Sun exposure among teenage and young adult cancer survivors in the United Kingdom

Skin cancers are a common form of second malignant neoplasm among teenage and young adult cancer survivors (TYACS). The Children's Oncology Group specifies that TYACS should adhere to safe sun practices and be screened for skin cancer annually. Cross‐sectional self‐report data collected by our group indicate over a third of TYACS (n = 229; mean age: 19.8 years) intentionally sunbathe, with many reporting sunburn. TYACS sunbathing, sunburn, and sunbed use are similar to the general population (P > 0.05). These data suggest TYACS require intervention to limit sun exposure and improve their sun safety habits.


INTRODUCTION
In the United Kingdom, the cancer survival rate among teenagers and young adults (TYA) exceeds 80%. 1 However, TYA cancer survivors (TYACS) are at risk of developing second primary skin cancer. [2][3][4] Immunosuppression and treatment with high-dose radiotherapy have been identified as specific risk factors for developing a later skin cancer. [4][5][6] Data from the Childhood Cancer Survivor Study indicate among those diagnosed with second primary nonmelanoma skin cancer 46% had multiple occurrences and 38% reported returning to hospital more than twice to have the carcinoma treated or surgically removed. 7 Due to the high incidence and burden of secondary skin cancer among TYACS, the Children's Oncology Group (COG) specifies that TYACS should adhere to safe sun practices (i.e., wearing sunscreen and protective clothing), avoid UV exposure (sunbathing, tanning and sunbed use), and be screened for skin cancer annually. 8,9 These guidelines are based on evidence that skin damage induced from excessive sun exposure is linked to the development of skin cancer and that early diagnosis of skin cancer can lead to smaller tumors, potentially less Abbreviations: COG, Children's Oncology Group; GP-TYAs, general population controls; TYA, teenagers and young adults; TYACS, teenage and young adult cancer survivors intensive treatment, and better outcomes. 10 However, data on TYACS' sun exposure in the United Kingdom are nonexistent. Therefore, the aim of this study was to explore the incidence of, and factors associated with, sunbathing, sunburn, and indoor tanning among TYACS and general population controls (GP-TYAs) in the United Kingdom. This information is crucial for developing interventions aimed at improving sun protection and skin screening among TYACS.

METHODS
TYACS and GP-TYAs, aged between 13 and 24 years, were invited to complete a health and lifestyle questionnaire that contained three survey items assessing the incidence of sunbathing and sunburn last summer and the use of indoor sunbeds over the past year. TYACS both on (i.e., receiving active cancer treatment) and off treatment were eligible to participate and were recruited online via CLIC Sargent or through outpatient clinics at University College London Hospital. GP-TYAs were recruited in two waves through online channels, schools, and UCL participation networks. These items were taken from a sun health behavior instrument previously used to assess sunrelated behaviors in Scottish adolescents. 11  Abbreviations: TYA, teenager and young adult; GP-TYAs, general population TYAs; OFT-TYAs, off-treatment TYAs, OT-TYAs on treatment TYAs. Odds ratios adjusted for age and gender; all regressions P < 0.005. a Not meeting current COG guidelines on sun exposure was classified as reporting one or more of sunbathing, sunburn, or indoor sunbed use. Sunbathing refers to sunbathing regularly last summer to get a tan (i.e., intentionally staying out in the sun with the desire for skin to go browner or more golden in color), sunburn refers to skin going red or pink due to being in the sun.
Descriptive statistics were produced to determine the proportion of TYACS and GP-TYAs in each group reporting intentional tanning, sunburn, or sunbed use and the proportion meeting current COG sun-safety lifestyle guidelines on UV exposure. Statistical comparisons between each group were made using chi-square tests and logistic regression analysis for categorical variables and ANOVAs for continuous variables. Multivariable models were adjusted for age and gender. Only data from wave 1 of GP-TYA recruitment were available for analysis.  Table 1. 41.6%, n = 62 off treatment) and 47.6% (n = 148) of GP-TYAs. Very few young people within any group used sunbeds (6.6%, 6%, and 8.4%, respectively). As shown in Table 2, less than a third of participants were meeting COG sun safety guidelines on UV exposure. After adjusting for age and gender, there were no significant differences (P > 0.05) in the behaviors of young people on cancer treatment, off cancer treatment, and in the general population.

DISCUSSION
This study demonstrates TYACS in the United Kingdom have a similar sun-exposure behaviors to GP-TYAs in that they often sunbathe and burn in the sun. Encouragingly (given that it is illegal for under 18s to use indoor tanning booths in the United Kingdom) very few young reported using indoor sunbeds.
These findings reflect studies of childhood cancer survivors in the United States, which indicate high levels of sun exposure is common. 13,14 For example, data from project REACH indicate 60% of TYACS (n = 153, mean age: 26 years, time since diagnosis: 14 years) report more than 8 hours of sun exposure per week with very little or no use of protection. 14 Deliberate tanning and sunburn among TYACS and GP-TYAs is concerning given existing data that indicate that neither group are particularly adherent to sun protection. 14,15 There are data that indicate that young people counteract skin protection behaviors by purposely sunbathing and that TYACS treated with radiotherapy (despite acknowledging their increased risk of skin cancer) do not perceive UV exposure as a risk factor for skin cancer. 13 These data signify psychoeducational interventions that highlight TYACS increased risk of skin cancer, and the importance of sun-protection habits is warranted. A randomized controlled trial group-based educational day intervention that included risk counseling demonstrated a positive effect on sun safe practices among 75 adolescent survivors of childhood cancer. 16