The effect of sociodemographic and clinical featureson disease perception and sun protection behavior inpatients with cutaneous melanom

Introduction: Melanoma is a malignant tumor that originates from melanocytic cells and can often be located in the skin, but also in the mucosa, eyes and meninges. In the recent years, its incidence has increased all over the world, especially in the white race, and it is considered as an important public health problem. In its development, the most important risk factor with a proven mutagenic role among those identified so far is the ultraviolet radiation (UVR); the basic step in preventing melanoma, treating melanoma and preventing recurrences is to reduce the UV exposure, that is, to ensure that people develop sun protection behavior. In addition, individuals' perceptions and evaluations of the disease determine their quality of life and compliance with treatment, and in this thesis study, it was aimed to evaluate the effects of clinical and sociodemographic characteristics on disease perception and sun protection behaviors in patients diagnosed with cutaneous melanoma, comparatively among themselves and with the normal population. Methods: Between July 1, 2021 and July 30, 2022, 35 patients diagnosed with cutaneous melanoma, aged 18 years and over, who applied to Dokuz Eylül University Faculty of Medicine, Department of Skin and Venereology, and had similar characteristics to melanoma patients in terms of age and gender, who could change their sun protection habits and 70 healthy control groups without any non-melanoma skin cancer or photosensitive disease were included in the study. Detailed verbal information about the study was given to the patients and to the control group, and a written informed consent form was signed. After determining the patient and control groups, the case report form containing physical and sociodemographic data, personal and family history information was filled with face-to-face interview technique. Sociodemographic data such as age, gender, education level, occupation, income level, marital status, place of residence, working environment; physical characteristics such as height, weight, waist circumference, presence of freckles, hair and eye color, presence of melanocytic nevus (number and size); CV data such as the presence of chronic disease, regular medication use, history of malignancy, history of non-melanoma skin cancer, alcohol, cigarette and coffee consumption; Family history data, such as family history of malignant melanoma and extracutaneous malignancy, were recorded. Factors that may play a role in etiology (such as the presence of dyspastic nevus, presence of diseases such as xeroderma pigmentosum, phototherapy history, immunosuppression status, sunburn history) were questioned in both the patient and control groups, while in the patient group, age at first diagnosis of malignant melanoma, lesion area, histopathological subtype, Breslow thickness, accompanying mutations, stage, number of nevi histopathologically resulting in melanoma, and treatments received were noted. The skin types of the patients were determined according to the Fitzpatrick classification and scored between 1-6. Sun exposure and sunburn history in patients diagnosed with cutaneous melanoma, were questioned regarding the period before melanoma diagnosis; sun exposure habits and sun protection attitudes were questioned regarding the period after the diagnosis of melanoma; were evaluated cross-sectionally in the healthy control group. The Decision Making Scale (DMS), which consists of the 'perception of benefit' and 'perception of harm' dimensions, was used to evaluate the determination of individuals to protect themselves from the sun. In order to evaluate the perception of illness, the 'opinions about the disease' dimension and the 'reasons of illness' dimension of the Illness Perception Scale (IPS) were used to investigate the interpretation, perception and evaluations of people about their illness. The analysis of the data collected within the scope of the study was performed using IBM SPSS version 25.0. The results were evaluated within the 95% confidence interval, and a p value of <0.05 was considered significant. Results: The mean age of the patients diagnosed with cutaneous melanoma included in our study was 49.14±11.52 years, while the mean age at first diagnosis of melanoma was 44.14±12.61 (min 19 max 66). There was a slight male predominance with a rate of 54.3%. More than half of the patients (51.4%) had a high education level and were university graduates. 22.9% of them were in absolute closed and 71.4% of them were in a predominantly open+closed working environment. 85.7% of the patients were urban residents. 71.4% of patients diagnosed with cutaneous melanoma had light skin color (type 1-3). Compared to the control group, the ratio of light hair (red/blond/light brown) and light eye color (green/blue/hazel) was significantly higher in the patient group (p=0.023, p=0.001). The number of acquired melanocytic nevi was 25 and above in 51.4% of the patient group. There was a history of dysplastic nevus in approximately half of the cases (45.7%) (p=0.001). Smoking was found to be significantly higher in the healthy control group compared to the patient group (p = 0.033). Family history of malignant melanoma was statistically significantly higher in the patient group (p=0.015). Of the patients diagnosed with cutaneous melanoma included in the study, 37.1% had intermittent sun exposure and 54.3% had occupational sun exposure. A history of sun exposure five or more days a week was statistically significantly higher in the patient group (p=0.027). 