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There is a paucity of studies assessing awareness and prevention of skin cancer among Chinese populations.
The aim of the study is to compare attitudes and practices regarding skin cancer risks and prevention between Chinese Asian and North American Chinese populations and between Fitzpatrick scores.
A cross-sectional, internet-based, 74-question survey in Chinese was conducted focusing on Han Chinese participants internationally. The survey included Likert-type scales and multiple-choice questions. All participants were required to read Chinese and self-identify as being 18 years or older and Chinese by ethnicity, nationality, or descent. Participants were recruited on the internet over a 6-month period from July 2017 through January 2018 via advertisements in Chinese on popular social media platforms: WeChat, QQ, Weibo, Facebook, and Twitter.
Of the 113 completed responses collected (participation rate of 65.7%), 95 (84.1%) were ethnically Han Chinese, of which 93 (96.9%) were born in China and 59 (62.1%) were female. The mean age of these 95 participants was 35.8 (SD 13.3) years; 72 (75.8%) participants were born after 1975. Few but more North American Chinese reported that Chinese Asian populations received annual skin checks (4/30, 4.2% vs 0/65, 0%;
Cultural differences and Fitzpatrick scores can affect knowledge and practices with respect to sun protection and skin cancer among social media–using Chinese Asian and North American Chinese communities based on respondent demographics. Most participants in all groups understood that people of color have some risk of skin cancer, but >30% of all groups across regions and Fitzpatrick scores are unaware of current skin protection recommendations, receive insufficient sun safety education, and do not use sunscreen. Outreach efforts may begin broadly with concerted public and private efforts to train and fund dermatologists to perform annual total body skin exams and provide more patient education. They should spark community interest through mass media and empower Chinese people to perform self-examinations and recognize risks and risk mitigation methods.
Skin cancer is a global health issue. Among people of color (POC), the outcomes are far worse than that of the general population [
China is the most populous country with approximately 1.4 billion people; Han Chinese is the largest ethnic group native to China, making up 92% of the Chinese population and 19% of the global population. Despite the attention to skin in the market for skin products and treatments among Chinese consumers, skin cancer incidence rates continue to increase in Chinese populations [
One study noted that, between 2004 and 2011, the overall incidence of melanoma in China increased from 0.4/100,000 to 0.48/100,000 [
Nonetheless, compared to the wealth of research on skin cancer risks, incidence, awareness, and prevention among Western White and people of color populations [
In this study, international Han Chinese perspectives on skin cancer were recruited through social media and anonymously surveyed in simplified Chinese. Trends and gaps in knowledge of risk factors and preventative measures were identified and used to determine necessary educational measures for developing future interventions with patients, educators, and providers.
Participants were recruited on the internet over a 6-month period via advertisements in Chinese on popular social media platforms: WeChat (Tencent Holdings Limited), QQ (Shenzhen Tencent Computer System Co, Ltd), Weibo (Sina Corporation), Facebook (Meta Platforms, Inc), and Twitter (Twitter, Inc). All participants were required to read Chinese and self-identify as being 18 years or older and Chinese by ethnicity, nationality, or descent. No financial compensation was provided.
An internet-based survey was adapted into Chinese from an English survey used in previous studies for assessing current knowledge and management of skin cancer in English-speaking populations [
Data analysis and visualization were completed in Excel (Microsoft Corporation) and R (R Foundation for Statistical Computing). Comparisons with chi-square and Fisher exact tests were made—for query responses with all counts 10 or greater and at least 1 less than 10—between responses by Chinese participants in Asia (group 1) versus those of Chinese participants in North America (group 2), and by those with modified Fitzpatrick scores ≤14 (modified Fitzpatrick group 1 [FG1]) versus those with modified Fitzpatrick scores ≥15 (modified Fitzpatrick group 2 [FG2]).
