
==== Front
Prev Med Rep
Preventive Medicine Reports
2211-3355

S2211-3355(24)00277-8
10.1016/j.pmedr.2024.102862
102862
Short Communication
Awareness of skin cancer screening coverage in U.S. healthcare plans: Is there a need to better educate the public?
Terzian Tamara Tamara.Terzian@cuanschutz.edu
a⁎
Box Neil Neil.Box@comelanoma.org
b
Nicklawsky Andrew Andrew.Nicklawsky@cuanschutz.edu
c
Nern Karen karen.nern@epiphanydermatology.com
d
Torchia Enrique C. Enrique.Torchia@thesunbus.org
e⁎
a Department of Dermatology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
b Colorado Melanoma Foundation and Department of Epidemiology, School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
c Department of Pediatrics-Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
d Epiphany Dermatology, Edwards, CO, United States
e Health Outcomes & Research, The Sun Bus, LLC, Aurora, CO, United States
⁎ Corresponding authors. Tamara.Terzian@cuanschutz.eduEnrique.Torchia@thesunbus.org
14 8 2024
10 2024
14 8 2024
46 10286215 5 2024
9 8 2024
13 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Objectives

To understand whether financial barriers or the lack of accessibility to dermatology services was a significant motivation for the public to seek free skin cancer screening.

Methods

An anonymous and voluntary survey was administered to participants of The Sun Bus free skin cancer screening program in 2023 at U.S. outdoor events in Colorado, Texas, Arizona, New Mexico, Iowa, Wyoming, Missouri, and Montana. 491 respondents answered questions on motivation, healthcare coverage, and demographics. Survey data was analyzed using Qualtrics’ crosstab IQ and statistical tests software.

Results

Skin screening found suspicious lesions in 45 % of 1300 participants with 18 % of respondents sharing a previous history of skin cancer. Concern for a lesion or Curiosity were the two top reasons for 60 % of respondents to seek free skin screening and remained the top reasons after data was stratified by gender, age, or income. Only 15 % of respondent were motivated by the cost of dermatology services or a long wait to see a dermatologist. A total of 38 % of people surveyed reported comprehensive plans covering skin screening while 46 % were unaware of the inclusion of screening in their healthcare plan. Notably, this unawareness increased up to 52 % among younger and less affluent respondents. Additionally, females were less likely than males to be aware of skin screening options in their healthcare plans.

Conclusions

This work highlights the significance of promoting public awareness of dermatology services covered by health insurance and the need for continued efforts in skin cancer education and screening programs.

Keywords

Skin cancer
Skin cancer screening
Skin cancer prevention
Healthcare coverage
Mobile health clinics
Gender-differences
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
Actinic keratosis
==== Body
pmc1 Introduction

Skin cancer is the most common type of neoplasm worldwide (CDC, 2024, Urban et al., 2021). In the U.S., keratinocyte tumors such as Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) account for 97 % of cases while melanoma results in the most mortalities (Aggarwal et al., 2021). Treatment costs of skin cancer to the healthcare system is significant with the financial burden exceeding $8 billion/year according to the Academy of American Dermatology (AAD) (AAD2).

Excessive exposure to ultraviolet light plays a crucial role in the genesis of skin cancers, whose risk can be effectively reduced by the adoption of sun safe behaviors like the use of long sleeves/pants, sunscreen, hats, or sunglasses when outdoors. Cancer screening (e.g., for breast or cervical tumors) has been shown to be an effective strategy to detect early stage lesions and reduce the overall mortality associated with cancer (Duffy et al., 2020, Tranberg et al., 2015). However, the latest U.S. Preventive Task Force on skin cancer screening did not recommend widespread screening of adults due to the lack of high-quality evidence of its effectiveness at reducing skin cancer deaths (Henrikson et al., 2023). Nevertheless, the Task Force found strong evidence that detection of skin cancers at earlier stages, particularly in melanoma, improves patient survival rates (Henrikson et al., 2023).

Approximately 14–30 % of the U.S. population has a skin cancer screening yearly (Coups et al., 2010, Heckman et al., 2018), but comprehensive data on this subject is limited, as is information regarding individuals seeking complimentary skin screening or deferring screening due to financial constraints. To date, there are only a handful of national resources for those seeking free skin cancer screening in the U.S.: The Skin Cancer Foundation (TSCF) and The Sun Bus (TSB) operate independent mobile clinics whereas The AAD (AAD1) offers a list of providers offering complimentary screening. These resources are constrained by date and geographic location.

