Multimedia: Skin cancer: in your face
Authors: June K Robinson, Darrell S Rigel
Journal: BMJ (1999)

In 1999 in the United States there will be over a million new cases of skin cancer, and, whereas the incidence for all other cancers in the United States has stabilised or declined, the incidence of melanoma continues to rise, especially for white men. Since 1985 the American Academy of Dermatology, a non-profit organisation with 12 000 physician members, has run a skin cancer control programme aimed at promoting awareness of melanoma and persuading people to practise sun protection. This year the association has worked with Campbell Mithun Esty, an advertising agency, to develop a particularly striking message about preventing skin cancer.

The new advertisement, being shown on television, uses a case history of a man with deforming skin cancer to emphasise the importance of sun protection. It adopts what has come to be known as the “tombstone approach,” which is characterised by a generalised threat of death or destruction from a particular type of behaviour. This approach has been used in smoking campaigns in the past decade, though with only varying levels of success because people have defensively avoided the message, selectively perceived the message in ways that reduced the threat, or discounted the message source.

In recent years, however, case histories have persuaded viewers to change attitudes. The testimonies of real people with real stories have had a strong impact because they put a face on seemingly remote dangers and show the worst that can happen. In Massachusetts, for example, a decline in smoking among middle school students has been linked to documentary style commercials, the most dramatic of which centres on a woman dying of emphysema (BMJ 2 January 1999, p 66). In a recent study of antitobacco advertisements by the firm Teenage Research Unlimited the three adverts that tested best with teenagers featured patients, including the California advert with a woman smoking through a hole in her neck.

The American Academy of Dermatology has built on these recent experiences in motivating teenagers to design a public service announcement that threatens teenagers with something they might consider even worse than dying—the possibility of living with skin cancer and its highly destructive results. The 1999 programme, “Skin Cancer Can Kill You. And now the Really Bad News,” features the example of Don Biederman, an entertainment attorney who had squamous cell carcinoma of the nose treated with more than 30 operations. In 1996 he had a resection of the nose and left cheek that resulted in his wearing a prosthesis. This brave man was willing to narrate the announcement about his experience with childhood sunburns of the nose, which led to his skin cancer, in the hope that he could prevent others from having a similar experience.

The advertisement uses clips from home movies shot in Super 8 film showing Biederman as a toddler playing on the beach and his now dead father reclining shirtless on a lounge chair. The family scenes at the beach are juxtaposed with close-ups of Biederman as he narrates his transformation from sun worshipper to cancer patient. To emphasise that skin cancer is not a minor annoyance, he is shown in profile view removing his prosthesis. The concept was tested in focus groups, who did not find it “repulsive” but rather were moved by this man’s experience and were motivated to take sun protection precautions with their children. 

In April 1999 the academy released the advertisement to television networks and 925 local stations. The ABC network rejected the segment as too graphic to broadcast nationally; an official at ABC described it as the “rip your face off “ advert. The opinions of station managers ranged from “powerful and provocative” to “so graphic that people will switch to a different station.” The stance of some television station managers was criticised by radio commentators because, while they refused to show the advert, they were, at the same time, broadcasting gruesome news footage of the high school shooting in Littleton, Colorado, and of massacres in Kosovo. Interestingly, by refusing to air the advertisement, ABC created a controversy that was discussed in prime time and may have increased public awareness of the dangers of unprotected sun exposure more than if they had taken the video and simply left it on the shelf or relegated it to time slots late at night, when it would not compete with paid advertising.

Other countries have had forthright approaches in their media messages regarding skin cancer. Australian television has shown surgical removal of skin cancer and an in depth portrayal of a person dying of melanoma, who advised people to protect themselves from the sun. While some viewers in the United States may not yet be ready to see such frank presentation of the morbidity of skin cancer, we only regret that some of the public was denied the opportunity to see a sensitive treatment of the story of a brave man who wanted to prevent others from getting skin cancer.