprehensive can-
cer center in the Northeastern United States with
melanoma participated. All participants lived within
a four state geographical area surrounding the cen-
ter. Criteria for inclusion were: a) diagnosed with
cutaneous malignant melanoma; b) greater than
18 years of age, and; c) English speaking. During
an outpatient follow-up visit, the attending oncolo-
gist described the study to the patient and interested
422 Manne and Lessin
patients were provided with an informed consent, re-
search authorization, and study survey and asked to
mail in consent and survey. 321 patients were ap-
proached. 92 patients did not participate (29%). Thus
the participation rate was 71%. Thirty-four percent
gave no reason for refusing. The most common rea-
sons for refusal were “not interested” (16%) and “no
time” (26%). Thus, the final sample size was 229.
A comparison of patients who did not partici-
pate and participants in terms of current age, gen-
der, age at diagnosis, and time since diagnosis, indi-
cated that a greater percentage of participants were
female (57.2%) than refusers (43.6%), χ
2
(320) =4.9,
p < .05.
Non-Psychological Measures
Demographic Information
Participant age, gender, ethnicity, marital status,
income, and education were assessed.
Medical Status, Health History and Access to/use
of Health Care
Medical status information included Breslow
score (a grading system for prognosis) (Breslow,
1970), age and stage at diagnosis, whether the per-
son had a recurrence, current disease status, and time
since diagnosis. Health history included the number
of objective melanoma risk factors, which consisted
of five factors identified by Rigel and Carucci (2000):
presence of blonde or red hair, fair skin, three or
more blistering sunburns prior to age 20, history of
three or more years of an outdoor summer job as a
teenager, and presence of marked freckling on the
upper back. In addition, the number of first degree
relatives with melanoma was assessed. Medical ac-
cess was assessed by whether participants had med-
ical insurance, had a primary care physician they saw
regularly, and had regular dental care.
Melanoma Knowledge
The Melanoma knowledge scale consisted of 23
true-false items assessing knowledge about the dis-
ease (e.g., “Melanoma is the most deadly form of skin
cancer”) and risk factors (sun exposure family his-
tory, skin color) (α =.67).
SSE guideline knowledge was assessed by a sin-
gle item asking how often the American Cancer
Society recommends people conduct SSE (1 = sev-
eral times a year).
Physician Recommendation and Education About
SSE and Sun Protection
For SSE, two questions asked whether a doctor
suggested the participant examine his/her skin and
whether a doctor had shown the participant the best
way to do SSE (yes/no). For sun protection, three
items were summed: whether a doctor told the per-
son to reduce the amount of time s/he spends in sun,
to wear a hat or long sleeves when out in the sun, and
to use sunscreen regularly (yes/no).
Psychological Measures
Perceived Melanoma Risk
A three item scale adapted from Schwartz and
colleagues (1994) was used to assess melanoma risk.
The first item assessed estimated percent risk of
developing a recurrence of melanoma (0–100%).
The second item assessed perceived risk for a re-
currence compared with the average person of
the same age and a third item assessed perceived
melanoma risk compared with a similar family his-
tory of melanoma. The second and third items em-
ployed a Likert rating scale (1 = much lower than
other people,5 = much higher than other peo-
ple). The three items were evaluated separately. An
additional indicator of perceived risk was susceptibil-
ity to photoaging (Jackson and Aiken, 2000). Three
items assessed this variable (e.g., “If I were not to
use sun protection, I would be very susceptible to
sun damage”) (1 = strongly disagree,5= strongly
agree)(α =.86). The three risk items were analyzed
separately.
Distress
The 15-item Impact of Events scale (Horowitz
et al., 1979) assessed cancer-specific distress (α =
.92).
A single item measure assessed how distressed the
participant presently was about his/her melanoma
(1 = extremely distressed,4 = not at all distressed).
Sun Protection and SSE Among Melanoma Survivors 423
SSE and Sun Protection Benefits and Barriers
The SSE benefits and barriers scale were
adapted from Rakowski and colleagues’ (1996) ben-
efits and barriers for mammography as well as a mea-
sure used in our prior work with family members of
patients with colorectal cancer (Manne et al., 2002).
Scale items are shown in Table I. The benefits scale
had seven items (α =.71) and the barriers scale had
ten items (α =.74).
Four sun protection benefits and barriers mea-
sures were administered: Perceived sun protec-
tion benefits and barriers measure was taken from
Jackson and Aiken (2000)(α =.84, .74, respectively).
Glanz and colleagues (1999) sun protection behav-
ior benefits scale consisted of six items that assesses
how much the participant believes each sun protec-
tion habit would protect themselves against the sun
(α =.70). The perceived advantages of sunbathing
(Jackson and Aiken, 2000) measure contained seven
items (α =.94).