The Sun Bus is a nonprofit and member of the National Association of Charitable and Free Clinics, with a mission to reduce the burden of skin diseases, including cancer, through free skin screening, education, and research programs. In 2023, The Sun Bus conducted a study to examine the motivations of individuals seeking complimentary screening and to determine if financial constraints or limited accessibility to dermatology services played a significant role in their decision-making process.

2 Methods

2.1 Study design

The study was conducted from February to November 2023 and was open to any member of the public that attended outdoors local fairs (e.g., Wyoming State fair, Douglas, Wyoming), festivals (e.g., The Taste of Fort Collins, Fort Collins, Colorado), sporting events (e.g., Phoenix Raceway for the National Association for Stock Car Auto Racing (NASCAR) championship, Avondale, Arizona), and workplace wellness events in eight states: Colorado, Texas, Arizona, New Mexico, Iowa, Wyoming, Missouri, and Montana. Participants of the screening program were given the choice of receiving a skin exam for either full body, upper or lower body, sun exposed areas, or a spot check. Individuals who had a skin screening on The Sun Bus were invited to take a voluntary and anonymous survey within a week after their visit. All questions contain the option of Prefer not to answer, which was excluded from the analysis done for this study. Non-binary gender selection was also excluded due to low sample number (n = 2). The survey collected demographic information including age, skin cancer history, skin type, ethnicity, education, healthcare insurance coverage, and employment status. Table 1 and Fig. 1 states the wording and answer options for questions on motivation and inclusion of skin screening in participants’ healthcare plans.Table 1 Chi square analysis of selection data (number, %) stratified by age and gender to the questions on “What motivated you to participate in the free skin screening clinic?” and “Which of the following best describes coverage for dermatology services on your health insurance plan?” from the The Sun Bus adult participant survey conducted during 33 outdoor events in eight states in the United States in 2023.

	N (%)	Male	Female	N (%)	Male	Female	
	Total	≤45 y	>45 y	≤45 y	>45 y	Total	≤$80K	>$80K	≤$80K	>$80K	
What motivated you to participate in the free skin screening clinic?a	409	55 (13)	132 (32)	89 (22)	134 (32)	341	60 (18)	98 (29)	88 (26)	95 (28)	


	
Concern about a skin lesion		13 (24)	51 (39)	24 (27)	55 (41)		22 (37)	32 (33)	33 (38)	33 (35)	
Curiosity		23 (42)	42 (32)	37 (42)	40 (30)		24 (40)	32 (33)	30 (34)	30 (32)	
Encouraged by spouse/significant other		7 (13)	25 (19)	2 (2)	7(5)		6 (10)	21 (21)	3(3)	5 (5)	
The expense of visiting a dermatologist		6 (11)	1 (1)	17 (19)	18 (13)		3 (5)	4 (3)	15 (17)	18 (19)	
Long wait time to see a dermatologist		5 (9)	7 (5)	7 (8)	8 (6)		4 (7)	7 (7)	5 (6)	4 (4)	
Previous positive experience by		1 (2)	5 (4)	2 (2)	6 (4)		1 (2)	2 (2)	2 (2)	5 (5)	
family member/friends 											


	
Chi square p value		<0.01					<0.01				
Which of the following best describes coverage for dermatology services on your health insuranceplan?	434	59 (14)	139 (32)	95 (22)	141 (32)	366	58 (16)	109 (30)	95 (25)	109 (30)	


	
Comprehensive; skin screening covered		21 (36)	68 (49)	27 (28)	51 (36)		17 (26)	56 (50)	22 (21)	38 (33)	
Basic; skin screening not covered or not included		12 (20)	14 (10)	16 (17)	29 (21)		13 (20)	9 (8)	20 (19)	20 (17)	
Don't know		26 (44)	57 (41)	52 (55)	61 (43)		28 (42)	44 (39)	48 (46)	51 (44)	
Chi square p value 		2.E-02					<0.01				
a − “Other” (n = 62) selection was excluded from analysis due large range of differing answers.

