Effect of Skin Self-examination Education Delivered During the Mammography Experience.
Phase: NA
Conditions: Melanoma
Sponsor: Northwestern University

Effect of SSE education delivered during the mammography experience.  
 
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PROTOCOL TITLE:  
Effect of skin self-examination education delivered during the mammography experience.  
 
 
 
PRINCIPAL INVESTIGATOR: 
June K. Robinson, MD 
Research Professor of Dermatology 
Northwestern University Feinberg School of Medicine 
645 N. Michigan Avenue, Suite 1053 
Chicago, IL 60611 
(312) 503-5941 
june-robinson@northwestern.edu  
 
 
 
RESEARCH PERSONNEL: 
Dalya Abou-el-Seoud, BS 
Elona Liko-Hazizi, BS 
Megan Perez, BS 
Kathryn Kim, BA 
 
STATISTICIAN: 
 
Namita Jain, MD/MPH 
 
IRB APPROVAL DATE: 
05/18/2018 
 
NCT03512457 
 

Effect of SSE education delivered during the mammography experience.  
 
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1.0  Purpose of the Study .......................................................................................................................... 3 
2.0  Background / Literature Review / Rationale for the study ................................................................ 3 
3.0  Inclusion and exclusion criteria ......................................................................................................... 4 
4.0  Procedures Involved .......................................................................................................................... 4 
5.0 Multiple sites .................................................................................................................................... 10  
6.0  Incomplete Disclosure or Deception ............................................................................................... 10 
7.0  Recruitment ..................................................................................................................................... 10 
8.0  Consent Process ............................................................................................................................... 10 
9.0  Process to Document Consent ......................................................................................................... 10 
10.0  Risks to Participants ...................................................................................................................... 10 
11.0  Potential Benefits to Participants ................................................................................................... 11 
12.0  Financial Compensation ................................................................................................................ 11 
13.0  Provisions to Protect the Privacy Interests of Participants ............................................................ 11 
14.0  Data Analysis ................................................................................................................................. 12 
15.0  Confidentiality and Data Management .......................................................................................... 12 
15.1  Data Monitoring Plan to Ensure the Safety of Participants ........................................................... 13 
16.0  Data Banking ................................................................................................................................. 13 
17.0  Qualifications to Conduct Research and Resources Available ..................................................... 13 
18.0 References ...................................................................................................................................... 13 
 
 
 
 
 

Effect of SSE education delivered during the mammography experience.  
 
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1.0 Purpose of the Study 
The proposed study is the second phase of a project assessing the feasibility and effectiveness of 
enhancing the early detection of melanomas among women, who are engaging in health promotion by 
having mammograms. The initial phase of the project framed risk messages, developed posters and 
brochures with the input provided by women undergoing screening mammograms, and assessed the 
feasibility of delivering the program during the mammogram visit at the Lynn Sage Comprehensive 
Breast Center of Northwestern Medicine/ Prentice Women’s Hospital. Now, we seek to evaluate 
performance of skin self-examination (SSE) by women, who receive information during their 
mammogram appointment, and follow-up with dermatology for a melanoma screening examination.   
 
In the second phase, a more intensive intervention in which women will not only receive information 
about SSE, but will also receive a reminder to perform SSE one week after the screening mammogram 
and information on how to schedule an appointment with dermatology will be provided. The number of 
women who perform SSE at home and find a concerning mole (lesion), number who see a 
dermatologist, and number who have a concerning lesion biopsied will be compared in two arms of the 
study 1) women who receive the intensive intervention 2) women who receive the informational 
brochure about SSE alone.    
 
Our hypothesis is that women who receive more the intensive educational intervention will be more 
likely to perform SSE at home and schedule a follow-up dermatologist appointment as compared to 
those who receive the information brochure alone. This project builds upon Robinson’s successful SSE 
training program for melanoma patients that resulted in patients’ accurate evaluations of suspicious 
lesions relative to dermatologists’ skin examinations.4  
 
