INTRODUCTION

Skin cancer is the most common form of diagnosed cancer in the United States, and the incidence of skin cancer has risen dramatically worldwide in the last decade, which makes skin cancer prevention a public health concern worldwide (Glanz, Schoenfeld, & Steffen, 2010; Guy & Ekkwueme, 2011). Individuals with an increased chance of developing skin cancer have the following risk factors: outdoor occupations, participating in regular sunbathing by natural or artificial sunlight, light or fair skin, and those who are uninformed about the importance of preventative measures. Knowledge about skin cancer and methods to prevent the disease have increased among the general public; however, "despite such awareness, American adolescence and young adults have the lowest skin protection rates of all age groups" (Heckman et al., 2011). Glanz et al. found in their study project SCAPE that tailored communication (tailored materials and personal feedback risks) showed significant improvements in individuals' skin cancer preventative behavior change. Studies like this lend proof to the fact that continued research needs to be done to unveil the most effective methods to use for specific populations, especially for young adults.

In today's society, advancing medical knowledge, diagnostic testing, and noninvasive treatments have taken precedence over primary prevention of skin cancer. By educating and providing techniques to young adults regarding primary prevention and early detection, skin cancer can be better controlled and cases can be reduced (Kasparian, McLoone, & Meiser, 2009). In this systemic review of the literature, we hope to identify the most effective methods of prevention that young adults (aged 18-30 years) can practice.

METHODS

Scholarly Databases, Search Terms, and Criteria

Using the predetermined search terms skin cancer, melanoma, young adults, prevention, incidence, behaviors, and barriers, a systematic search was conducted on the following search engines: MEDLINE, PubMed, OhioLINK, University of Cincinnati Search Summons, and CINAHL. Initial search results for articles relating to prevention and behaviors related to skin cancer in young adults (aged 18-30 years) yielded 13,788 articles. After applying initial limitations, the search results produced 118 articles. Final limitations and study reviews produced 20 articles used for this systematic review of literature. These limitations include articles written in English, date range no earlier than 2008, full-text articles, randomized controlled studies, and academic articles. Inclusion criteria consisted of young adult (aged 18-30 years), sun exposure, ultraviolet (UV) tanning bed use, use of sun protection, melanoma and nonmelanoma skin cancers, prevention and counseling, education, and use of skin cancer screenings. Exclusion criteria consisted of studies with most populations outside of the age range (younger than 18 years and older than 30 years), participants already diagnosed with skin cancer, practitioner-focused pieces, and articles published in nonscholarly journals.

Levels of Evidence

While researching articles to determine the best practice based on evidence, a practitioner must understand that not all articles or suggestions are equivalent when deciding which techniques to bring into practice. A critical analysis is necessary to determine which evidence is most beneficial to the healthcare system. The 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence II is a grading schema that allows the clinician to quickly establish pertinent findings and "to appraise evidence for prevalence, accuracy of diagnostic tests, prognosis, therapeutic effects, rare harms, common harms and usefulness of (early) screening" (OCEBM, 2011, p. 1). On the basis of a scale rating of Level 1 (likely strongest evidence) to Level 5 (likely weaker evidence), the clinician can quickly determine best evidence for practice when reading a research article. The OCEBM Level of Evidence II does not intend for the grading scale to be an absolute gold standard for care, recognizing that judgment, individual patient situation, and clinical experience must coalesce with the grade to evaluate the pertinent findings. This technique can be used to determine the best evidence-based practice to increase the likelihood of skin protection and to reduce multiple risk factors of skin cancer.

Strengths and Limitations

Skin cancer poses a potential threat to all people. Research and interventions need to focus on specific preventative methods that are effective for young adults (aged 18-30 years). Because of the fact that this age group is the least compliant in practicing preventative measures, one can generalize effectual sun-protective approaches and techniques to the entire population (Kasparian et al., 2009). Once practitioners are armed with the facts and data of which preventative methods are most effective, this evidence-based information can be used to provide more successful anticipatory guidance. By creating a more educated population, proper education should have a direct effect on reducing the over two million new cases of skin cancer diagnosed per year in the United States (Lin, Eder, & Weinmann, 2011).

The target population represents one limitation to current research. The systematic review is assuming that what will work for one age group is transferable to the entire population. In addition, once research and information regarding effective preventative methods are established, practitioners cannot force people to practice those methods or to comply with recommendations. Another limitation in most of the studies is that the survey instruments or devices used in measuring skin cancer protection methods are not universal, making it difficult to interpret the studies' results.

