Skin Cancer Risk Factors and Screening Among Asian American Individuals

Key Points

Question  Do skin cancer risk factors and screening differ among Asian American individuals?

Findings  In this cross-sectional study of 84 030 National Health Interview Survey participants, Asian American individuals were less likely than Non-Hispanic White individuals to sunburn and more likely to seek shade, wear long sleeved shirts, or wear long clothing to the ankles, after adjusting for personal history of skin cancer. Differences among Asian American subgroups were additionally noted.

Meaning  The study results suggest that differences in sun-protective behaviors among Asian American individuals may help identify high-risk subgroups and inform culturally aware interventions to decrease skin cancer risk when indicated, and future studies should further sample Asian American individuals to evaluate for potential masked health disparities through disaggregated analysis.

Importance  Asian American individuals are the fastest growing racial group in the US but remain underrepresented in health disparities research, including research on skin cancer risk factors and screening. Improved understanding of preventable skin cancer risk factors and screening may demonstrate unmet needs among Asian American individuals.

Objective  To examine sunburns, sun-protective behaviors, indoor tanning, and total body skin examinations (TBSEs) for skin cancer screening among Asian American subgroups compared with non-Hispanic White individuals.

Design, Setting, and Participants  The National Health Interview Survey is a nationally representative cross-sectional survey in the US that assesses health behaviors. Self-identified Asian Indian, Chinese, Filipino, non-Hispanic White, and other Asian respondents from survey years 2000, 2005, 2010, and 2015 were included. Data were analyzed from July to November 2021.

Main Outcomes and Measures  Any sunburn within the last year; sun-protective behaviors included applying sunscreen, staying under shade, wearing long-sleeved shirts, wearing long clothing to the ankles, wearing hats, and wearing caps most of the time or always when out in the sun; any indoor tanning within the last year; any TBSE ever.

Results  Of 84 030 participants, 5694 were Asian American (6.8%) and 78 336 (93.2%) were Non-Hispanic White; of these individuals, 1073 (weighted prevalence, 21.0%) were Asian Indian, 1165 (19.4%) Chinese, 1312 (23.5%) Filipino, and 2144 (36.1%) Other Asian. All Asian American subgroups were more likely to seek shade, wear long clothing to the ankles, and wear long-sleeved shirts but less likely to sunburn, apply sunscreen, tan indoors, and receive TBSE than Non-Hispanic White individuals. Asian Indian individuals were less likely than Chinese participants to apply sunscreen (adjusted odds ratio [aOR], 0.55; 95% CI, 0.41-0.74) or wear a hat (aOR, 0.53; 95% CI, 0.37-0.76) and more likely to wear long-sleeved shirts (aOR, 1.89; 95% CI, 1.52-2.33) or long clothing to the ankles (aOR, 1.56; 95% CI, 1.28-1.90).

Conclusions and Relevance  The results of this cross-sectional study found that disaggregated comparisons among Asian American individuals demonstrated differences in skin cancer risk factors that may be used to identify high-risk subgroups and inform culturally aware counseling when indicated. Future studies should further sample Asian American individuals to evaluate for potential masked health disparities through disaggregated analysis.

Asian American individuals are the fastest growing racial group in the US, growing from 11.9 million in 2000 to 23.2 million in 2019.¹ Yet, Asian American individuals remain underrepresented in health research, including research on skin cancer risk factors and screening.² Improved knowledge of preventable skin cancer risk factors and screening among Asian American individuals may demonstrate unmet needs.^1,2

Aggregating Asian American individuals into a single racial category masks heterogeneity in socioeconomic status, health behaviors, and health outcomes across subgroups.^1,2 Cultural practices, skin phototypes, and perceptions of skin color vary widely across Asian American subgroups, which may manifest as important differences in skin cancer risk and prevalence.² Lower rates of sunscreen use among Asian American individuals in general compared with non-Hispanic White individuals have been observed, and disaggregated analyses may identify specific Asian American subgroups at particularly high risk of skin cancer who require additional intervention.³ This study aimed to examine prevalence of sunburns, sun-protective behaviors, indoor tanning, and total body skin examinations (TBSEs) among Asian American individuals compared with non-Hispanic White individuals, as well as examine potential differences through direct comparisons among Asian American subgroups.