Table I. SSE Benefits and Barriers Scale Items
Item
By doing SSE, I can find moles or growths on my skin that are
cancerous or may become cancerous.
a
Doing SSE is a part of overall good health care.
a
I would be more likely to do SSE if my doctor said it was very
important.
a
SSE is very important for people with my history of cancer.
a
Regular SSE would help me to live a long life.
a
Those people who are close to me will benefit if I do regular
SSE.
a
Doing regular SSE would help me feel in control of my health.
a
Doing regular SSE would help me avoid developing another
serious form of skin cancer.
Doing SSE would provide me peace of mind about my health.
a
I do not feel confident performing an SSE.
There are so many moles and freckles on my body that
performing SSE would be difficult.
Doing my own SSE makes me nervous because I am not sure
what skin cancer would look like.
The thought of finding an abnormal mole or growth makes me
quite anxious.
Doing SSE would be very embarrassing.
Staying out of the sun lowers my risk for skin cancer and so I
really do not need to do SSE regularly.
Doing SSE gets in the way of other things I have to do for
myself and others.
It would take too much time to do regular SSE.
I would prefer a doctor examine my skin for signs of skin cancer
rather than having to do my own SSE.
Doing a SSE would be somewhat difficult as I do not know
exactly what I am looking for.
Note. SSE: skin self examination.
a
Benefit scale.
Perceived Melanoma Severity
A five-item scale adapted from Aiken and col-
leagues (1994), and from our prior work was used to
assess disease severity (α =.84). Higher scores indi-
cate higher perceived severity of melanoma.
Sunscreen self-efficacy was assessed using an
eight-item scale developed by Jackson and Aiken
(2000); (α =.90). Items assessed confidence in using
sunscreen in various situations.
Sun Protection, Sunbathing and Image Norms
for Tanness
Sun protection norms examined family and
friends’ sun protection practices and attitudes
(7 items) (α =.80). Sunbathing norms consisted of
five items assessing friends’ sun bathing practices and
attitudes (α =.64). Image norms for tanness were as-
sessed using five items examining fashions of pale-
ness and tan among celebrities (Jackson and Aiken,
2000). Internal consistency of this scale was very
low (α =.44) and item-total correlations were con-
sistently low, and thus the image norm scale was ex-
cluded from further analyses.
Outcome Measures
SSE Practice
Items were based on prior studies of SSE (e.g.,
Oliveria et al., 1999). Participants were asked “how
often have you performed a complete examination of
your skin by examining all of your skin, both the front
and back of your body, and the top of your scalp,
for signs of usual moles or growths in the past year”
A dichotomous indicator was created (never/ever).
Among persons performing an SSE, thoroughness
of examination was assessed by five additional items
asking if the individual used the assistance of an-
other person or a mirror when they conducted an
examination of their own skin (1 = never,6 = al-
ways) and whether the individual checked the follow-
ing four specific areas during the most recent SSE:
the upper and lower back, scalp, soles of feet and be-
tween the toes, and back of the neck and legs. These
areas were selected for assessment because they are
recommended in a comprehensive skin examination
(American Academy of Dermatology, 2006).
424 Manne and Lessin
SSE Stage of Adoption
Questions were modeled after algorithms for as-
sessing stage of adoption for other cancer screen-
ing practices (Manne et al., 2002; Rakowski et al.,
1996). The SSE practice item described above was
used to assess performance. Intentions among per-
sons not performing sun protection in the past year
were assessed by asking participants to choose be-
tween two responses: “I have never seriously thought
about engaging in sun protection” and “I am se-
riously thinking about engaging in sun protection
in the next year.” Intentions among persons who
performed SSE in the past year were assessed us-
ing a single Likert-rated item, “How likely are you
to continue to perform skin self-examinations on
a regular basis in the next year?” (1 = not at
all likely,7 = extremely likely). Stage of adop-
tion was a combination of performance and in-
tention: Precontemplation = did not perform in
the past year, is not considering; Contemplation =
did not perform in the past year, is considering;
Relapse risk = performed in the past year, future
intention less than “somewhat likely,” and Action =
performed in the past year, future intention greater
than “somewhat likely.”
Sun Protection Practice
The sun protection habits scale (Glanz et al.,
2002) measured five protective habits (use sunscreen
with SPF 15, wear a hat, wear a shirt with sleeves,
stay in the shade, wear sunglasses). Participants were
asked to rate how consistently they engaged in each
habit when exposed to the sun for more than 15 min-
utes (α =.65).
Sun Protection Stage of Adoption
Questions were modeled after algorithms for as-
sessing stage of adoption for other cancer screening
behaviors (e.g., Manne et al., 2002; Rakowski et al.,
1996). Participants were asked how often they prac-
ticed sun protection in the past year (1 = never,
5 = always) and their intention to practice sun
protection in the next year (1 = not at all likely,
7 = extremely likely). Intentions among persons not
performing sun protection in the past year were as-
sessed using a single item (“I have never seriously
thought about engaging in sun protection,” “I am
seriously thinking about engaging in sun protection
in the next year”). Intentions among persons who
reported practicing sun protection in the past year
were assessed using a single Likert-rated item assess-
ing likelihood of practicing sun protection in the next
year (1 = not at all likely,7 = extremely likely).