Due to the relative homogeneity in ethnicity, hair color, and eye color among ethnically Chinese people, scores were determined as a summation of points from questions modified to be more specific to skin phototyping for Chinese skin types [
How dark is your skin normally? (0=albino; 7=very dark brown)
How dark do you get if you tan? (0=albino; 7=very dark brown)
How easy is it for your skin to tan? (0=never tans; 7=always tans)
How easy is it for your skin to sunburn? (0=always sunburns; 7=never sunburns)
Since the maximum possible score was 28, half of the maximum (14) was chosen to be the dividing value between FG1 and FG2. In short, participants in FG1 had paler skin or experienced more sensitivity to burning than their FG2 counterparts.
This study has been reviewed and exempted by UCF institutional review board (IRB No. SBE-17-12900).
The response rate was 113 of 172 (65.7%). Of this subset, 95 (84%) participants were of Han Chinese ethnicity. Only the results from fully completed surveys by Han Chinese participants are reported to reduce cross-cultural confounding factors. Participant demographics and history of skin cancer are summarized in
Participant demographics and history of skin cancer (n=95).
Characteristic | Participants, n (%) | |
|
95 (100) | |
|
College or higher degree | 66 (70) |
|
Born in China | 93 (98) |
|
Born after 1975, residence in Asia | 54 (57) |
|
Born after 1975, residence in North America | 18 (19) |
|
||
|
China | 64 (67) |
|
Other Asian countries | 1 (1) |
|
United States | 26 (27) |
|
Canada | 3 (3) |
|
Australia | 1 (1) |
|
Other countries (unspecified) | 1 (1) |
History of precancerous and cancerous lesions | 1 (1) |
Skin cancer knowledge and preventative measures between regions. Survey responses from Han Chinese are displayed, and responses are separated for comparison into 2 groups based on the participants’ region of residence: Asia (group 1) and North America (group 2). The sample sizes from other geographical regions were too small for statistical analysis.
Category | Han, n (%) | Group 1, n (%) | Group 2, n (%) | |||||||
Group size | 95 (100) | 65 (100) | 30 (100) | N/Aa | ||||||
Skin cancer risk in Chinese less than White people | 73 (77) | 46 (71) | 27 (90) | .06 | ||||||
No skin cancer risk in Chinese | 10 (11) | 9 (14) | 1 (3) | .16 | ||||||
POCb can get skin cancer | 86 (91) | 58 (89) | 28 (93) | .78 | ||||||
Can identify melanoma as a type of skin cancer | 57 (60) | 42 (65) | 15 (50) | .18 | ||||||
Have not read about the latest skin care recommendations | 82 (86) | 56 (86) | 26 (87) | >.99 | ||||||
Interested but do not know how to get resources for recommendations | 35 (37) | 27 (42) | 8 (27) | .18 | ||||||
Know that sunscreen protects from skin cancer | 65 (68) | 42 (65) | 23 (77) | .34 | ||||||
|
.83 | |||||||||
|
Do not worry | 39 (41) | 26 (40) | 13 (43) |
|
|||||
|
Mild to moderate | 50 (53) | 34 (52) | 16 (53) |
|
|||||
|
Serious | 6 (6) | 5 (8) | 1 (3) |
|
|||||
|
.84 | |||||||||
|
Never | 8 (8) | 5 (8) | 3 (10) |
|
|||||
|
Unlikely | 29 (31) | 21 (32) | 8 (27) |
|
|||||
|
Likely to very likely | 58 (61) | 39 (60) | 19 (63) |
|
|||||
Clinician discussed risks of tanning | 2 (2) | 1 (2) | 1 (3) | .53 | ||||||
Clinician discussed skin cancer risks | 6 (6) | 4 (6) | 2 (7) | >.99 | ||||||
Received annual skin check | 4 (4) | 0 (0) | 4 (13) | .009 | ||||||
Received sun safety education from clinician | 26 (27) | 19 (29) | 7 (23) | .63 | ||||||
Felt clinician gave adequate sun safety education | 28 (30) | 15 (23) | 13 (43) | .04 | ||||||
Sunbathe to tan | 6 (6) | 2 (3) | 4 (13) | .08 | ||||||
Uses sunbeds or tanning booths | 0 (0) | 0 (0) | 0 (0) | >.99 |
aN/A: not applicable.
bPOC: people of color.
