Association between sun-protective behaviors and family history of melanoma: Results from NHANES 2003 to 2004.

To the Editor: Family history is an important nonmodifiable risk factor for melanoma present in approximately 8% to 12% of melanoma diagnoses. These patients have a 1.7 fold increased risk for developing melanoma compared with patients without affected first-degree relatives. In contrast, sun exposure is a significant yet modifiable risk factor for melanoma, which can be reduced by practicing appropriate sun-protective behaviors (SPB). Despite the increased melanoma risk associated with a positive family history, there have been limited population-based studies to assess how family history interplays with the propensity for SPB in at-risk individuals. Using the National Health and Nutrition Examination Survey (NHANES) data from 2003 to 2004, we examined the association between SPB and family history of melanoma.

The NHANES is representative of the general noninstitutionalized US population aged 20 to 59 years. Statistical analysis was performed with STATA (version 17.0, StataCorp) using survey commands to employ sample weights and adjust for cluster and strata of complex survey samples. The distribution of demographics, education level, and socioeconomic status stratified by family history are shown in Table I. Multivariable logistic regressions using SPB as the dependent variable and family history as the independent variable adjusted for patient demographics (eg, age, gender, annual household income, education, and hair color) were performed (Table II).

Table I

Demographic characteristics of patients with and without a family history of melanoma

	Characteristics	Positive family history of melanoma,Weighted percentages∗ (95% CI)	Negative family history of melanoma,Weighted percentages∗ (95% CI)
Gender
Male		43.6 (37.9-49.4)	49.7 (47.8-51.6)
Female		56.4 (50.6-62.1)	50.3 (48.4-52.2)
Mean age (y)
		39.2 (37.1-41.4)	39.0 (38.3-39.6)
Education level
<9th grade		0.7 (0.4-1.3)	5.2 (4-6.6)
9th-11th grade		5.1 (3-8.5)	12.4 (10.8-14.3)
High school or GED		19.9 (15.8-24.9)	27.2 (24.3-30.2)
College or AA degree		37.1 (29.8-45.1)	32.5 (30.1-35.1)
College graduate or above		37.1 (29-46.1)	22.7 (19.5-26.2)
Annual household income
Under $20,000		9.3 (5.3-16)	15.4 (13.3-17.7)
$20,000 or greater		90.7 (84-94.7)	84.6 (82.3-86.7)
Natural hair color
Red or blonde hair		19.4 (13.5-27.2)	13.2 (10.4-16.4)
Black or brown hair		80.6 (72.8-86.5)	86.8 (83.6-89.6)
SPF used most often		26.2 (24.5-28)	25.3 (24.1-26.4)
Number of sunburns per year		2.1 (1.6-2.5)	2.0 (1.9-2.2)

CI, Confidence interval.

Values are expressed as weighted percentages unless otherwise noted.

Table II

Multivariate analysis of sun-protective behaviors in patients with and without a positive family history of melanoma

Sun protective behaviors		Positive family history of melanoma, weighted proportions (95% CI)	Negative family history of melanoma, weighted proportions (95% CI)	Adjusted OR∗ (95% CI)	P value
Stay in the shade?
No		28.6 (22.4-35.9)	29.5 (26.2-33.1)	1 [Reference]
Yes		71.4 (64.1-77.6)	70.5 (66.9-73.8)	0.94 (0.69-1.30)	.710
Wear hat that shades the face and neck?
No		70 (62.6-76.4)	70 (67.2-72.7)	1 [Reference]
Yes		30 (23.6-37.4)	30 (27.3-32.8)	0.97 (0.66-1.43)	.870
Wear a long-sleeved shirt?
No		76.5 (71.5-80.8)	78.7 (75.3-81.7)	1 [Reference]
Yes		23.5 (84-94.7)	21.3 (18.3-24.7)	1.21 (0.85-1.71)	.270
Use sunscreen?
No		41.2 (35.5-47.2)	58.6 (55-62.1)	1 [Reference]
Yes		58.8 (52.8-64.5)	41.4 (37.9-45)	1.43 (1.09-1.88)	.010
In past year, did you have sunburn?
No		42.2 (35.5-49.3)	58.1 (54-62.1)	1 [Reference]
Yes		57.8 (50.7-64.5)	41.9 (37.9-46)	1.70 (1.20-2.42)	.010

CI, Confidence interval; OR, Odds ratio.

Adjusted for age, gender, annual household income, education level, and hair color. Bold indicates statistical significance (P < .05).

Of 4163 participants, 3076 with nonmissing questionnaire data for SPB and family history of melanoma were included in the analysis. Compared to the respondents without a family history, those with a known family history of melanoma were more likely to use sunscreen (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.09-1.88; P = .010), but were also more likely to be sunburnt in the past year (OR, 1.70; 95% CI, 1.20-2.42; P = .010). There was no association between a family history of melanoma and the practice of other SPB, including staying in the shade (OR, 0.94; 95% CI, 0.69-1.30), wearing hats that cover the face and neck (OR, 0.97; 95% CI, 0.66-1.43), or wearing long-sleeved shirts (OR, 1.21; 95% CI, 0.85-1.71; P > .05).

Our results align with prior findings, which showed that a greater proportion of individuals with a known family history of melanoma used sunscreen over other SPBs. The paradoxical increase in sunburns associated with sunscreen use demonstrates the importance of recommending alternate SPB. This is consistent with current World Health Organization recommendations, which state that sunscreen should only serve as an adjuvant to other behavioral interventions. Our study is limited by analysis of secondary data, the self-reported nature of population-based surveys, and the inability to determine degrees of family relationships. Moreover, the data from 2003 to 2004 may not be generalizable to the present patient population or reflect the advances in patient education on SPB made in recent years. Despite these limitations, this study provides a population-based analysis of SPB in individuals with a known family history of melanoma representative of the US population in the age group of 20 to 59 years, showing that this population was more likely to use sunscreen but not engage in other SPB.

Conflicts of interest

None disclosed.