The National Health Interview Survey (NHIS) is an annual, cross-sectional representative household survey of the US civilian noninstitutionalized population. We analyzed data from the 2000 and 2005 NHIS Cancer Control Modules (CCMs),¹³ which are the only source of national population-based data on cancer screening. CCMs focus on issues pertaining to knowledge and practices of cancer-related health behaviors. We specifically evaluated sociodemographic, health, and risk factor data, including age, body mass index, sex, educational attainment, race, employment, health insurance, and smoking and drinking status, as well as compliance with Healthy People 2010 recommendations for physical exercise. In all of the CCMs, participants were asked, “Have you EVER had all of your skin from head to toe checked for cancer by a dermatologist or some other kind of doctor?” Data were pooled and analyses took into account sample weights and design effects. Logistic regression analyses were performed with self-reported lifetime skin screening as the outcome of interest. In the logistic regression analyses, the corresponding values are odds ratios (ORs). OR estimates >1 (with the corresponding 95% confidence interval [CI] that does not include 1) indicate that the odds or risk of screening is statistically higher than the comparison group of interest. Conversely, ORs <1 (with a corresponding 95% CI that does not include 1) indicate that the odds of screening are significantly lower than the comparison group of interest. Florida data were compared with data from the different US geographic regions, as determined by the NHIS (ie, the rest of the South (not including Florida), Midwest, West, and Northeast). (For the specific state compositions of each region, see the US Census Regions and Divisions of the US.¹⁴)

Data management and analyses were conducted using SAS statistical software version 9.2 (SAS Institute Inc, Cary, NC), which allows the analysis of weighted, complex sample survey data and the adjustments for sample weights and design effects. Records from each survey year were weighted according to person-level weights provided in the annual NHIS data files. Weights were adjusted according to the number of representative years used in the analyses. All of the analyses were conducted at the Research Data Center of the National Center for Health Statistics to ensure participant confidentiality. The study was approved by the University of Miami institutional review board.

The daily routine of Floridians exposes them to more UV rays than most other people in the US.¹¹ Increased sun exposure equals an increased risk of developing skin cancer, but it does not necessarily translate to increased awareness of or participation in cancer screening. Our results found that compared with the rest of the nation, Floridians who were women older than 70 years, who reported being of “other” race, of non-Hispanic ethnicity, who had a high school education, who had health insurance, who were employed in the service industry, or who were unemployed (including those who are retired) had significantly higher skin cancer screening rates than their counterparts residing in the rest of the South, the Northeast, the Midwest, and the West. Even after adjusting for the sociodemographic and health-related indicators, Floridians retained significantly higher odds of reporting lifetime skin cancer screening compared with the other regions in the US. The biggest difference found was between Florida and the Midwest, with Florida having much higher screening rates. This shows that regional variations in screening rates exist in the US; these results are consistent with the limited number of previous research studies on this topic¹⁵; however, no previous studies have separated Florida, a state where residents are exposed to high UV rays all year long, from other distinct US regions to evaluate skin cancer–screening behaviors. It is important to note that all individuals in the US are exposed to UV rays no matter what their state of residence. For example, the mean UV index (on a scale of 0–12, 12 being the highest) for residents living in the rest of the South in July is between 8 and 9.¹¹

The literature has shown that elderly adults bear a disproportionate burden of morbidity and mortality from melanoma,¹⁶ and melanoma incidence is highest in non-Hispanic whites.⁴ Fortunately, in Florida, these groups reported the highest rates of skin cancer screening compared with the other US geographic regions. This positive health behavior may be due to several cancer initiatives in Florida that influence screening activities, which could be applied to other regions of the country. For example, the American Academy of Dermatology reports that Florida, compared with all other US states, has the highest number of free skin cancer screening sites.¹⁷ Included in this are the efforts of the Moffitt Cancer Center and Research Institute’s program, Mole Patrol, which provides free skin cancer screenings to individuals on Florida’s beaches, and that partners with several other Florida organizations to increase cancer awareness.¹⁸ Florida also has a comprehensive cancer plan, in which several government-led organizations focus on decreasing the incidence and mortality of cancer.¹⁹

Previous studies have found an association between higher dermatologist densities and lower melanoma mortality rates, due to greater opportunities for earlier detection.^20,21 A higher density of dermatologists in Florida compared with other states also may help account for higher screening rates.^20,22 Although it is not likely that other regions of the country can easily change the density of dermatologists within their region, it may be feasible to offer a greater number of free skin screenings, especially in the context of high-sun-exposure outdoor activities. Regardless, educational initiatives for both patients and health practitioners also can highlight the potential benefits and recommendations for skin cancer screening.

Consistent with previous studies, skin cancer screening rates have been shown to increase with a variety of socioeconomic indicators, such as higher educational attainment, health insurance, physical activity, and low unemployment.¹⁵ Therefore, increased targeting for those of lower socioeconomic status is warranted, particularly for Hispanics and people of African descent (who often do not believe they are at risk for skin cancer due to their darker skin tone).²³

It is important to note that, to date, the US Preventive Services Task Force has not found sufficient evidence to make recommendations regarding skin cancer screening²⁴; however, recent findings from a population-based skin cancer study in Germany strongly suggests that early detection does save lives.^25,26 This screening effort led to the detection of more than half of the melanomas diagnosed in the Schleswig-Holstein area of Germany. This resulted in an (expected) increase in melanoma incidence rates,²⁶ but a decline in the age-standardized melanoma mortality rate by nearly 50%.²⁵ The American Cancer Society recommends monthly self-examinations and yearly skin examinations by a doctor to detect skin cancer early and to make it easier to treat.²⁷ The American Academy of Dermatology and the Centers for Disease Control and Prevention also recommend that “physicians should examine exposed areas of the skin for cancer whenever the opportunity arises.”²⁸

The limitations of the present study include the cross-sectional nature of the NHIS. Another limitation is the self-reported nature of the NHIS data, which can limit its validity; however, a similarly worded question regarding self-reported whole-body skin examination has been validated with a sensitivity of 90.5, although it is important to note that this study was conducted outside the United States.²⁹ Also, there is no way to determine who is conducting the screening, and the literature has shown that screening accuracy varies by the type of practitioner.²⁴ Finally, it is unknown whether te older participants moved to Florida to retire or have lived their whole lives in Florida.

The strengths of this study include the use of the NHIS CCMs, which are the only source of national population-based data on cancer screening.¹³ In addition, using the NHIS and conducting analyses at the Research Data Center allowed for large sample sizes and the ability to compare Florida to the different geographic regions of the US.

In summary, living in the “Sunshine State” may raise awareness of the need for skin cancer screening, especially among individuals who are most at risk for melanoma. The results provided in the present study could be used by public health officials in other states, with the support of primary care physicians and other health care providers, to develop and implement local community health fairs specifically targeting the delivery of mass screening programs. This is particularly important for high-risk groups reporting low skin examination rates. In addition, other states with a high UV index (eg, the rest of the South) should develop targeted public health initiatives for their states. Increasing the early detection and prevention of melanoma remains a national cancer goal for the United States, especially in areas with a high UV index.