The National Health Interview Survey is an annual cross-sectional survey of health conditions, behaviors, access, and utilization that is representative of the US noninstitutionalized civilian population.⁴ Data from 2000, 2005, 2010, and 2015 collected from respondents 18 years or older were pooled. This study was exempted from Emory University institutional review board review and informed consent was waived due to the use of deidentified data.

Self-reported Asian Indian, Chinese, Filipino, and Other Asian participants, regardless of Hispanic or non-Hispanic ethnicity, were included. Non-Hispanic White individuals were included as a reference group. Among Asian American individuals, the most populous subgroup (Chinese American individuals) was used as the reference for subgroup comparisons.¹ Participants reporting 2 or more races were excluded. Outcomes included any sunburn during the last 12 months, sun-protective behaviors performed always or most of the time, any indoor tanning in the last 12 months, and any TBSE during a participant’s lifetime.

Prevalence estimates incorporated survey weights to produce nationally representative estimates; all met a reliability threshold with coefficients of variation at less than 30%.⁴ Outcomes were compared by race using Rao-Scott χ² tests. Multivariable logistic regression models additionally adjusted for survey year, sociodemographic variables, cancer-related health behaviors, skin phototype, and personal history of skin cancer. Missing data were excluded from analyses. The Benjamini-Hochberg procedure was used to adjusted for 10 outcome comparisons to limit the false discovery rate to 5%. Data were analyzed using Stata, version 17.0 (StataCorp) from July to November 2021, with P < .05 considered significant in 2-sided tests.

Of 124 631 pooled respondents from 2000 to 2015, 5694 (weighted prevalence, 4.7%) identified as Asian American and 78 336 (weighted prevalence, 69.6%) identified as non-Hispanic White. Of 5694 Asian American individuals, 1073 (21.0%) identified as Asian Indian, 1165 (19.4%) as Chinese, 1312 (23.5%) as Filipino, and 2144 (36.1%) as Other Asian. Lifetime prevalence of skin cancer was 3.7% among non-Hispanic White individuals compared with 0% among Asian Indian, 0.1% among Chinese, 0.8% among Filipino, and 0.1% among Other Asian individuals (Table 1).

The prevalence of sunburns in the past year was 12.4% among Asian Indian, 20.2% among Chinese, 24.2% among Filipino, and 19.0% among Other Asian individuals. Frequent use of at least 1 sun-protective behavior was 62.9% among Asian Indian, 65.7% among Chinese, 70.7% among Filipino, and 66.1% among Other Asian individuals. During the past year, 1.8% of Asian Indian, 3.1% of Chinese, 3.5% of Filipino, and 3.4% of Other Asian individuals tanned indoors. Lifetime prevalence of TBSE was 6.5% for Asian Indian, 8.9% for Chinese, 11.5% for Filipino, and 7.4% for Other Asian individuals (Table 2).

In multivariable models adjusting for sociodemographic variables, health behaviors, photosensitivity, and skin cancer history, all Asian American subgroups were less likely than non-Hispanic White individuals to sunburn, apply sunscreen, tan indoors, and receive TBSE (Table 3). Asian American individuals were more likely to stay in the shade, wear long sleeved shirts, and wear long clothing to the ankles. Filipino individuals (adjusted odds ratio [aOR], 1.57; 95% CI, 1.32-1.85) were more likely than non-Hispanic White individuals to engage in at least 1 sun-protective behavior. Comparing among other Asian American individuals only, with Chinese American individuals as a reference group, Asian Indian individuals were less likely than Chinese participants to apply sunscreen (aOR, 0.55; 95% CI, 0.41-0.74) or wear a hat (aOR, 0.53; 95% CI, 0.37-0.76) and more likely to wear long-sleeved shirts (aOR, 1.43; 95% CI, 1.06-1.93) or long clothing to the ankles (aOR, 1.70; 95% CI, 1.30-2.23).