Stage of adoption was a combination of past per-
formance and future intention: Precontemplation =
“never” or “infrequently” engaged, has not seriously
thought about engaging; Contemplation =
“never”
or “infrequently” engaged, seriously thinking about
engaging, Relapse risk = “often” or “always” en-
gaged, “not at all” to “somewhat likely” to practice
in the next year, and Action = “likely” to “extremely
likely” practiced in past year, “somewhat” to “ex-
tremely” likely to practice in the next year.
RESULTS
Descriptive Information
Descriptive information for non-psychological
variables is included in Table II, and descriptive in-
formation for the psychological variables is summa-
rized in Table III.
Engagement in Sun Protection and Skin
Surveillance Practices
SSE
Engagement in SSE is shown in Table IV. 15.7%
had never performed SSE in the past year. Twenty-
three and a half percent of survivors reported con-
ducting SSE more than once per month. In terms of
thoroughness of examination, among those report-
ing engaging in SSE, approximately 48.2% of partic-
ipants reported “often” to “always” having someone
else assist them or using a mirror during their most
recent SSE, 74% reported having someone else ex-
amine the upper and lower back, 33% reported hav-
ing someone else examine the scalp, 59% had some-
one else check the soles of the feet and between the
toes, and 77% had someone else check the back of
the legs. To provide strict definition of thorough SSE,
we used Weinstock’s definition (2004). Participants
who performed SSE were categorized as thorough
performers of SSE if they endorsed “sometimes” to
“always” having someone assist them or using a mir-
ror during SSE and endorsed checking all four spec-
ified areas of the body during their last SSE. Using
this criterion, 13.7% performed a thorough SSE the
last time they conducted SSE.
Sun Protection and SSE Among Melanoma Survivors 425
Table II. Non-Psychological Variables Included in the Analyses
Variable n6.0pt1,50.0pt % M SD Range
Demographic
Age 53.814.53 19–85
Gender
Men 98 42.8
Women 131 57.2
Educational level
High school or less 55 24.2
College or business degree 86 37.9
Some graduate school 46 20.1
Graduate degree 40 17.6
Ethnicity
Caucasian 227 99.1
Non-caucasian 2 0.9
Income $40–50,000 $10,000 $10–100,000
Medical status, health history and access
Breslow score 0.91 1.33 0–11
Age at diagnosis (yrs) 51.57 14.87 18–84
Stage at diagnosis
0208.8
1 149 65.4
24118.0
3156.6
431.3
Time since diagnosis (yrs) 2.34.13 1.5–2.2
Recurrence since original diagnosis (yes) 16 7.0
Number of melanoma objective risk factors
062.6
12812.2
29039.3
37532.8
42611.4
Number of FDRs with melanoma
0 187 81.7
13716.2
241.7
Has medical insurance (yes) 224 97
.8
Has primary medical doctor (yes) 215 94.7
Has regular dental care (yes) 207 90.8
Knowledge
Melanoma knowledge 17.47 1.97 10–22
Knowledge of SSE guideline (yes) 46 26.6
Physician recommendation (yes)
Has SSE recommendation 183 80.3
Physician shown how to do SSE 105 46.1
Physician shown what lesion looks like 160 70.2
Physician suggests sun avoidance 164 72.2
Physician suggests hat or long sleeves 159 70.0
Physician suggests sunscreen 185 81.5
Note. CMM: cutaneous malignant melanonma; FDRs: first degree relatives; SEE: skin self-examination.
Sun Protection Practices
Average engagement in sun protection is shown
in Table IV. The mean item rating on the habitual
sun protection practices scale corresponded to mid-
way between “sometimes” and “often” (M =3.57).
An examination of frequencies indicated that the fre-
quency of sun protection practices varied consider-
ably. A greater proportion of participants wore sun-
glasses and used sunscreen than wore a hat or a shirt
426 Manne and Lessin
Table III. Descriptive Information on Psychological Vari-
ables Included in the Model
Variable M SD Range
Perceived risk and distress
Perceived risk for recurrence 56.95 29.30 0–100
Risk compared with similar
family history
3.56 0.87 1–5
Risk compared with same age
person
4.32 0.77 1–5
Risk for photoaging 5.38 3.12 3–18
IES 16.86 15.67 0–63
Distress about melanoma 3.14 0.76 1–4
Severity .78 1.24 1–6
Benefits and Barriers
Sun protection benefits 37.13 7.38 12–48
Sun protection barriers 13.78 8.11 7–87
Glanz benefits of sun protection 26.44 2.87 16–30
Advantages of sunbathing 23.89 9.87 7–42
SSE benefits 32.71 3.97 8–36
SSE barriers 26.78 8.01 10–50
Sunscreen self-efficacy 23.26 7.97 8–40
Normative influences
Sun protection norms 25.03 6.90 7–42
Sun bathing norms 15.69 5.25 5–30
Note. IES: impact of events scale; SSE: skin self-examination.
with sleeves on a regular basis when in the sun for
more than 15 minutes. For example, 70.7% of par-
ticipants reported “often” or “always” wearing sun-
glasses when in the sun for more than 15 minutes
whereas 44.5% reported “often” or “always” wearing
a hat and 44.9% reported “often” or “always” wear-
ing a shirt with sleeves when in the sun for more than
15 min.