The study aims are as follows: 
1. Assess whether SSE education introduced during routine screening mammography encourages 
women to implement SSE at home, find concerning lesions, and seek follow-up with a dermatologist. 
2. Assess the effectiveness of additional reminders to perform SSE and providing information on how 
to schedule follow-up with a dermatologist on participant performance of SSE with identification of a 
concerning lesion or scheduling a screening examination with a dermatologist without performing 
SSE.   
2.0 Background / Literature Review / Rationale for the study 
1. Significance 
Invasive melanoma, a lethal form of skin cancer, is the seventh most common cancer in women. The 
vast majority of melanomas are curable if the cancer is caught early, yet over 10,000 people in the 
United States are estimated to have died of melanoma in 2017.1 New opportunities to decrease mortality 
from this deadly cancer, which is visible on the skin surface, are warranted.  
Melanoma incidence increased 3% per year for the last two decades in part due to indoor tanning by 
young women. In 1994, Dr. Robinson’s group found that 24% of teen women in Illinois tanned 
indoors.2 Since 1994, indoor tanning has increased from 24% to 40% among women between the ages 
of 18 and 30 years old.3 Currently, about 30 million people, most of whom are women, indoor tan every 
year. Indoor tanning for 10 or more sessions prior to age 30 is linked with a 6-fold increase in the risk 

Effect of SSE education delivered during the mammography experience.  
 
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of developing melanoma. The Food and Drug Administration recently recognized the need for 
screening and recommending regular skin exams among women who have tanned indoors.  
Reaching the vast numbers of at-risk women requires access to large numbers of women, preferably in a 
supportive health care environment. Because women have screening mammograms every 1-2 years 
starting at age 40, many at-risk women could become aware of their risk of developing melanoma 
during their mammogram experience.  
 Inclusion and exclusion criteria 
3.1 Inclusion Criteria for Patient  
Women 18 years of age and older, who are waiting to have a mammogram 
Women agree to complete informed consent and registration forms allowing follow-up 
reminders and access to their EMR record limited to the visit with a dermatologist or 
primary care physician regarding a concerning skin lesion and the results of the biopsy of the 
lesion. 
3.2 Exclusion Criteria for Patient 
Women who are unable to see to read a newspaper, unable to read English, and who have 
cognitive impairment causing problems with functioning at a sixth grade reading level or 
inability to speak. 
3.3 Special populations  
Special populations will not be invited to participate in this research.  
3.0 Procedures Involved 
3.1 Study Design 
 
Phase 1: Delivery of educational SSE program.  
Each of the eight changing rooms of the Lynn Sage Comprehensive Breast of Northwestern 
Memorial Hospital will be equipped with a poster, brochures (Fig 1 and Fig 2) and cards 
with information about obtaining an appointment with a dermatologist for concerning skin 
lesions.  
 
A woman research assistant will obtain consent to participate in the research and review of 
medical information, collect contact information and if the woman owns an iPhone X, 8+ or 
8, and ensure receipt of an informational brochure. Women will be asked if they own an 
iPhone X, 8+ or 8 to assess the prevalence of these specific phones in the population of 
interest. These iPhones models are of particular interest to the research team as they offer 
superior image quality compared to older models. If a woman has this type of phone, she 
will be asked about her experience using it to take close-up pictures.The woman will be 
asked her preference for being contacted by email, telephone, or text message. The two arms 
of the study will be delivered on different weeks. During weeks 1,3,5 and 7 of the study 
period 400 women will be given brochures and a card with information on scheduling 
dermatology follow-up prior to check-out (Group 1), (Fig 3). During weeks 2, 4, 6 and 8 of 
the study period, 400 women will be given brochures to perform SSE at home and proceed 
to check-out of the mammogram area (Group 2). The women in Group 1 will also receive a 
reminder about performing a SSE one week after their mammogram visit via phone call, 

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email or text message. One month after the mammogram visit both groups will be called and 
surveyed to see if they checked their skin and/or made an appointment to see a 
dermatologist. Three months after the mammogram, both groups will be asked to participate 
in a complete survey (either via REDCap or telephone), including whether the women 
followed up in dermatology and if any concerning lesions were biopsied. 
 
 
Phase 2: Assessment of SEE Implementation 
A research assistant will be present at the mammography center to collect consent, telephone 
numbers, iPhone model information, and email addresses to have women sign onto REDCap to 
complete a survey. A telephone survey will be administered to each woman enrolled in the study in 
both groups (N=800) one month after the mammogram asking if she performed a SSE at home and 
whether a follow-up with dermatology was made. An anonymous REDCap survey may be used 
in place of the telephone call, depending on participant’s preferred method of contact 
preference. Then, three months after the screening mammogram, an anonymous <2 minute REDCap 
survey will be sent via email to each woman enrolled in both groups to ascertain the number of 
women who identified that they were at increased risk for melanoma (history of sunburn, history of 
indoor tanning >10+sessions, family or personal history of skin cancer), performed a SSE at home, 
found a concerning lesion, made a follow-up appointment with a dermatologist, and had any 
concerning lesions biopsied. If participants do not complete the REDCap survey in 2 weeks, they will 
be called and surveyed via telephone. We anticipate a 20% attrition rate (Fig 3). Participants will be 
offered a $10 Amazon gift card in appreciation of completing the one month survey and an additional 
$10 for completing of a second REDCap survey three months after the mammogram visit. 