Skin cancer knowledge and preventative measures between Fitzpatrick groups. Survey responses from Han Chinese are separated for comparison into 2 groups based on the participants’ Fitzpatrick scores: those with modified Fitzpatrick score ≤14 (modified Fitzpatrick group 1 [FG1]) and those with modified Fitzpatrick score ≥15 (modified Fitzpatrick group 2 [FG2]).
Category | FG1, n (%) | FG2, n (%) | ||||||
Group size | 61 (100) | 34 (100) | N/Aa | |||||
Skin cancer risk in Chinese less than White people | 48 (79) | 25 (74) | .62 | |||||
No cancer risk in Chinese | 5 (8) | 5 (15) | .49 | |||||
POCb can get skin cancer | 55 (90) | 31 (91) | >.99 | |||||
Can identify melanoma as a type of skin cancer | 37 (61) | 20 (59) | .86 | |||||
Have not read about the latest skin care recommendations | 52 (85) | 30 (88) | .77 | |||||
Interested but do not know how to get resources for recommendations | 24 (39) | 11 (32) | .50 | |||||
Know that sunscreen protects from skin cancer | 47 (77) | 18 (53) | .02 | |||||
|
.75 | |||||||
|
Do not worry | 23 (38) | 16 (47) |
|
||||
|
Mild to moderate | 34 (56) | 16 (47) |
|
||||
|
Serious | 4 (7) | 2 (6) |
|
||||
|
.30 | |||||||
|
Never | 3 (5) | 5 (15) |
|
||||
|
Unlikely | 19 (31) | 10 (29) |
|
||||
|
Likely to very likely | 39 (64) | 19 (56) |
|
||||
Clinician discussed risks of tanning | 2 (3) | 0 (0) | .32 | |||||
Clinician discussed skin cancer risks | 5 (8) | 1 (3) | .54 | |||||
Received annual skin check | 3 (5) | 1 (3) | >.99 | |||||
Received sun safety education from clinician | 22 (36) | 4 (12) | .02 | |||||
Felt clinician gave adequate sun safety education | 18 (30) | 10 (29) | .99 | |||||
Sunbathe to tan | 4 (7) | 1 (3) | .65 | |||||
Uses sunbed or tanning booth | 0 (0) | 0 (0) | >.99 |
aN/A: not applicable.
bPOC: people of color.
Reasons for not using sunscreen. The proportion of respondents who denied using sunscreen and their cited reasons are tabulated. Participants were only able to select one reason for not using sunscreen.
Category | Han (n=95), n (%) | Group 1 (n=65), n (%) | Group 2 (n=30), n (%) | FG1 (n=61), n (%) | FG2 (n=34), n (%) | ||||||||||
Do not use sunscreen | 37 (39) | 27 (42) | 10 (33) | .45 | 20 (33) | 18 (53) | .05 | ||||||||
|
10 (27) | 6 (22) | 4 (40) | .83 | 7 (35) | 3 (17) | .24 | ||||||||
|
Inconvenient to use sunscreen | 11 (30) | 8 (30) | 3 (30) |
|
3 (15) | 8 (44) |
|
|||||||
|
Choose other means of sun protection | 2 (5) | 2 (7) | 0 (0) |
|
1 (5) | 1 (6) |
|
|||||||
|
Do not know how to use sunscreen correctly | 1 (3) | 1 (4) | 0 (0) |
|
1 (5) | 0 (0) |
|
|||||||
|
Other reasons | 13 (35) | 10 (37) | 3 (30) |
|
8 (40) | 6 (33) |
|
aPercentages in this category are based on the “do not use sunscreen” numbers.
Sun protection aside from sunscreen. Methods other than sunscreen used to protect against UV exposure outdoors are detailed. Some respondents have overlaps between categories as well as with sunscreen usage.