SSE and Sun Stage of Adoption
Stage frequencies are shown in Table IV.The
majority of participants were in the “action” stages
of SSE and sun protection. Because there were few
participants in the relapse risk stage of adoption for
sun protection, this subject (and this category) was
excluded from further analyses.
Correlates of SSE and Sun Protection
Overview
Education was combined into three cate-
gories, ethnicity was combined into two categories
(Caucasian/non-caucasian), and marital status was
combined into two categories (married/not mar-
Table IV. SSE and Sun Protection Habits and Stage of
Adoption
Variable n % M SD Range
SSE in past year
Never 36 15.7
Ever 193 84.3
Once 7 3.1
2–3 times 51 22.2
4–5 times 42 18.3
6 times (every
other month)
31.3
12 times (monthly) 35 15.3
>12 times 54 23.5
Sun protection habits
a
Use sunscreen 136 59.43.67 1.27 1–5
Wear hat 102 44.53.06 1.48 1–5
Wear shirt 103 44.93.21 1.30 1–5
Seek shade 122 53.23.46 1.20 1–5
Wear sunglasses 162 70.73.94 1.22 1–5
Average total habits
score
3.57 0.83 1–5
SSE stage of adoption
Precontemplation 17 7.4
Relapse risk 6 2.6
Contemplation 19 8.3
Action 187 81.7
Sun stage of adoption
Precontemplation 5 2.6
Relapse risk 1 0.5
Contemplation 55 28.5
Action 132 68.4
Note. SSE: skin self-examination.
a
Number of participants rating “often” to “always.”
ried). A dichotomous category was formed for SSE
(never/ever performed SSE in past year). A con-
tinuous variable for the mean item rating of sun
protection behavior engagement was used. As de-
scribed above, two “stage” variables were created,
one for SSE and one for sun protection. Sepa-
rate analyses were conducted for the four outcome
variables.
Independent variables were partitioned into
six separate classes of candidate correlates: 1) De-
mographics: age, gender, education, ethnicity, in-
come, marital status; 2) Medical status, health
history and access: Breslow score, stage at diagno-
sis, age at diagnosis, recurrence since first primary
(yes/no), current disease status, and time since diag-
nosis, insurance status, engagement in regular den-
tal care, access to primary physician, number of
first degree relatives with melanoma, number of ad-
ditional melanoma risk factors; 3) Knowledge; 4)
Physician recommendation; 5) Perceived melanoma
risk and cancer-related distress (for sun protection,
Sun Protection and SSE Among Melanoma Survivors 427
Table V. Logistic Regression Results for Separate Classes of Predictors for Skin Self-Examination
Compliance and Stage of Adoption
Variable β Wald χ
2
p OR
Dependent variable: SSE compliance
Demographic variables
Gender .75 4.10 .04 2.10
Physician recommendation
Physician shown how to do SSE .94 5.48 .02 2.50
Physician shown appearance of lesion .77 4.24 .04 2.20
Physician recommendation 1.04 6.84 .01 2.80
Psychological variables
SSE barriers −.10 14.52 .00 0.90
Dependent Variable: SSE stage of adoption
Demographics
Gender 10.59 .001 3.01
Physician recommendation
Physician shown how to do SSE 12.11 .001 3.69
Physician shown appearance of lesion 11.54 .001 3.13
Physician recommendation 5.63 .018 2.39
Psychological variables
SSE benefits 6.52 .01 0.91
SSE barriers 15.77 .000 1.10
Severity 5.07 .02 0
.74
Note. OR: odds ratio; SSE: skin self-examination.
susceptibility/risk for photoaging was added to the
model), 6) Additional psychological factors: For sun
protection habits, severity, sun protection benefits
and barriers, advantages of sunbathing, sun protec-
tion benefits, sun self-efficacy; for SSE, severity, SSE
benefits and barriers; normative influences (for sun
protection only).
The analyses for each outcome measure were
conducted in three stages. First, separate regressions
were used to identify variables from within each
class that were significantly associated with each out-
come. Second, significant variables within each cate-
gory were evaluated together to determine whether
they were significant predictors after taking into
account the contribution of other variables within
each class. Third, psychological factors were en-
tered into the equation after non-psychological fac-
tors. Variables selected from the non-psychological
classes were combined and entered into the regres-
sion equation in one step. Variables selected from
the psychological categories were entered in a sec-
ond step, with the non-psychological factors from
the first step forced to remain in the model. Back-
ward selection was used to choose the final set of
psychological variables to retain in the model. The
final model contained only psychological variables
that were significantly associated with outcomes
once adjustments were made for non-psychological
variables.