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Fig 3. CONSORT diagram for two arms of study 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Group 2: Educational Intervention Alone 
 
Poster in changing room 
Women receive brochure and proceed to 
check-out N= 400 
1 month after mammogram: contact both groups to determine 
if women checked their skin and made a follow-up 
appointment with dermatology  
Completed survey 
N=320 
Women undergoing screening mammography 
1 week after mammogram: reminder call/email to perform SSE 
for intensive intervention group 
Group 1: Intensive Intervention 
Poster in changing room, Women receive brochure 
 Women receive card to schedule dermatology follow-
up prior to check-out N= 400 
Completed survey 
N=320 
3 months after mammogram: REDCap survey or telephone 
call to both groups with full survey 
Estimated 20% attrition rate in each group 
Dermatology 
examination N=150 
Dermatology 
examination N=150 

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3.2 Informed Consent, Participant Surveys, and Educational Intervention 
As patients wait to have the mammogram, they will be screened for eligibility. Following 
completion of the mammogram, patients will return to the changing room and put on their 
clothing. After exiting the changing room in the Lynn Sage Comprehensive Breast Center of 
Northwestern Medicine/Prentice Women’s Hospital and as they are preparing to leave, a 
research assistant (RA) will interview potential participants to acquire a randomly selected 
convenience sample of eligible participants (n=800). Participants will be invited to complete 
a survey that will assess will assess knowledge of melanoma and the risk of developing a 
melanoma. They will be provided with a consent form and the research study will be 
discussed, questions will be invited and then they will be asked to sign a consent form and to 
fill out a registration form containing contact information. (see attached) 
The complete survey includes general demographic items such as age, education, household 
income, race and ethnicity. The survey questions are as follows:   
1. During your visit for mammography, did you notice any information about checking 
your skin for melanoma?  
___Yes __ No 
2. Did you think this applied to you? 
___Yes __ No 
3. If no, why not? (open ended)  
4. If yes, why? (open ended)  
5. Did you check your skin? (If no, please proceed to question #7) 
___Yes __ No  
6. If yes, did you notice any concerning moles? 
___Yes __ No 
7. If no, will you consider checking your skin in the future?  
___Yes __ No 
8. If you found any concerning moles, did you make an appointment to see a 
dermatologist? 
___Yes __ No 
 
The RA will record the responses.  
 
3.3 Research procedures and activities 
Follow-Up 
1 week after the mammogram, RA will contact participants in group 1 via their preferred 
method to remind them to perform SSE and schedule a dermatologist appointment if they 
find a concerning mole. (see attached telephone script) 
1 month after the mammogram, the RA will call participants in group 1 and administer a 
survey to see if they checked their skin and/or made an appointment with a dermatologist. 

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(see attached telephone script) An anonymous REDCap survey may be used in place of the 
telephone call, depending on participant’s preferred method of contact preference.  
  
The survey questions are as follows:  
1. Did you read the brochure?  
___Yes __ No  
2. Did you check your skin? (If no, please proceed to question #4) 
___Yes __ No  
3. If yes, did you notice any concerning moles? 
___Yes __ No 
4. If no, will you consider checking your skin in the future?  
___Yes __ No 
5. If you found any concerning moles, did you make an appointment to see a dermatologist? 
___Yes __ No 
 
If no, do you intend to do so in the near future? 
 