RESULTS

Primary Care Counseling

Interventions and strategies of skin cancer prevention, including clinical and self-examination of the entire body, continue to be an effective way to control the incidences of melanoma mortality by detecting curable melanoma lesions. Cancer detection techniques should be discussed during appointments in a primary care setting; however, limited controlled studies have been conducted to prove this as a key factor for evidence-based practice (Kasparian et al., 2009). By presenting the patient with educational material with instructions on conducting a self head-to-toe examination to recognize suspicious skin lesions, practitioners are holding the patient accountable for his or her own skin safety. Patients must also be reminded to protect themselves from sunburns. Some studies indicate that sunburn in adolescence can predispose a person to skin cancer later in life; however, the actual percentage of prevention is controversial among researchers. Therefore, it is important to instill healthy sun-protective behaviors and attitudes in children and young adults so that such practices as wearing sunscreen, avoiding tanning beds, and realizing that one does not have to be tan to be attractive resonates as habits in adulthood.

Behavioral counseling regarding sun-protective activities in the pediatric primary care setting has produced a moderately significant statistical improvement in skin care safety in adolescence and young adults (Lin et al., 2011). It is important for practitioners to advocate for the use of sunscreen and other interventions that can reduce sunburn and exposure to UV rays. Adolescents respond and relate to computer-based programs that introduce the importance of decreasing sun exposure midday, wearing sunscreen, and donning other protective gear. Young women are more concerned with the perceived increased attractiveness that a suntan can psychologically create, suggesting that the primary motivation for tanning is enhancement of physical appearance (Kasparian et al., 2009). Appearance-focused counseling needs to be available to this demographic (Lin et al., 2011). Also, more randomized control trials should be conducted to determine the most effective way to present the benefits of refraining from indoor tanning and sun exposure for young adults, especially women. An inadequate number of healthy ideals exist to relinquish the suggestion that a suntanned body enhances physical appearance. Healthier and improved opinions that reverse the effects of self-consciousness from peer judgment and snub idyllic "norms" of body image would enhance the potential for permanent, long-term behavioral changes in young women (Hillhouse, Turrisi, Stapleton, & Robinson, 2008).

Social comparison with peers' opinions can determine related risks and behaviors a young person is willing to engage, or not engage in, independent of his or her own beliefs about self. Minimal trials studying the use of educational material or counseling to create optimum sun-protecting behaviors have been conducted; however, Hoffner and Ye (2009) found that presenting information about sunscreen and skin cancer, either with positive framing or negative framing, improves the intention of sunscreen use in the future when compared with the control group who was given information about nutrition. Positive framing introduces constructive lifestyle changes and outcomes, including the idea that wearing sunscreen aids in maintaining young, healthy-looking skin. Oppositely, negative framing that motivates modifications with negative dangers, such as the problems of not choosing a protective lifestyle, may cause skin cancer and prematurely aged skin.

More research needs to be conducted to determine if behavioral counseling and introduction of healthy skin material by a primary care provider increases the rate of early prevention and detection of skin cancer. A systematic review of the material revealed that most of the general population does not engage in adequate sun-protective behavior, and there is limited research of best evidence-based practice that determines why or what interventions will significantly decrease sun exposure and risk of skin cancer (Kasparian et al., 2009; Lin et al., 2011). Future research needs to be conducted to determine why people engage in unsafe skin lifestyles so that early prevention interventions and educational programs can become commonplace in the primary care setting.

Sun Protection

To prevent the harmful effects of UV exposure, individuals must protect themselves. Using sunscreen with at least 30 sun-protection factor (SPF), remaining in the shade, and wearing protective clothing (hats and long sleeves) are effective preventative methods to help limit direct UV exposure (Burnett & Wang, 2011; Linos et al., 2011; Teramura, Mizuno, Naito, Arkane, & Miyachi, 2012).

Sunscreens have been shown to provide excellent prevention against squamous cell carcinomas and their precursors, actinic keratosis (Burnett & Wang, 2011). In more recent years, an SPF of 30 specifically has been also shown to significantly reduce the rate of developing risks factors for melanoma, known as melanocytic nevi, in children (Burnett & Wang, 2011; Green, Williams, Logan, & Strutton, 2010). Sunscreens, however, can give individuals a false sense of security. Studies have shown that higher SPF sunscreens are associated with longer sun exposure when compared with the lower SPF sunscreens (Teramura et al., 2012). Several trials have also shown that sunscreens are rarely applied correctly because individuals are not likely to apply sunscreen in the correct dosages or frequently enough for full UV protection (Buller et al., 2011; Linos et al., 2011; Teramura et al., 2012). One study found that, to achieve laboratory dosing, individuals should apply double the recommended amount of sunscreen directed to get the desired thickness needed to achieve the UV protection as indicated by the SPF percentage (Teramura et al., 2012). Because of improper application, the use of sunscreen as the sole protection against skin damage is not associated with decreased reports of sunburns (Linos et al., 2011). Fewer reported sunburns have been found to be associated with combinations of wearing hats, being covered in longer length clothing, and seeking shade (Linos et al., 2011). Avoiding the sun during peak hours of 10 A.M. to 3 P.M. will also help cut back the UV exposure. Comprehensive skin coverage is what is needed to achieve optimum UV protection.