SSE
Separate logistic regression analyses were con-
ducted for each variable within each class of vari-
ables in the first step. Results of separate regres-
sion analyses, shown in Table V, indicated the
following variables were associated with SSE: 1) De-
mographic: gender; 2) Medical status, health history
and access: no variables; 3) Physician recommenda-
tion: physician recommends SSE, physician shown
how to perform SSE, physician shown what a suspi-
cious lesion looks like; 4) Knowledge: no variables;
5) Perceived risk and distress: no variables; 6) Addi-
tional psychological factors: SSE barriers. Results of
analyses entering all variables together within each
class when there was more than one variable in a class
indicated that physician recommendation did not re-
main significant. Results of the final logistic regres-
sion entering gender and SSE barriers (Table VI)
indicated that both gender and SSE barriers were
significantly associated with SSE. Participants who
performed SSE were likely to be of female gender
(60.1%).
Sun Protection Habits
Results are shown in Table VII. Results of
separate regression analyses indicated the following
428 Manne and Lessin
Table VI. Summaries of Hierarchical Logistic Regression
Analysis: Association of Psychological Factors with SSE and
SSE Stage After Accounting for Non-Psychological Factors
Variable β
Wald
χ
2
p OR
Dependent variable: SSE
Non-psychological
variables
Gender .69 3.08 .08 1.99
Psychological variables
SSE barriers −.10 13.12 .00 0.91
Dependent variable: SSE Stage of
Adoption
Non-psychological variables
Gender 8.35 .004 2.8
Physician shown how to
do SSE
8.68 .003 0.30
Psychological variables
SSE barriers 7.35 .007 1.07
Note. OR: odds ratio; SSE: skin self-examination.
variables were associated with sun protection habits:
1) Demographic: age; 2) Medical status, health his-
tory, and access: dental care, time since diagnosis,
recurrence; 3) Physician recommendation: recom-
mended wearing shirt, hat, or long sleeves when in
the sun; 4) Knowledge: no variables; 5) Perceived risk
and distress: risk and Impact of Events scale score; 6)
Additional psychological factors: Sun protection bar-
riers, advantages of sunbathing, benefits of sun pro-
tection and self-efficacy; sun protection norms. Re-
sults of analyses entering all variables together within
each class (when more than one variable within a
class was associated with the outcome) indicated the
following variables were associated with sun protec-
tion: 1) Demographic: age; 2) Medical status, health
history and access: dental care, time since diagno-
sis; 3) Physician recommendation: physician recom-
mends wearing shirt, hat or long sleeves when in the
sun; 4) Knowledge: no variables; 5) Perceived risk
and distress: risk and Impact of Events scale score;
6) Additional psychological variables: advantages of
sunbathing; sun protection norms. Results of the fi-
nal regression entering age, dental care, time since
diagnosis, physician recommending wearing shirt, hat
or long sleeves when in the sun in the first step, and
the psychological variables of perceived risk, Impact
of Events scale score, advantages of sunbathing, and
sun protection norms, are shown in the top panel of
Table VIII. Less likelihood of regular dental care,
greater likelihood of physician recommendation to
wear sun protective clothing, fewer perceived advan-
tages of sunbathing, and higher sun protection norms
were significantly associated with higher sun protec-
tion habits.
SSE Stage
Ordinal logistic regression (logistic regression
with a cumulative logit link function) was used to
evaluate the association of each predictor variable
with each ordinal outcome measure. Results are
shown in the bottom panel of Table V. Results in-
dicated the following variables were associated with
stage of adoption of SSE: 1) Demographic: gender;
2) Medical status, health history and access: no vari-
ables; 3) Knowledge: no variables; 4) Physician rec-
ommendation: physician recommends SSE, shown
how to perform SSE, shown what a suspicious le-
sion looks like; 5) Risk and distress: none; 6) Ad-
ditional psychological variables: SSE benefits, SSE
barriers, and severity. Results of analyses after in-
cluding all variables found to be significant within a
single class together indicated the following were as-
sociated with adoption of SSE within the two classes
in which more than one factor was significant: 1)
Demographic: gender; 2) Medical status, health his-
tory and access: none; 3) Knowledge: none; 4) Physi-
cian recommendation: physician shown how to per-
form SSE; 5) Risk and distress: none; 6) Additional
psychological variables: SSE barriers. The factors
identified by stepwise selection within each of the
non-psychological blocks were entered into the
model to predict each outcome. These factors were
then forced to remain in the model while stepwise
selection was used to identify psychological factors
that were significant predictors of outcome after ad-
justment for the non-psychological factors included
in the model. Results are shown in the bottom panel
of Table VI. Results indicated that gender, whether
the physician had shown the participant how to per-
form SSE, and SSE barriers were significantly associ-
ated with SSE stage. Thus, a psychological factor was
a significant predictor of SSE stage. Participants who
were in the action stage were more likely to be of fe-
male gender and to perceive fewer barriers. Partici-
pants in the precontemplation and relapse risk stages
were more likely to be male.