6. Did you share the brochure with anyone else?  
___Yes __ No 
 
7. If yes, who did you share it with: 
a) A relative: son, daughter, father, mother, sister, brother 
b) A friend : woman, man 
c) Someone I work with: woman, man  
 
 
REDCap Survey 
3 months after the mammogram, an anonymous REDCap survey will be emailed to each 
woman enrolled in both groups. If participants do not complete the REDCap survey in 2 weeks, 
they will be called and surveyed via telephone. The following items with relevance to the 
research: 
1. Do you have a history of sunburn? Yes/No 
2. Do you have a history of more than 10 indoor tanning sessions? Yes/No 
3. Do you have a personal or family history of melanoma? Yes/No 
4. Have you ever performed a skin self-examination prior to your most recent 
mammogram? Yes/No 

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5. Did you perform a skin self-examination after your most recent mammogram? 
Yes/No 
If no, then go to item 8.  
6. Did you find a concerning mole? Yes/No 
7. If you found a concerning mole, did you make an appointment to see a 
dermatologist? Yes/No 
8. If you did not perform a skin self-examination, did you still make a follow-up 
appointment to see a dermatologist for a skin examination? Yes/No 
9. Have you had an appointment with a dermatologist yet?  Yes/No 
10. If you found a concerning mole and saw a dermatologist, was the concerning mole 
biopsied? Yes/No 
a. If yes, was the biopsy done at Northwestern? Yes/No 
b. If No, were you told by your dermatologist that the skin biopsy was 
melanoma? Yes/No 
11. If you saw a dermatologist, were any other concerning moles biopsied?  Yes/No 
 
EMR review 
If a woman responds yes to item 9 indicating that they made an appointment with a 
dermatologist, then the EMR will be checked to ascertain the findings of the dermatologist. 
The pathology report of biopsied mole(s) will be reviewed and added to the deidentified 
database.  
 
3.4 Measures  
The number of women with risk factors for melanoma, who performed SSE after the 
screening mammogram, who found a concerning mole, who saw dermatology, who 
had a concerning lesion biopsied in each group will be analyzed by descriptive 
statistics. The difference in proportions of women who 1) performed SSE 2) saw a 
dermatologist in the educational intervention group from the intensive intervention 
group will be compared using a 2 test. If the woman responded “yes” to follow-up 
in dermatology, a chart review of the electronic medical record will be performed to 
assess whether any lesions were biopsied and pathology of the concerning lesions.  
The accuracy of the woman’s selection of a concerning lesion will be assessed by 
examining the correspondence rate between the woman’s assessment during SSE and 
the dermatologist. The overall correspondence rate will be calculated with a random 
intercept-only mixed logistic regression model. The statistical analysis will be 
performed by Namita Jain, MD, MPH. 
 
Online data  
REDCap survey (see page 8 above) 
 
Approvals required  

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Dr. Friedewald obtained permission for this research to be conducted in the Lynn Sage 
Comprehensive Breast Center of Northwestern Medicine/Prentice Women’s Hospital  
  
            4.7 Vulnerable populations 
No vulnerable populations will take part in this study. 
  
4.0 Multiple sites 
4.1 Northwestern University will serve as the study site solely responsible for contacting 
participants and conducting study procedures. 
 
6.0 Incomplete Disclosure or Deception  
6.1 N/A. This research will not use incomplete disclosure or deception.  
 
5.0 Recruitment 
7.1 Recruitment of Patients 
A woman research assistant will perform in-person interviews with participants to ascertain 
if women is eligible for the study and interested to participant. Women who sign written 
consent and fill out a registration form will be entered into the study. (n=800) (see attached 
forms)  
 
8.0 Consent Process 
8.1 Written consent will be obtained at the following location: Lynn Sage Breast Center of 
Prentice Hospital/Northwestern Medicine. (see attached consent document) 
8.2. N/A. Non-English speaking participants will not be enrolled in this research.  
8.3. Participants who are not yet adults (infants, children, teenagers) will not be enrolled in this 
research. Participants in structured interviews, who are the age of 18 years or older, will be 
enrolled in this research. Assent will be required from all participants. The RA will obtain verbal 
assent from each participant and will be documented. The RA will read the assent script to the 
participant and will then document the participant’s response. 
8.4 Cognitively Impaired Adults: Participants will be screened for preexisting conditions that 
would prohibit their participation due to being over burdened by co-morbid diseases, unable 
to participate in a conversation at a sixth grade language level due to cognitive impairment 
(e.g., by a stroke), and unable to speak and read English, inability to see to read a newspaper.  
Subjects having conditions that contraindicate participation will not be enrolled in this research. 
8.5. Adults Unable to Consent: Please see above rationale for excluding Cognitively Impaired 
Adults. 
 