Category | Han (n=95), n (%) | Group 1 (n=65), n (%) | Group 2 (n=30), n (%) | FG1 (n=61), n (%) | FG2 (n=34), n (%) | ||
Wide-brimmed hats or long-sleeve clothing | 58 (61) | 39 (60) | 19 (63) | .76 | 40 (66) | 18 (53) | .23 |
Sunglasses | 59 (62) | 35 (54) | 24 (80) | .02 | 36 (59) | 23 (68) | .41 |
Umbrella | 48 (51) | 38 (59) | 10 (33) | .02 | 34 (56) | 14 (41) | .17 |
aFG1: modified Fitzpatrick group 1.
bFG2: modified Fitzpatrick group 2.
Skin lightening is a multibillion dollar industry among Chinese people. Despite Chinese culture’s well-known and generally strong preferences for whiter, lighter-toned skin [
Given that skin cancer incidence rates and mortality continue to increase among Chinese people [
In this study, most participants were Han Chinese, which is consistent with Chinese ethnic demographics. Most participants were born in China after 1975 (
Consistent with the participants’ age distribution, only one of the participants had a history of precancerous or cancerous lesions (
While participants across all groups predominantly (>89%) believe that POC can get skin cancer, most participants believe that Chinese people are less at risk than Caucasian people (
The potential significance of geographic location could be linked to experience bias. The higher awareness of skin cancer by Chinese people in North America may be related to living in heterogenous communities, wherein non-Asian counterparts are subject to skin cancer. Nonetheless, there is consistent recognition across regions and Fitzgerald scores that skin color does not guarantee immunity to skin cancer.
Knowledge about skin cancer is limited in Chinese communities; only 50.0%-64.4% of participants can define melanoma as a type of skin cancer (
Group 1 and group 2 have read the latest skin care recommendations at comparable rates (
Across location and modified Fitzpatrick score groups, 37.7%-47.1% of respondents in each group lacked concern regarding the risk of skin cancer in their lifetime (
While most participants are either likely or very likely to see a clinician for a new lesion, participants consistently reported low rates of annual skin checks; significantly more annual skin checks occured in North America than in Asia (
Most Chinese people across all groups had neither received sun safety education from their clinicians nor were generally satisfied with the education when provided (
While no participants used sunbeds, outdoor sun tanning practices were more popular among North American Chinese than Chinese Asian people (
Sunscreen use was reported in 47.1%-67.2% of participants across locations and modified Fitzpatrick score groups (
Nonetheless, a sizeable minority do not use sunscreen. Efforts are needed to confirm that these individuals are using other forms of UV protection, including hats, umbrellas, and sunglasses; in this study, 35 (37%) of all 95 Han Chinese participants stated that they used no forms of UV protection at all (
No significant differences concerning the lack of sunscreen use were found between group 1 and group 2 nor FG1 and FG2 (
It is worthwhile to note that some people reported a lack of knowledge on correct sunscreen use (
In terms of alternative methods for sun protection, group 1 and group 2 used wide-brimmed hats and long-sleeve clothing at similarly high rates (39/65, 60% vs 19/30, 63%,
Between FG1 and FG2, protective clothing, sunglasses, and umbrella use rates were similar between the groups (
It is imperative to educate and motivate Chinese communities to intervene in the growing severity of diagnoses and incidence of skin cancer. Given the similarities in responses between groups, it is not unreasonable to begin with a standard guide translated into various languages and methodology for addressing skin cancer knowledge and behavior between clinicians and Chinese patients in various languages. Effective dissemination of educational messages can be achieved via social media and other forms of mass media [
Moreover, Chinese communities have expressed interest in skin exams and increased breadth and depth of sun safety education. Efforts should be made in dermatology residency programs internationally to emphasize skin cancer risks, signs, and symptoms among all skin types, including Chinese; review specific techniques for skin protection to aid in patient education; and train residents to complete total body skin exams (TBSEs). We recommend that annual TBSEs should be conducted by a dermatologist.