Sun Protection Habits Stage
Ordinal logistic regression (logistic regression
with a cumulative logit link function) was used to
Sun Protection and SSE Among Melanoma Survivors 429
Table VII. Regression Results for Separate Classes of Predictors for Sun Protection Habits and Sun
Protection Stage of Adoption
Variable β F Wald χ
2
p OR
Dependent variable: Sun protection habits
Demographics
Age .21 10.08
∗∗
.002
Medical Status/health history and access
Dental care .10 4.93
∗
.03
Time since diagnosis .19 8.48
∗∗
.004
Recurrences .45 4.41
∗
.037
Knowledge
Melanoma knowledge .19 8.08
∗∗
.005
Physician recommendation
Recommend wear hat/shirt .16 5.59
∗
.019
Teachable Moment constructs
Perceived risk .17 6.5
∗
.01
IES −.16 5.49
∗
.02
Additional psychological factors
Sun protection barriers −.16 5.9∗ .02
Advantages of sunbathing .26 15.57
∗∗∗
.000
Benefits of sun protection .20 9.27
∗∗∗
.003
Sunscreen self-efficacy .19 8.20
∗∗
.005
Norms for sun protection −.25 14.88
∗∗∗
.000
Sunbathing norms .20 9.21
∗∗
.003
Dependent variable: Sun protection habits stage of adoption
Demographics
Gender 13.96 .000 2.92
Medical status/health history and access
Dental care 12.43 .000 0.21
Knowledge
Melanoma knowledge 10.92 .001 0.78
Psychological factors
Sun protection barriers 12.47 .000 1.07
Benefits of sun protection 7.49 .006 0.88
Sunscreen self-efficacy 30.54 .000 0.89
Melanoma severity 8.99 .003 0.70
Note. OR: odds ratio; SSE: skin self-examination.
∗
p < .05;
∗∗
p < .01;
∗∗∗
p < .001.
evaluate the association of each predictor variable
with sun habits stage of adoption. Results, shown
in the bottom panel of Table VII, indicated the fol-
lowing variables were associated with sun protection
habits stage of adoption: 1) Demographic: gender; 2)
Medical status, health history and access: dental care;
3) Knowledge: melanoma knowledge; 4) Physician
recommendation: no variables; 5) Risk and distress:
none; 6) Other psychological variables: sun protec-
tion barriers, benefits of sun protection, severity, and
sun protection self-efficacy. Results of analyses after
including all variables found to be significant within
the psychological variables category together indi-
cated that sun protection self-efficacy was associated
with sun habits stage of adoption. The factors iden-
tified by stepwise selection within each of the non-
psychological blocks were entered into the model
to predict each outcome. These factors were then
forced to remain in the model while stepwise selec-
tion was used to identify psychological factors that
were significant predictors of outcome after adjust-
ment for non-psychological factors. Results (bottom
panel, Table VIII) indicated that gender, dental care,
knowledge and sunscreen self-efficacy were signifi-
cantly associated with sun protection stage. Post-hoc
comparisons indicated that participants who were in
the action stage of adoption were more likely to be of
female gender (59%). A greater proportion of partic-
ipants in the action stage had seen a dentist in the
past year (94%) versus participants in the precon-
templation stage (50%). Participants in the action
stage had higher melanoma knowledge and higher
self-efficacy than participants in the precontempla-
tion stage of sun protection habits adoption.
430 Manne and Lessin
Table VIIII. Summaries of Hierarchical Regression Analysis:
Association of Psychological Factors with Sun Protection Habits
and Sun Stage after Accounting for Non-Psychological Factors
Variable β R
2
F
Wald
χ
2
p OR
Dependent variable: Sun protection habits
Non-psychological
variables
.05 4.11
∗
.01
Age .02
Time since
diagnosis
.05
Dental care (yes) −.14
∗
Physician
recommends
hat/shirt
.15
∗
Psychological
variables
.16 5.61
∗∗∗
.000
Perceived risk 12
IES −.03
Advantages of
sunbathing
.18
∗
Sun protection
norms
−.23
∗
Dependent variable: Sun protection habits
stage of adoption
Non-psychological
variables
Gender 4.93 .03 2.02
Dental care (yes) 5.93 .01 0.32
Melanoma
knowledge
8.38 .00 0.79
Psychological
variables
Sunscreen
self-efficacy
18.64 .00 0.91
Note. OR: odds ratio; IES: impact of events scale.
∗
p < .05;
∗∗
p <
.01;
∗∗∗
p < .001.
Correspondence Between SSE and Sun Protection
Analyses indicated that participants who per-
formed one or more SSE in the past year did
not engage in significantly more sun protection
(t(226) =1.6. p > .05).