9.0 Process to Document Consent  
9.1. Written consent will be obtained in the changing area of the Lynn Sage Comprehensive 
Breast Center. (See attached consent document) 
 
10.0 Risks to Participants                                                                                                     
10.1. The potential risks to participants are expected to be minimal, if they occur. Subjects 
will be participating in an educational intervention that may enhance their awareness of their 
risk of developing skin cancer. All study participants will be provided with an email address 

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and phone number to contact study staff in the event they have concerns. If a subject 
becomes concerned that they have a suspicious lesion, the control subject will be instructed 
to make an appointment with their own dermatologist for an examination. The research 
assistant will communicate other concerns to the PI. In such circumstances, Dr. Robinson 
will consult with the patient’s own dermatologist and an appropriate referral will be made.                           
Because of the potential for the educational intervention to help the subject identify 
melanoma at a stage of development with the best prognosis, we feel that the potential 
benefits, in reduced morbidity and mortality, to the subject outweigh the risk of potential 
enhanced anxiety in discovering a suspicious mole. Should subjects report high levels of 
anxiety a referral for psychological support will be made.                                                                              
10.2. We do not believe that subjects in this study will be exposed to any risk of physical or 
psychological harm as a result of either the intervention or research processes. Our measures 
do not assess individuals at risk of immediately harming themselves (e.g. suicide); therefore 
we will not have to screen the data to potentially intervene with individuals who may be a 
risk to themselves. 
10.3. N/A. There are no anticipated risks to others who are not participants.                                                  
11.0 Potential Benefits to Participants  
Because of the potential for the educational intervention to help the subject improve their 
ability to detect melanomas in the early and potentially curable phase, they will reduce their 
risk of death from melanoma. We feel that the potential benefits in reduced morbidity and 
mortality to the subject outweigh the risk of potential enhanced anxiety in discovering that 
they are at risk to develop another melanoma. Should subjects report high levels of anxiety, a 
referral for psychological support will be made.  
 
The knowledge to be gained by the proposed study is key to the evaluation of the long-term 
benefit of skin self-examination. By evaluating means of encouraging and facilitating regular 
skin self-examination, the applicants believe that it will be possible to determine if the 
educational intervention that can be used in mammogram facilities, which would be 
beneficial if brought into widespread use. 
12.0 Financial Compensation  
12.1 N/A. Participants will receive a $10 Amazon gift card for participation in the second 
survey (telephone call/REDCap one month after mammogram visit) and an additional $10 
Amazon gift card for completing a third survey (REDCap) three months after the 
mammogram.  
 
13.0 Provisions to Protect the Privacy Interests of Participants  
13.1. This research includes provisions for protecting the privacy of participants. Study 
interactions will take place in person. The research team will make every effort to address 
the questions and concerns of potential and current participants.  
 
Steps will be taken to ensure that the participants feel at ease. To reduce the sense of 
intrusiveness a subject may experience in response to survey questions, subjects will be 
informed that they may decline to provide any information they do not wish to disclose. The 

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information being collected is limited to only the minimum amount of data necessary to 
accomplish the research purposes.  
 
13.2. The research team will be permitted to access study-related, subject-reported 
information and the EMR of subjects who have a visit with the dermatologist for a 
concerning mole. The database will have deidentified data. 
 
14.0 Data Analysis 
14.1. This convenience sample of women undergoing screening mammograpy will all receive 
education either as a brochure and a 1-week reminder or as only the brochure. Demographic 
characteristics of the two groups will be examined using means and standard deviations (age) and 
counts and percentages for all categorical variables. Primary outcomes of SSE performance, biopsy, 
and diagnoses will be compared using Chi-square tests of association or Fisher’s exact tests where 
sample sizes were restrictive. Due to the skewed nature of the anxiety scale, a Wilcoxon rank sum 
test will be used to compare anxiety, the secondary outcome, in the two groups. Descriptive 
statistics will be performed for the tertiary outcome of dissemination. 
 
15.0 Confidentiality and Data Management: 
1. There are no biological specimens. All of the following data is collected in person consent 
and responses to structured interviews and focus groups.  
2. Our systems are guarded against outside entry by Northwestern’s own firewall supporting 
128-bit encryption. This level of encryption provides the highest level of protection against 
hackers, computer break-ins, etc. All data is deidentified. Experienced research assistants 
will be employed and will receive training that includes emphasis upon the importance of 
confidentiality of information, and all personnel on the project will complete the required 
NIH training in the protection of human research participants.  
3. Data will be retained in separate locked file cabinets and on computers with restricted and 
password protected access, without links to the master code list. All data based on the 
research will be reported in aggregate form. No individual respondents will be identified. 
Electronic data will be maintained in a study specific database on the server of the 
Department of Dermatology at the Feinberg School of Medicine. Paper- based files will be 
kept in a locked cabinet in a locked room within the Northwestern University Department 
of Dermatology research offices. Identifiable data will be kept separate from the case report 
forms and source documents. Data gathered as a result of this study are available to 
inspection on request by Food and Drug Administration or other government regulatory 
agency auditors, and the Northwestern University Institutional Review Board (IRB).  
 
