Increased Risk of Skin Cancer Seen in Military Veterans

For military veterans, future research should be accompanied by systematic efforts to improve skin cancer prevention, treatment, and outcomes among military service members and veterans, according to Carolyn J. Heckman, PhD.

Those who served on active duty in the military are at an increased risk for skin cancer, including melanomas and keratinocyte cancers, compared with those who have not. Future research is needed on this understudied group in order to further test clinician screening interventions for military veterans.1 

Because of the importance of combat and military readiness, it can be difficult for military service people to mitigate the risk of developing skin cancers. Some of the risks for the military veteran population include having an increased exposure to UV radiation, minimal sun-protective strategies, and a lack of education surrounding the risks of UV exposure, yet the majority of military veterans have never been screened for skin cancer by a physician, according to researchers at Rutgers Cancer Institute of New Jersey.1,2

According to Carolyn J. Heckman, PhD, associate professor of Medicine and co-leader of the Cancer Prevention and Control Program at Rutgers Cancer Institute of New Jersey, another reason for the elevated risk of skin cancer in this patient population is due to the fact that older White men are over-represented in the military.

“Veterans are more likely to be older White men, and they're going to be at higher risk based on their age, race, and sex. There are physical, genetic, and behavioral factors that play a role. People may have genes that make them more susceptible or a family history of skin cancer. They may have sensitive skin to the sun, fair skin, fair hair, fair eyes, freckles, and burn easily, those kinds of things. More sun exposure, indoor tanning, if they don't protect their skin, or wear clothing and hats can put them at risk,” stated Heckman. “People in the military might be more likely to be at risk if they're deployed to warm, sunny locations that don't have shade structures, or if they don't have access to sunscreen. They may have uniforms that cover most of their body when they're working, but people might not know how to protect themselves when off duty.”

In order to track and care for veterans, some experts have recommended those who have served on active duty should receive periodic, routine physician screenings for skin cancer. However, there previously have not been any recommendations by the US Preventive Services Task Force in regard to routine skin cancer screenings for the average-risk US population, and little is known about the history of these screenings for veterans.

As a result, data were drawn from the 2015 National Health Interview Survey, a probability-based in-person survey of civilian, non-institutionalized US adults. A sample of 33,672 adults aged 18 years and older were recruited. Within a specific study approved by the Rutgers Health Sciences Institutional Review Board, 2,862 US Military veterans who never reported a history of skin cancer and responded to the physician skin cancer screening items were examined and asked whether they ever had all of their skin checked for cancer by a dermatologist or other doctor.

“We looked at data from the National Health Interview Survey which is run by the CDC. These data are a few years old, but unfortunately, I don't expect that much has changed in terms of this topic since then,” stated Heckman.

The primary goal of the study was to examine the prevalence and correlates of physician skin cancer screening among military veterans. Methods of the trial included asking veterans whether they had ever served in a foreign country, determining their sex, age, highest educational attainment, race/ethnicity, and region of residence in the US. Additionally, the study asked patients about their insurance coverage, which included TRICARE (military), private, Medicaid, other health insurance, veterans’ affairs health care only, or uninsured.

Individuals were also questioned regarding their source of routine preventive health services, how much worry they have regarding paying medical bills, family history of skin cancer, sun sensitivity, the number of sunburns they have had in the past year, and whether or now they had previously used an indoor tanning device.

The sample of participants examined in the study was consistent to the US veteran population and consisted largely of non-Hispanic White, middle-aged and older men. Findings revealed that 30.88% of veterans reported ever having a physician skin exam. Of those who reported that they have had a physician skin exam, 51.60% indicated their exam took place within the past year.

The rates of screening were higher among the more physically active individuals, and those who reported having skin that is more sensitive to the sun, a factor that puts them at a higher risk for developing melanoma. There were varied screening rates for skin cancer depending on veterans’ insurance status. Nearly 2/3 of the evaluated veterans had either TRICARE or private health insurance. The highest screening rates were reported in those with TRICARE insurance, and the lowest rates among uninsured veterans.

Based on results of the multivariable logistic regression analysis, numerous other factors were shown to be associated with a significantly higher rate of physician skin cancer screening.

“We found that about 31% of veterans had reported ever having a physician skin exam, and that's a relatively low rate. Then, we found some things which correlated with skin cancer screening. If they were older, had higher education, White race, if they had TRICARE, military health insurance…these were all factors that were associated with greater skin cancer screening prevalence,” stated Heckman.

Factors associated with higher levels of skin cancer screening rates also included living in the Northeast as opposed to the Midwest, receiving preventive health care at a doctor’s office, and engaging in sun protection behaviors.

While the paper written by Heckman and her colleagues, Elliot Coups, PhD, Sharon Manne, PhD, and Jerod Stapleton, PhD, concluded the importance of physician skin cancer screening for those who have served in the military, Heckman notes the benefit for screenings in all higher-risk individuals and what oncologists can do to further understand how to work with this patient population.

“There are many evidence-based sources for provider and patient education in the scientific literature, CMEs, and the internet. Examples are the CDC, National Cancer Institute, American Academy of Dermatology, and Skin Cancer Foundation. Patients should be referred to oncologists if providers suspect cancer based on signs, symptoms, biopsies, etc,” stated Heckman.

All in all, military service members must receive proper education regarding skin cancer prevention and identification before combat, and further research should be accompanied by systematic efforts to improve skin cancer prevention, treatment, and outcomes among military service members and veterans.

“Oncologists should keep in mind that veterans with skin cancer may need assistance accessing healthcare benefits for which they may be entitled. They may need additional support with ongoing surveillance and skin protection,” added Heckman. “The awareness is not high enough. People have misconceptions and need to be educated and learn about their own personal risk factors. Additionally, there are systemic barriers such as limited numbers of military dermatologists and lack of accessibility for some health-care services.”

References:
  1. Coups EJ, Xu B, Heckman CJ, et al. Physician skin cancer screening among U.S. military veterans: Results from the National Health Interview Survey. PLOS ONE 16(5). https://doi.org/10.1371/journal.pone.0251785
  2. Gall, R., Bongiorno, M., & Handfield, K. (2021). Skin cancer in the US Military. Cutis, 107(1), 29–33. https://doi.org/10.12788/cutis.0153