77.1% of the patients had a history of sunburn in the past, 44.4% of them had bullous sunburn, and the first sunburn in 70.4% of these patients occurred in childhood and adolescence. While everyone (100%) participating in the study, including the control group, stated that they had experienced a mild sunburn at least once in their life, it was seen that the number of people with more than six mild sunburns was statistically significantly higher in the patient group (p=0.046). There were 17 patients (48.6%) who stated that they had experienced painful sunburn at some point in their lives, and 11 of these patients (64.7%) stated that they had experienced painful sunburn when they were between the ages of 0-19. It was observed that the patient and healthy control groups 'rarely' and 'never' sunbathed for tanning purposes in the summer at similar rates (90.4% and 85.7%, respectively). 'Never' going on holiday for sunbathing purposes was higher in the patient group than in the control group (62.9% and 22.9%, respectively), and less than 30 minutes of sun exposure between June and August, between 11:00 and 15:00, was higher in the patient group. While it was 74.3% (n=26), it was found to be 34.3% (n=24) in the control group. There was no statistically significant difference between the two groups in terms of 'use of sunscreen while sunbathing' and use of physical protection such as 'sitting in the shade', 'covering clothes', 'protective hats' and 'sunglasses' when exposed to intense sunlight. The DMS, which is used to show how committed people are to sun protection, was evaluated for the period after the diagnosis of cutaneous melanoma in the patient group, and the mean benefit perception score (13.91±3.346) was expected to be higher than the harm perception score (6.66±2.520) was found, but there was no statistically significant difference between them and the healthy control group. Considering the rates of not having experienced any sunburn in the last year, which can be considered as an indicator of adequate sun protection, the patient and healthy control groups were found to be similar to each other (82.9% and 90%, respectively). While a negative correlation was detected between the age at first diagnosis of melanoma and the DMS benefit dimension (p=0.035)(Pearson), the average DMS benefit score of those with a university education level was determined to be significantly higher than those with primary, secondary and high school degrees (p=0.003). While age and gender do not have an effect on sun protection behaviors; those with a university education were more likely to use sunscreen 'often' and 'always' while sunbathing; when exposed to intense sunlight, 'often' and 'always' wearing clothing and sunglasses and sitting in the shade were found to be statistically significantly higher (p=0.001, p=0.038, p=0.001, p=0.026). While living in an urban or rural area and marital status do not seem to have any effect on sun protection behaviors; It was observed that those with an income of 5000 TL or more were more likely to use clothes that cover the body and use sunglasses 'frequently' when exposed to intense sunlight. Painful sunburn 3-5 times in the last year was also less common in those with income over 5000 TL (p=0.005, p=0.007, p=0.036). When evaluated according to their stages, it was observed that patients diagnosed with Stage 1 cutaneous melanoma 'never' or 'rarely' went on sunbathing holidays more often than others and experienced painful sunburn more often (3-5 times) in the last year (p=0.030, p=0.001). It was observed that the presence of any chronic disease, photosensitizing skin diseases such as xeroderma pigmentosum and vitiligo, a history of dysplastic nevus, a history of non-melanoma skin cancer, and a family history of MM (especially in first-degree relatives) did not have any effect on sun protection behaviors. While most of the patients perceived the existing cutaneous melanoma as a disease that was chronic, had negative and serious consequences, that they could not understand and had high concerns about, thought that they could control this disease on their own and with treatment. Most of the patients believe that their illness is caused by psychological factors such as stress or anxiety, the person's attitude - negative thinking about his life, family problems, overwork, the person's emotional state (feeling bad, tense, lonely and empty) and personality traits while thinking that it originates from; he stated that factors such as accidents, injuries, luck or bad luck had much less impact on their illnesses. It was observed that nearly half of the patients considered sun exposure as a factor that definitely caused melanoma. While there was no significant difference in terms of other variables, it was determined that patients with a history of sunburn in the past believed that their illness had negative, serious consequences and could not make sense of their illness (p = 0.005, p = 0.021). It was observed that those who thought their disease had negative, serious consequences 'always' wore clothes that covered the body when exposed to intense sunlight (p<0.05); it was observed that those who 'often' used protective hats when exposed to intense sunlight had a high belief that the disease could be controlled with treatment, and on the contrary, those who 'never' used protective hats had the opinion that the disease could not be controlled with treatment (p<0.05). Conclusion: Our study is the first to evaluate the effects of clinical and sociodemographic characteristics on the perception of illness and sun protection behaviors in patients with cutaneous melanoma, in comparison with each other and with the healthy control group. According to the results of the study, it was determined that clinical and sociodemographic characteristics affect the perception of illness and sun protection behaviors in patients with cutaneous melanoma; it is seen that being diagnosed with melanoma creates positive awareness in people about sun protection. Changing these patients' perception of the disease positively, improving their quality of life, and raising awareness about UVR damage will help increase their compliance with treatment, especially sun protection behaviors. Large-scale, multicenter, prospective studies are needed to support these data. Key words: Melanoma, disease perception, sun protection behavior