4. Only approved research personnel will have access to the stored data. The PI is ultimately 
responsible for receipt and transmission of the data. As per Department of Dermatology 
protocol, data will retained indefinitely after the completion of the study.  
  
5. All data and other information in this study will be maintained confidentially. In order to 
protect against risks posed by a potential loss of confidentiality, we will take the following 
steps: First, subjects will be assured they are free to refrain from answering any questions 
they do not wish to answer. Secondly, all data will be identified only by a unique subject 

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number. All data is recorded by a study number, which preserves the confidentiality of the 
information. 
 
6. Please refer to Section 15.0 for the data analysis plan, which includes statistical procedures. 
 
15.1 Data Monitoring Plan to Ensure the Safety of Participants: 
As previously described, all participants are encouraged to contact the PI, Dr. Robinson at 
Northwestern, to report complaints or adverse events. A telephone number and email address 
will be given to patients to contact Dr. Robinson if they have any concerns or increased anxiety, 
or if they become worried about developing skin cancer. Instructions for reporting adverse 
events and complaints, as well as for contacting the Investigators, are included in the consent 
documents and on all contact information provided to participants through the course of the 
study. Any significant adverse events will be reported to NIH in addition to the local IRB, in 
compliance with federal regulations.  
 
Our measures do not assess individuals at risk of immediately harming themselves (e.g., 
suicide); therefore, we will not have to screen the data to potentially intervene with individuals 
who may be a risk to themselves.  
 
Dr. Robinson has been a board certified physician for over three decades and has conducted a 
NCI funded R01 of a similar nature. We will notify the Northwestern University IRB, our 
project officers, and NCI within 24-48 hours of any serious adverse event. We will provide an 
annual report to the NCI Project Officer summarizing all adverse events, should any arise.  
 
16.0 Data and if applicable, Specimen Banking Not applicable. 
 
17.0 Qualifications to Conduct Research and Resources Available 
17. 1. All members of the research team have completed and maintained current Human 
Subjects Protection Training, such as CITI and the Department of Dermatology compliance 
modules. The PI has over 30 years of clinical research experience, including multiple NIH-
funded studies and studies involving the educational training of physicians.  
 
17.2 The PI’s office is located within the clinical research office in the Clinical Research 
offices of the Department of Dermatology of Northwestern University. Dr. Robinson’s skin 
cancer control group occupies 500 sq. ft. with 4 offices and a small conference room. All 
standard office equipment is available for use including PC, fax, color printer, locked filing 
cabinets, etc.  
 
Northwestern provides web-based submission of IRB protocols and financial management.  
 
There are no anticipated adverse consequences associated with the research. However, 
should a participant request medical or psychological resources, the PI and Co-Is are 
available for debriefing and will arrange referrals as necessary. 
 
The PI will ensure that the RAs are thoroughly trained on the protocol, the research 
procedures, and their respective duties and functions. The RAs will be readily available to 
participants for questions and technical troubleshooting. The PI and RAs will personally 

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meet on a weekly basis to discuss study progress and review duties and functions as 
applicable. A continual, open dialogue among the PIs and RAs will be encouraged. 
 
18.0 References 
1. American Cancer Society. Cancer Facts & Figures 2016 (2016). 
http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/ 
2. Robinson JK, Rademaker AW, Sylvester J, Cook B. Summer sun exposure: knowledge, attitudes, and 
behaviors of Midwest adolescents. Prev Med 1997;26:364-72.  
3. Schneider S, Kramer H. Who uses sunbeds? A systematic literature review of risk groups in developed 
countries. J Eur Acad Dermatol and Venereol. 2010;24(6):639-48 
4. Robinson JK, Wayne JD, Martini MC, Hultgren BA, Mallett KA, Turrisi R. Early detection of new 
melanomas by patients with melanoma and their partners using a structured skin self-examination skills 
training intervention: a randomized clinical trial. JAMA Dermatol 2016;152(9):979-985. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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