Skin cancer screening in the homeless population
1. University of Utah School of Medicine, Salt Lake City, Utah
The homeless population is a medically vulnerable patient population in our communities. Of particular concern to dermatologists is the risk for the development of skin cancer in the homeless, in light of their chronic sun exposure and suboptimal sun protection behaviors. Two free skin cancer screenings conducted at the Fourth Street Clinic in Salt Lake City, Utah, in 2011 and 2012, resulted in the diagnosis of 13 skin cancers in 62 patients. These events also highlighted that many homeless patients had suboptimal skin cancer prevention behaviors. We believe that education, awareness, and disease prevention can be relatively easily accomplished by local homeless clinics as a first line of defense against skin cancer in the homeless population.
Homelessness affects approximately 3.5 million people in a given year . The homeless are, therefore, an important patient population that requires healthcare services in our communities. Extrinsic circumstances make the homeless a particularly vulnerable population to preventable diseases. Barriers to care include reduced access to healthcare services and preventive medical practices as well as lack of education about good health practices and risk factors for disease. Environmental conditions such as chronic sun exposure also place this population at higher risk of certain disease processes. Of particular concern to the dermatology community is the prevention and diagnosis of skin cancer because early screening and education can successfully prevent considerable morbidity [2, 3] and mortality .
The medical literature commonly discusses the vast need for increased healthcare resources among the homeless population, but often overlooks the need for skin cancer screening in favor of more imminently fatal disease screenings. This void needs to be rectified. Skin cancer is the most commonly diagnosed cancer in the United States, although it goes largely unnoticed in the homeless population. One study by Chau et al. looking at general cancer risk behaviors and screening in homeless populations briefly addressed the issue of skin cancer . Through surveys completed by homeless individuals in the greater Los Angeles area, they determined, not surprisingly, that the homeless population had a high risk of skin cancer because of regular sun exposure, lack of sunscreen use, and low skin cancer screening rates . They also found that many were receptive to additional education in skin cancer prevention and would “be willing to use sunscreen or wear a hat if provided to them free of charge .” Building upon this information and in response to the general lack of data, we decided to study the skin cancer risk factors and prevalence in the homeless population of Utah, as well as their reception to skin cancer preventative services.
Between 2011 and 2012, two free skin cancer screenings were conducted at the Fourth Street Clinic in Salt Lake City, Utah. The Fourth Street Clinic is a nonprofit community clinic, which “helps homeless Utahans improve their health and quality of life by providing high quality health care and support services .” This is accomplished with the help of 50 staff members, more than 150 volunteers, and donations from numerous community sponsors .
The events were advertised as a free comprehensive skin cancer screening. Medical students and dermatology residents performed full body skin exams. An attending dermatologist from the University of Utah oversaw all activities. Out of concern for follow up, suspicious lesions were biopsied on site and sent for free evaluation by the University of Utah Department of Dermatopathology. Individuals diagnosed with skin cancer were followed up in dermatology clinics at the Fourth Street Clinic if electrodesiccation and curettage or topical therapies sufficed, or referred to a University-affiliated Mohs surgeon or resident continuity clinics for further surgical therapies as indicated.
In addition to providing an opportunity for skin cancer screening, these events afforded the opportunity to educate patients on sun avoidance and sun protection behaviors, such as sunscreen use and sun-protective clothing. Educational pamphlets on skin cancer as well as samples of sunscreen were given to patients.
In two screenings, 29 and 33 patients filled out a basic demographic and risk factor survey provided by the American Academy of Dermatology (AAD), underwent a skin cancer screening, and received educational materials on skin cancer and risk factor modification. In 2011, four suspicious skin lesions were biopsied resulting in the diagnosis of two skin cancers, one basal cell carcinoma (BCC) and one squamous cell carcinoma (SCC). In 2012, ten patients had seventeen suspicious lesions biopsied with the resultant diagnosis of six BCCs and five SCCs.
Both years we were also able to ascertain the skin cancer prevention behaviors in homeless individuals and their understanding about skin health. In 2011 and 2012, 26 percent and 55 percent of the patients indicated that they would not have seen a physician for a skin related problem without the free screening, a clear indication that they lack consistent healthcare access. We also identified that a large portion of the patient population, unsurprisingly, had suboptimal skin cancer prevention behaviors: sunscreen was used by 10 percent of the 2011 patient population and 15 percent of those seen in 2012; 52 percent of the patients seen in 2011 and 30 percent of those in 2012 reported never using sunscreen. Only 16 percent of patients in 2011 and 22 percent in 2012 indicated that they wear sun protective clothing. On a more positive note, 45 percent of the patients in 2011 and 50 percent from 2012 reported that they seek out shaded areas when possible, reducing their sun exposure when able (See Table 1).
Our skin cancer screening events at a clinic servicing the homeless population serves to further highlight the need for skin cancer screening as an important preventative measure in the homeless population. This is especially vital in light of their high-risk circumstances, in particular, increased UV radiation exposure and lack of healthcare access. As demonstrated above, the homeless population has a low rate of consistent sunscreen use, a high number of reported blistering sunburns, and poor access to dermatologic screening, all of which culminate in a higher risk of developing skin cancer. These issues make the homeless population an ideal target for skin cancer screening and sun-protection counseling and education. Skin cancer screening is a cost-effective and relatively non-invasive cancer screening technique that has not, per the literature, been applied to the homeless population to date. Based on our experience, we herein demonstrate that education, awareness, and disease prevention can be relatively easily accomplished by local homeless clinics as a first line of defense against skin cancer in the homeless population.
References1. National Coalition for the Homeless. Homelessness in America: Unabated and Increasing. 1997. 1012 14th Street, NW, Suite 600, Washington DC 20005; 202/737-6444.
2. Guy GP & Ekwueme DU. Years of potential life lost and indirect costs of melanoma and non-melanoma skin cancer: a systematic review of the literature. Pharmacoeconomics 2011 Aug 16 [Epub ahead of print] [PubMed].
3. Shih ST, Carter R, Sinclair C, et al. Economic evaluation of skin cancer prevention in Australia. Prev Med 2009; 49(5): 449-53. [PubMed]
4. Schneider JS, Moore DH, & Mendelsohn ML. Screening program reduced melanoma mortality at the Lawrence Livermore National Laboratory, 1984-1996. JAAD 2008; 58(5): 741-9. [PubMed]
5. Chau S, Chin M, Chang J, et al. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev 2002; 11:431-438. [PubMed]
6. Fourth Street Clinic website: http://www.fourthstreetclinic.org. Accessed on October 15, 2012.
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