Prevalence of sunburns, sun-protective behaviors, indoor tanning, and TBSE among Asian American individuals differed from non-Hispanic White individuals and between subgroups in this large, nationally representative study. Asian American individuals were more likely to seek shade, wear long clothing to the ankles, and wear long-sleeved shirts but less likely to apply sunscreen, sunburn, tan indoors, and receive at least 1 TBSE. Asian Indian individuals were less likely than Chinese participants to apply sunscreen or wear hats, but more likely to wear long-sleeved shirts or long clothing to the ankles. The study results were consistent with studies showing that Asian American individuals stay in the shade and wear long clothing to the ankles more often but apply sunscreen less frequently than non-Hispanic White individuals.^3,5

Limited data exploring skin tone preferences among Asian American individuals make it difficult to interpret observed patterns of sun-protective behaviors. Drawing from studies in Asia, we may hypothesize that associations of darker skin tones with lower socioeconomic status may play a role.⁶ However, conflating beliefs of Asian individuals with Asian American individuals may not be appropriate; a survey of 546 Asian American individuals in California indicated that sun-protective behaviors and attitudes differed depending on the location where a participant was raised, degree of acculturation, and generation.⁷ Understanding views that Asian American individuals have around skin tone is essential, because preferences for lighter skin tones among Asian American individuals may reflect colorism, an ingrained form of discrimination that assigns lighter skin with privilege that is associated with White supremacy and internalized racism.⁶ Colorism has substantial consequences, including higher rates of perceived prejudice and depression among darker-skinned Asian American individuals and increases in skin-whitening product use globally.^8,9 Therefore, discussion of clinical counseling for skin cancer risk factors among Asian American individuals must consider the limited benefit of screening a population with low skin cancer prevalence against medical risks, such as vitamin D deficiency and the risk of perpetuating colorism.¹⁰

Oversampling of Asian American minority subgroups may facilitate future disaggregated analyses that identify higher risk subgroups who may benefit from culturally tailored skin cancer prevention.¹¹ Previous studies have demonstrated that having a culturally aware or sensitive clinician improves patient satisfaction, treatment adherence, and health outcomes.^12,13 A group of 19 Black patients who were treated in a dermatology skin of color clinic perceived trained clinicians as more understanding and trustworthy compared with prior dermatologists.¹⁴

This study is limited by use of self-reported outcomes, but self-reported and measured levels of sun-protective behaviors have been well correlated.¹⁵ Further disaggregated analysis within other Asian American subgroups besides prespecified groups in the National Health Interview Survey was not possible.^1,4 Differences in sun-protective behaviors may be explained by residual confounding in unmeasured covariates, such as acculturation.⁷

The results of this cross-sectional study suggest that Asian American individuals were more likely to seek shade, wear long-sleeved shirts, and wear long clothing to the ankles and less likely to sunburn, apply sunscreen, tan indoors, and receive TBSE compared with non-Hispanic White individuals. Disaggregated analyses revealed differences among Asian American subgroups. Oversampling of Asian American subgroups in future dermatologic studies may facilitate further disaggregated analyses to evaluate for potential masked health disparities.

Accepted for Publication: November 30, 2021.

Published Online: January 26, 2022. doi:10.1001/jamadermatol.2021.5657

Corresponding Author: Howa Yeung, MD, MSc, Department of Dermatology, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA 30322 (howa.yeung@emory.edu).

Author Contributions: Mr Supapannachart and Dr Yeung 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.

Concept and design: Supapannachart, Yeung.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Supapannachart, Wang.

Critical revision of the manuscript for important intellectual content: Supapannachart, Chen, Yeung.

Statistical analysis: Supapannachart, Yeung.

Administrative, technical, or material support: Supapannachart.

Supervision: Chen, Yeung.

Conflict of Interest Disclosures: Dr Chen has received royalties for quality of life instruments, including RosaQoL and ItchyQoL, neither of which were used in the present study. No other disclosures were reported.

Funding/Support: Dr Yeung is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under award numbers L30AR076081 and K23AR075888.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or US Department of Veterans Affairs.