DISCUSSION
Cutaneous oncologists agree that it is impor-
tant for melanoma survivors to engage in regular
SSE and sun protection. However, the level of en-
gagement in these behaviors among survivors has
received relatively little attention. Our results indi-
cate that engagement in SSE in the prior year was
high. Our findings were similar to those reported
by Robinson and colleagues (1998) and suggest that
vast majority of melanoma survivors perform SSE.
About forty percent of participants performed SSE
at least monthly. However, there are two issues that
should be noted. First, among those survivors con-
ducting SSE, only 13.7% performed thorough skin
self-examination. These findings are similar to results
reported by Weinstock and colleagues (2004) among
patients seen in a primary care practice and sug-
gest that, although many skin cancer survivors con-
duct regular SSE, the thoroughness of these exami-
nations may not be adequate in many cases. Second,
almost 24% of survivors performed SSE more fre-
quently than once a month. This level of SSE may
be problematic, because it may be harder for the pa-
tient to spot changes in moles. Post-hoc comparisons
of survivors conducting SSE more at more frequent
intervals than monthly did not suggest that cancer-
related distress was associated with screening. Future
research should evaluate why patients engage in such
frequent SSE, and health care professionals should
educate survivors regarding appropriate intervals for
SSE and the rationale for engaging in monthly ex-
ams.
It was surprising that engagement in sun protec-
tion was not higher, particularly given the fact that
physician advice about sun avoidance and protection
was so widely provided. Because other investigators
have not used the same sun protection scale as em-
ployed in the present study, comparisons with other
results cannot be made. We can compare our results
with a recent study we conducted of family mem-
bers of melanoma which used the same scale (Manne
et al., 2004). Average ratings across most sun pro-
tection habits were consistently about a half a point
higher than our study of family members. Thus, sun
protection habits appeared to be adopted more reg-
ularly among survivors than their family members.
While physician education about SSE was provided
to the majority of patients, it is somewhat surprising
that only half of the sample reported they had been
shown how to perform SSE. It is interesting to note
that there was variability among the five sun protec-
tion practices. Health care professionals counseling
survivors about sun protection should be aware that
survivors are less likely to wear shirts with sleeves
and hats and more likely to wear sunglasses and sun-
screen, and may wish to focus more on education
regarding appropriate sun protection attire. The in-
ternal consistency of the sun protection habits in-
dex was relatively low, indicating that sun protection
may not be a univariate construct among melanoma
Sun Protection and SSE Among Melanoma Survivors 431
survivors. A composite index may not be as use-
ful an indicator of sun protection behavior among
melanoma survivors.
It is surprising that the teachable moment con-
structs we hypothesized would be associated with
SSE and sun protection, perceived risk and distress,
were not associated with SSE and were only asso-
ciated with sun protection habits in univariate anal-
yses. The findings regarding perceived risk are par-
ticularly surprising because prior studies have found
that perceived risk is associated with SSE among per-
sons at risk due to a personal or family history of
skin cancer (Robinson et al., 1998, 2002) and sun
protection among family members of persons with
melanoma (Azzarello et al., 2006) and among aver-
age risk individuals (Borland et al., 1990; Cody and
Lee, 1990) One possible explanation for these find-
ings is that perceived risk for recurrence was rela-
tively high in this population and thus there was lit-
tle variability in perceptions of risk. The majority of
the sample (88%) rated their risk for melanoma re-
currence as higher than the average person of the
same age, and approximately half of the sample rated
their risk for melanoma recurrence as higher than
a person with a similar family history of melanoma.
Thus, it is possible that a “ceiling effect” in this sam-
ple explained the lack of association between risk
and screening practices among survivors. A second
explanation is our risk measure, which did not con-
tain perceptions of risk for a new primary melanoma.
A similar explanation may explain the lack of find-
ings for cancer-related distress. Although the aver-
age score on the Impact of Events scale was not
extremely high and there was a wide variability in the
Impact of Events scale scores, scores on the measure
assessing current distress about cancer were high.
The majority of the sample (87%) rated themselves
as presently “quite” or “extremely” distressed about
their diagnosis. Because the association between can-
cer screening and distress has been inconsistent in
the literature (Schwartz et al., 1994; van Dooren
et al., 2003) it will be important to use prospective
methodologies to evaluate the association between
distress and SSE and sun protection. Overall, the
findings supporting both risk and distress in screening
practices among melanoma survivors are not strong.
These findings suggest that assumed mechanisms un-
derlying the “teachable moment” may not motivate
screening practices among melanoma survivors and
suggest that future studies assessing cancer screening
among melanoma survivors should not focus solely
on these two factors.
Our findings provide only partial support for
Health Behavior Model constructs as correlates of
SSE. Only one construct from the Health Behavior
Model, perceived barriers to performing SSE, was as-
sociated with SSE. Our findings point to a limited
role for commonly-studied psychological factors in
SSE among survivors and a stronger role for physi-
cian education about how to perform SSE. Physicians
should be aware that their patients may need to be
shown how to correctly perform SSE. Females were
mores likely to perform SSE. A similar gender differ-
ence with regard to SSE was noted in previous work
(Berwick et al. 1996; Oliveria et al., 1999; Robinson
et al., 2002).