Fig. 1 Distribution of selection data (%) stratified by age, gender, and income to the question “Which of the following best describes coverage for dermatology services on your health insurance plan?” from The Sun Bus adult participant survey conducted during 33 outdoor events in eight states in the United States in 2023.

2.2 Statistical analysis

Qualtrics software (v01-24, Qualtrics, Provo, UT) was used to formulate survey questions and collect data with analysis performed using Qualtrics’ crosstab IQ and statistical functions. Chi-square tests for independence were performed between categorical data such as age, gender, income with selection data on motivation and knowledge of healthcare plans. Post hoc pairwise comparison z-tests were also performed between groups (e.g., males vs. females).

2.3 Institutional ethical review

The study was covered by the human research exempt COMIRB protocol 22-1266 under the Protocol Review and Monitoring System of the Colorado Cancer Center and Colorado Multiple Institutional Review Board at the University of Colorado Anschutz Medical Campus. The authors have complied with all regulations and ethical standards associated with this IRB protocol and the host institution’s guidelines.

3 Results

3.1 Summary of suspicious lesions detected in participants of The Sun Bus 2023 skin screening program

The Sun Bus had over 43,000 interactions with the public in 33 events across eight states in 2023. These interactions included people who engaged with educational displays or literature, conversed with staff/volunteers, received free sunscreen, participated in skin screening, or joined interactive displays and demonstrations. Educational literature or displays/demonstrations provided information on best sun-safe practices, signs and types of skin cancer, and the harmful effects of excessive exposure to ultraviolet light on the skin. The complimentary skin cancer screening identified 962 lesions in 1300 individuals of which 397 were identified as benign Seborrheic Keratoses. Among the remaining lesions, 436 were deemed suspicious precancerous or cancerous, including 217 Actinic Keratosis, 72 BCC, 72 neoplasms of uncertain behaviors, 40 SCC, and 35 Melanoma. Individuals with suspicious lesions were advised to schedule a follow-up appointment with a dermatologist of their choice.

3.2 . Demographics of study participants

Of those screened, 491 (38 %) individuals aged between 18 and 90 years old completed the survey. A previous history of skin cancer was reported by 18 % (90) of respondents with 42 cases of Basal Cell Carcinoma and 9 cases of melanoma. Females comprised 56 % of the respondents, males 46 %. Regarding ethnicity, 88 % identified as Caucasian, with 7 % reporting Hispanic/Latino heritage, and 5 % identifying as Asian, African American, Native American, or other ethnicities. Participants were also asked to specify their skin type, with Fitzpatrick Type III being the most selected at 33 %, followed by Type IV (30 %), Type II (19 %), Type V (11 %), Type VI (1 %), and Type I (6 %). In terms of education, 51 % of respondents held a college or associate degree, followed by 20 % with a high school diploma. Additionally, 27 % of individuals reported a post-bachelor's degree, such as a Master's, PhD, or MD.

Most respondents (69 %) had some level of employment, either full time, self-employed/contract/free-lance, or part time. The remainder included retired individuals, students, active military, unemployed or other professions (e.g., homemaker). Correspondingly, there was representation across all income levels. Only 12 % of respondents worked outside or in a hybrid model of indoors/outdoors (27 %) while the rest had indoor jobs. The respondents were also asked about their healthcare coverage. Most respondents were insured at the time of their skin screening with only 4 % being under-insured and 4 % being uninsured, which was below the national average of 11.2 % found by the CDC Household Pulse Survey (2020–23) (National Center for Health Statistics, 2020–2024).

3.3 Motivation of participants to seek free skin cancer screening

One of the primary objectives of the study was to investigate whether financial constraints or limited accessibility to dermatology services influenced individuals seeking free skin cancer screening. However, the top two motivating factors were Concern for a lesion (30 %) and Curiosity (30 %). The Other category, accounting for 13 % of responses, included convenience of receiving a skin screening at an event or workplace, overall interest in health, or a family history of cancer. Only 15 % of respondents were prompted by the Expense or a Long wait time to see a dermatologist. Concern for a lesion and Curiosity remained the top two reasons when responses were stratified by gender, age (≤45 years old vs. >45 years old) or annual income (≤$80,000 vs. >$80,000). However, there were some important distinctions. Younger respondents were more likely to be prompted by Curiosity (41 % vs. 31 %) while older respondents were more likely to be motivated by Concern for a lesion (40 % vs. 26 %) (p < 0.05). Expense to see a dermatologist was more important for younger than older respondents (16 % vs. 7 %) and in females compared to males (16 % vs. 4 %), whereas males were more likely to be encouraged by a spouse (18 % vs. 4 %) (p < 0.05).