Avoidance of Tanning Beds

Despite the fact that the International Agency for Research on Cancer labeled tanning beds as "carcinogenic to humans," young adults still continue to expose themselves to the deadly light (Zhang et al., 2012). In response to this label, the tanning bed industry has launched a campaign to downplay the health risks associated with use by focusing on the healthy benefits the UV light produces, such as skin cells producing vitamin D. However, researchers' evidence proves time and again that the health risks outweigh any potential benefits from any exposure. Zhang et al. revealed that there is a significant relationship between the use of tanning beds and the increased risk of developing all three types of skin cancer; it was also the first study to unveil a dose-response effect. The strongest evidence reports a 75% greater risk of melanoma in those who start using tanning beds at an earlier age, during adolescence or young adulthood. (Boniol, Autier, Boyle, & Gandini, 2012). Wehner et al. (2012) found that tanning bed exposure was associated with a 67% increased risk of squamous cell cancer and a 29% higher risk of basal cell cancer. The significant increase in skin cancer risk when exposed to tanning beds at an early age makes educating young adults about the ill effects crucial.

Research has revealed that primary providers are seen as the most reliable source for information, and they have the greatest opportunity to counsel patients about changing tanning bed behaviors (Robinson, Kim, Rosenbaum, & Ortiz, 2008). Unfortunately, time constraints and insurance company reimbursements interfere with the ability of providers to spend enough time counseling patients, and most providers are reduced to distributing generalized pamphlets or videos in an effort to educate. The best chance for primary care providers to deliver information that will be utilized by young adult patients is by using personalized, tailored communications with adapted behavior modifications and appearance-focused interventions to reveal underlying UV damage to skin such as photoaging, appearance information, and UV photolight (Dodd & Forshaw, 2010; Glanz et al., 2010). Two other groups that can prove useful in the fight to restrict tanning bed use are lawmakers and nonmedical professionals. Lawmakers can use their power to place restrictions on the tanning bed industry. California was the first state to enact a law on October 9, 2011, and other countries around the world began initiatives that will ban anyone under the age of 18 years from using a tanning bed (Zhang et al., 2012). Although this is a step in the right direction, further restrictions need to be placed on light wattage, exposure time, or eliminating home tanning bed sales altogether in an effort to change the ease of accessibility. Another group that can work in conjunction with healthcare professionals is nonmedical professionals, such as estheticians and cosmetologists. When properly educated to recognize skin cancer, nonmedical professionals who work with areas of the body that are highly susceptible to skin cancer have the opportunity to identify suspicious areas earlier. These technicians have more contact with the general population and are able to spend more time discussing the potential dangers of tanning bed use (Ng, Chang, Cockburn, & Peng, 2012).

CONCLUSION

Skin cancer is the single most common cancer in adults (aged 25-29 years) and second most common in young adults (aged 15-29 years) in the United States (Baghianimoghadam, Mohammadi, Noorbala, & Mzloomy-Mahmoodabad, 2011; Diao & Lee, 2013). Because of the increasing rate of incidence, skin cancer prevention has become an even more important public health concern (Glanz et al., 2010; Guy & Ekwueme, 2011). Undeniably, exposure to UV radiation can cause skin cancer. There have been numerous studies conducted looking at the effects of counseling, sunscreen use, and avoidance of indoor recreational tanning. All of these methods help in reducing the exposure to UV radiation, and proper practice of these techniques can ultimately prevent the likelihood that an individual will develop skin cancer.

Persistent anticipatory guidance is needed for the target population of individuals between the ages of 18 and 30 years. The education needs to include risk factor information regarding peak hours to avoid direct sunlight, the amount of sunscreen needed to protect sun-exposed areas, and the harm intentional UV exposure poses. Everyone is subjected to UV radiation throughout the day; therefore, constant reminders how to minimize its harmful effects are necessary at every patient encounter. All too often, it is assumed that people know more than they actually do concerning cause and effect of UV rays. The attitude and behaviors of young adults will not only impact them but will also have a direct influence on future generations concerning healthy sun-protective behaviors and attitudes. More research needs to be conducted to determine the best evidence-based techniques and practices for educating the general public to reduce the incidence and prevalence of skin cancer worldwide, especially the young adult population.

REFERENCES