Psychological constructs played a slightly
stronger role in sun protection. Fewer perceived
advantages of sunbathing, greater self-efficacy and
higher sun protection norms were significantly
associated with higher sun protection habits or sun
protection stage of adoption. Our findings regarding
sunscreen self-efficacy are consistent with Jackson
and Aiken (2000) and also consistent with other
work with family members of melanoma patients
(Azzarello et al., 2006; Manne et al.
, 2004). The
findings regarding the role of sun protection norms
extend studies focusing on average risk and college
age persons (Arthey and Clarke, 1995; Banks et al.,
1992; Jackson and Aiken, 2000) and family members
of patients who are at increased familial risk for skin
cancer (Manne et al., 2004). Sun protection among
melanoma survivors appears to be associated with
the opinions and sun protection practices of friends.
The non-psychological factors associated with sun
protection were largely consistent with prior work.
Previous studies have also shown that males are
less likely to use sunscreen (Keesling and Friedman,
1987) and more likely to wear a hat (Hill et al., 1991)
while women are more likely to wear a shirt or use
other upper body protection (Hill et al., 1991).
Before closing, there are a number of study lim-
itations that should be mentioned. Most importantly,
self-report measures of SSE and sun protection may
not be valid or reliable. Self-reports of SSE may be
subject to social desirability (Weinstock et al., 2004).
Survivors may be more likely to feel social pres-
sure to report SSE than the general population, and
social desirability factor may have resulted in a pos-
itive reporting bias to our prevalence figures. Un-
fortunately, there is no objective measure of home
performance SSE. The validity of self-reported sun
protection behavior is a similar concern. A sec-
ond measurement issue regards our measures of sun
432 Manne and Lessin
protection and SSE stage of adoption. Another mea-
sure of sun stage of adoption has been employed
by other investigators (Rossi et al., 1995) which al-
lows categorization into preparation and mainte-
nance stages of adoption. We may have had more
variability in sun stage of adoption if we had used this
measure. In addition, we asked participants about
sun protection in general, rather than asking about
stage of adoption for each sun protection habit in-
dividually. As was noted previously, there was vari-
ability in engagement of sun protection habits (e.g.,
hats were worn less frequently than sunglasses) and
separate measures of stage of adoption for each sun
habit may have yielded more variability in sun pro-
tection stage of adoption. The SSE stage of adoption
measure did not take into account either SSE thor-
oughness or overly frequent SSE. Thus, this measure
was not an extremely sensitive SSE measure for the
survivor population. Third, the study used a cross-
sectional methodology. Causality cannot be inferred
from this type of design. Fourth, our sample was com-
prised of patients in a comprehensive cancer center
who were being seen for a follow-up appointment.
The vast majority of participants were insured and all
received a total cutaneous exam from the oncologist
at the cancer center. Thus, our sample was likely bi-
ased towards patients with access to medical care and
patients who comply with post-treatment care. The
recruitment source may have biased the rates of SSE
by accounting for the large proportion of participants
who engaged in regular SSE in the past year. Fifth,
our sample may be biased as refusers were more
likely to be male. Because males were less likely to
perform SSE, our rates of SSE may have been higher
in the present sample than in the general population
of melanoma survivors. Finally, we did not include a
measure of sun exposure or sunbathing.
In terms of theoretical implications, the results
of the present study suggest that psychological con-
structs taken from key health belief models do not
play as strong a role in understanding screening prac-
tices among melanoma survivors as these constructs
have played in understanding behavior of the general
population. Future work should entertain novel con-
ceptualizations of screening in this population. Our
findings have implications in terms of interventions
to improve acceptance of screening and improve
sun protection practices among melanoma survivors.
First, male melanoma survivors were less likely to en-
gage in SSE and sun protection and thus interven-
tions targeted to male survivors may prove beneficial.
Second, reducing reliance on the beliefs of friends
and the general population regarding sun protection,
reducing perceived barriers to sun protection, and
bolstering confidence in sunscreen use may improve
sun protection. Finally, it is important that derma-
tologists and other health care professionals provid-
ing care to melanoma survivors educate survivors
about correct SSE performance and the importance
of wearing protective clothing when out in the sun,
discuss the disadvantages of sunbathing, and counsel
patients to be role models for family and friends re-
garding sun protection.
ACKNOWLEDGMENTS
We thank Maryann Krayger for her superb tech-
nical assistance in preparing this article and James
Babb and Eric Ross for statistical consultation. We
thank Briana Floyd, Julie Hess, Nicole Fasanella,
and Summer Sherburne-Hawkins for data collec-
tion and the patients who participated in this study
for their time. This work was supported by grant
K24 #AR02102 to Dr. Lessin, by funding from the
Greater Harrisburg Foundation, and by grant CA
107312 from the National Cancer Institute.
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