Gender Differences in Melanoma Awareness and Detection Practices Between Middle-aged and Older Men With Melanoma and Their Female Spouses FREE

Invasive melanoma incidence and mortality rates have risen most steeply in the United States in middle-aged and older men. From 1969 to 1999, melanoma incidence increased 3-fold in middle-aged men and 5-fold in older men. During this period, mortality rates increased 66% in middle-aged men and 157% in older men compared with 19% and 49% in women in these age groups, respectively.¹

Men are less likely than women to examine their own skin, seek physician examinations for melanoma, or examine the skin of their spouses.^2- 4 Observed sex differences in melanoma awareness and detection practices have previously been reported in population-based studies of average-risk individuals and in siblings of patients with melanoma.^5- 6 Our aim was to compare awareness and screening practices in middle-aged and older men with melanoma with those of their unaffected female spouses and/or partners (hereinafter “female spouses”; only 7 of 158 women [4%] identified themselves as partners). Such information would be useful in planning family-based interventions to enhance early detection of melanoma in this high-risk group.

Male patients 40 years or older with invasive cutaneous melanoma and their female spouses were surveyed concurrently within 3 months of diagnosis at Stanford University Medical Center, Stanford, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and the University of Michigan Health System, Ann Arbor, from September 1, 2004, through January 31, 2006, as described elsewhere in this issue of the Archives.⁷ After providing their informed consent, couples were asked to complete surveys without consulting each other. Most survey questions pertained to the year prior to the man's melanoma diagnosis.

Statistical analyses were performed using SAS software, version 9.1 (SAS Institute Inc, Cary, North Carolina). Each measure was dichotomized, and the responses of men and their female spouses were compared using the McNemar χ² test for paired data. We report P values and assume statistical significance at α = .05.

A total of 164 men of a larger cohort⁷ had female spouses, 6 of whom declined to participate (4% female spouse refusal rate); 158 couples completed dual surveys. Ninety-eight percent of female spouses lived with the affected man, and 94% had known him for at least 10 years.

The results of our analysis are summarized in Table 1 and Table 2. Female spouses were more likely than their husbands to (1) be aware of the ABCD rule (asymmetry, border irregularity, color variegation, and diameter >6 mm) (31% vs 18%) (P = .004); (2) read information about skin cancer detection (85% vs 65%) (P < .001); (3) perform skin self-examination (58% vs 46%) (P = .04); and (4) use sunscreen regularly (55% vs 32%) (P < .001), despite having lower levels of education (16% college education or beyond vs 52% for men) (P < .001). Men agreed or strongly agreed that their female spouses (1) ensured that the men went to see a physician (80%); (2) kept in touch with health matters better than the men did (69%); and (3) helped the men with skin self-examination (62%).

We sought to determine melanoma awareness and risk-reduction practices in the year prior to diagnosis for men with newly diagnosed melanoma and their unaffected female spouses. While other studies^8- 9 have demonstrated sex differences regarding melanoma awareness, ours is unique to our knowledge in its concurrent examination of awareness and detection practices in male patients and their unaffected female spouses. Despite having equal sun sensitivity and only half the rates of personal and/or family history of melanoma and nonmelanoma skin cancer, female spouses had greater melanoma awareness and risk-reduction practices than the men.

Recognition of the unique role of the female spouse is crucial to improving screening and skin self-examination (SSE) efforts in middle-aged and older men. Sex differences in SSE have been demonstrated, and earlier detection of melanoma by women is attributable, at least in part, to their greater health information–seeking practices.¹⁰ Schwartz et al¹¹ found that women had significantly thinner primary melanomas than men, but men and women had equally thin second primary melanomas. Increased levels of awareness in both men and women were believed to contribute to detection of thinner subsequent melanomas, and these results suggest that heightened awareness can lead to earlier detection.

Joint education of patients and their partners may improve secondary prevention for melanoma. Robinson et al¹² demonstrated significant improvement in SSE through couples training compared with solo learning in a randomized, controlled intervention designed to enhance partner participation. Efficacy of SSE improved with increasing quality of the couple's relationship and the partner's motivation and ability to provide social support.¹³

Possible study limitations, as described previously,⁸ include reliance on self-reported information, recall bias, and uncontrolled findings resulting from potential differences in study sites.

In conclusion, female spouses should be made aware of their potential to improve their husbands' melanoma screening practices. Health fairs, common to many areas, should consider integrating melanoma screening into existing women's health services. How to publicize and frame messages to draw men's attention and participation warrants further attention.

Correspondence: Dr Swetter, Department of Dermatology, Stanford University Medical Center, 900 Blake Wilbur Dr, W0069, Stanford, CA 94305 (sswetter@stanford.edu).

Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Swetter, Johnson, Miller, and Geller. Acquisition of data: Swetter, Layton, and Johnson. Analysis and interpretation of data: Swetter, Layton, Brooks, and Geller. Drafting of the manuscript: Swetter, Layton, Johnson, Brooks, Miller, and Geller. Critical revision of the manuscript for important intellectual content: Swetter, Johnson, and Geller. Statistical analysis: Brooks and Miller. Obtained funding: Swetter and Geller. Administrative, technical, and material support: Swetter, Johnson, and Geller. Study supervision: Swetter and Geller.

Financial Disclosure: None reported.

Funding/Support: This study was funded by the Harry J. Lloyd Charitable Trust for Melanoma Research, Overland Park, Kansas.

Role of the Sponsor: The sponsor had no role in the design and conduct of the study, in the collection, analysis, and interpretation of data, or in the preparation of the manuscript, review, or approval of the manuscript.

Additional Contributions: Mitzi C. Rabe, RN, BSN, OCN, served as study coordinator at the University of Michigan. The Melanoma Prevention Working Group provided valuable contributions to the study design and analysis.