Current screening guidelines confound this recommendation—the US Preventative Services Task Force states that there is insufficient evidence to determine the effectiveness of visual skin exam screenings in US patients without obvious related signs or symptoms [
Differences in health care systems provide another challenge to implementing TBSEs. In China, traditional Chinese medicine (TCM) is practiced alongside Western medicine, each with its own set of diagnostics, interpretations, therapeutics principles, and treatments [
Furthermore, China’s multitiered health care system is intended to coordinate between primary health care with general practitioners and secondary and tertiary health care at hospitals, with more complex levels of care and with more resources available at higher-tiered hospitals. Currently, there is limited use of primary health care services in China and preferential use of hospitals for medical services [
Supplementarily, self-examination techniques should be taught through private and public health organizations to be conducted at regular intervals appropriate to individuals’ genotypic, phenotypic, and environmental risk levels; all communities should be encouraged to seek clinical evaluation for lesions identified by tools such as the ABCDE rule (asymmetry, border irregularity, color nonuniformity, diameter >6 mm, and evolution) or the “ugly duckling” sign. Resources for POC to recognize their risks of malignancy and methods to protect against UV radiation—such as how to properly apply sunscreen—should be commonplace, and some examples can be found on the American Academy of Dermatology [
For the individual patient, culture, phenotypes, and lifestyles can significantly influence responses to upon all steps of the process, from information intake to application. Thus, all these factors ultimately should be considered in individualized educational programs and clinicians’ care for Chinese patients both in Asia and in North America.
Aside from the limitations of recall bias for survey-based research, future comparisons of groups by demographics of sex, age, and level of education would elucidate further stratifications of attitudes and practices and may provide suggestions for tailoring educational programs more specifically for individual patients [
Contextual exposure to UV radiation was not accounted for as part of this study. Though it certainly influences practices for sun protection and the risk of skin cancer, everyone has noninsignificant exposure risks to UV radiation. Among melanoma cases, the most common subtypes in China are acral and mucosal, followed by superficial spreading [
We consequently plan to expand our survey questions and recruit more participants to gain further insight concerning awareness of, exposure to, and behavior related to vocational and avocational exposure risks to UV radiation effects on skin health [
Given the population size of Han Chinese and the diaspora across the globe, new surveys will capture additional demographics and clarify regional geographical differences in cancer incidence and burdens within different Chinese provinces [
Furthermore, we will collaborate with more Chinese dermatology researchers and clinicians to expand our outreach. The collaboration would facilitate the surveying of more older participants who were born prior to 1975, allowing us to compare viewpoints between generations.
In conclusion, our Chinese-language survey was used to assess and compare Han Chinese attitudes and practices related to skin cancer risks and prevention. We identified manifestations of cultural differences between Chinese Asian and North American Chinese communities that use social media, and we determined that opinions and behaviors among Han Chinese people may differ by modified Fitzpatrick score.
From our findings, we proposed several aims for educational programs by clinicians and health care organizations in Asia and North America for the largest ethnic group in the world. Through a collective and adaptive effort across all levels of health care, knowledge and practices with respect to sun protection and skin cancer among Chinese populations globally can be improved to reduce morbidity and mortality among this subset of POC.
Survey questions in Chinese as seen by participants and English translation of questions.
Select highlights of sun safety and skin cancer–related resources from China.
modified Fitzpatrick group 1
modified Fitzpatrick group 2
people of color
total body skin exam
traditional Chinese medicine
This work was supported by grants from the University of Central Florida College of Medicine Focused Inquiry & Research Experience Program. We would also like to thank the Basal Cell Carcinoma Nevus Syndrome Life Support Network (now called Gorlin Syndrome Alliance) for providing access to SurveyMonkey resources. Portions of this manuscript were presented in poster form at the Society for Investigative Dermatology 2022 Annual Meeting, Portland, OR, May 19, 2022.
None declared.