3.4 Awareness of skin cancer screening in participant’s current healthcare plan

Insured respondents were also asked whether skin cancer screening was included in their healthcare plan. Over 40 % of older males and high-income earners indicated having comprehensive plans that covered skin screening (Fig. 1). Conversely, lower income earners were less likely to have a comprehensive plan, or any skin screening options in their existing plan. Unexpectedly, 46 % of insured respondents did not know whether skin screening was covered. This lack of awareness was more accentuated in younger respondents and in those with lower incomes (Fig. 1 and Table 1). Female respondents were also more likely to be unaware of skin screening options in their healthcare plan compared to males (p < 0.05 and see Table 1), regardless of their age or income (Fig. 1).

4 Discussion

A major strength of The Sun Bus study was its recruitment of a diverse pool of participants across eight U.S. states during outdoor public events. This design provided for a real word view of the public’s attitudes and behavior towards skin screening and their knowledge of their healthcare plans, albeit in those actively attending festivals, fairs, or sporting events (e.g., NASCAR).

The study found that participants of the screening program did not proactively pursue dermatological care when primarily concerned about a skin lesion. It is also important to note that those primarily motivated by cost or wait time for dermatology services, fundamentally worry about their skin health, including the potential risk of skin cancer. Moreover, even those mainly driven by curiosity invested time and effort in obtaining a free screening than consulting with their primary healthcare provider about their skin health. These findings are striking because most of the individuals were insured with comprehensive plans that included skin cancer screening with annual incomes that would not prevent them economically from seeking dermatological care. This work suggests that more than half of participants were driven by worries for their skin health, highlighting the ongoing need for initiatives like The Sun Bus and better public outreach by dermatology providers.

There were two additional noteworthy findings: (1) a substantial number of insured individuals were unaware of the inclusion of skin screening in their healthcare plans, and (2) a higher awareness among males of their skin screening coverage. The higher awareness by men is particularly surprising considering their poor health literacy, especially among youth (Palmer et al., 2024), inadequate engagement with healthcare services (Baker, 2016), and greater likelihood to defer medical care (Thompson et al., 2016, Hohn et al., 2020). In addition, the discrepancy in awareness between genders contrasts with existing research indicating that males generally exhibit less sun-safe behavior than females (Morton and Harrison, 2022). One plausible explanation for this unexpected male behavior would be the recent COVID-19 pandemic, which may have prompted men to be more mindful of their health. This notion finds some support in a non-peer-reviewed market study by Healthgrades (Healthgrades), which showed that 66 % of males expressed increased concern about their health compared to pre-pandemic times. This suggests a marked shift in men's attitudes towards managing their health and that of their families.

5 Conclusions

This study has revealed a reluctance among certain segments of the public to self-educate about their healthcare plans or take advantage of available dermatology services despite a clear need. It also underscores the necessity for alternative approaches that promote skin cancer prevention, including raising awareness of dermatology services covered by health insurance, which may be indirectly enhanced by free skin cancer screening programs.

CRediT authorship contribution statement

Tamara Terzian: Writing – review & editing, Writing – original draft, Validation, Resources, Project administration, Methodology, Investigation, Formal analysis. Neil Box: Writing – original draft, Resources, Funding acquisition. Andrew Nicklawsky: Writing – review & editing, Visualization, Validation, Formal analysis. Karen Nern: Writing – review & editing, Resources, Funding acquisition. Enrique C. Torchia: Writing – review & editing, Writing – original draft, Visualization, Software, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.

Acknowledgements

We thank the Colorado Melanoma Foundation for funding this work, and the participants of The Sun Bus skin cancer screening program. This work was supported in part by the Biostatistics and Bioinformatics Shared Resource of the University of Colorado Cancer Center funded by the National Cancer Institute at the National Institutes of Health (P30CA046934 ).
==== Refs
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