HJCE

Skin Cancer Coverage in a National Newspaper: A Teachable Moment

News Coverage of Skin Cancer

MAUREEN K. HENEGHAN, BSC, CAROLE HAZAN, MD, ALLAN C. HALPERN, MD, MS, SUSAN A. OLIVERIA, SCD, MPH Abstract—Background. The objectives of this study were to (1) identify the number of published articles related to skin cancer in The New York Times newspaper from 1980-2004; (2) assess the content of the articles related to skin cancer, and (3) examine the trends in media coverage of skin cancer over time. Methods. We performed a content analysis on articles related to skin cancer appearing in The New York Times during January 1, 1980, through December 31, 2004, using the ProQuest® online content repository database and key words skin cancer. We conducted an advanced focus search of all “skin cancer” articles using key words “melanoma,” “squamous cell carcinoma,” “basal cell carcinoma,” “sunscreen,” “tanning,” “sunbathing,” and “tanning salon”. Results. We identified 874 published articles relating to skin cancer. Melanoma was the primary subject of the 874 articles, with 29% of the articles focusing on some aspect of melanoma. Coverage of other major subjects included sunscreen (11%), tanning (9%), basal cell carcinoma (7%), squamous cell carcinoma (3%), sunbathing (2%), and tanning salon (2%). The remaining 37% of articles contained some mention of skin cancer, but skin cancer was not the main topic nor were any of the focus terms. Over the 25-year period we examined, there was a slight upward trend in the number of skin-cancer-related articles, although we observed year-to-year variation. Conclusions. Understanding how the print media portrays skin cancer issues provides valuable feedback for federal agencies and cancer organizations and may ultimately help promote skin cancer prevention and education. J Cancer Educ. 2007; 22:99-104.

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According to a 2004 poll conducted by Princeton Survey Research Associates International in which 3,000 adults were surveyed,9 31% of Americans follow health news in daily newspapers “very closely.” Other sources of media that respondents followed very closely for health news included nightly network news (38%), cable news (34%), magazines (39%), radio (32%), and the Internet (25%). Additional studies have indicated that the mass media can have a strong impact on health behaviors, causing people to change their behavior or take action as a result of having read, seen, or heard a health news story. For example, adolescents who read fashion, entertainment, and gossip magazines have a greater receptivity to cigarette advertisements and may be more likely to smoke than adolescents reading health and fitness magazines.10 Also, a systematic review of the effectiveness of mass media campaigns for reducing alcohol-impaired driving and crashes determined that mass media campaigns were effective in reducing both behaviors.11 The media has a powerful impact in supplying the public with health information,12-20 and the media’s contribution to skin cancer education is crucial in further enhancing the public’s knowledge. Newspapers are a major source of information, especially in the medical and scientific field.16,21-23 From a public health standpoint, newspapers have the ability to set the agenda in ways that promote attitude, behavior, and even public policy changes.24-27 Newspaper coverage of skin cancer

n response to the rising incidence of skin cancer in the United States, numerous programs have been developed by the American Cancer Society, the Skin Cancer Foundation, the Center for Disease Control and Prevention, the American Academy of Dermatology (AAD), and the Environmental Protection Agency to disseminate information to the public about limiting sun exposure, using sunscreens and protective clothing, minimizing sunburns, and avoiding tanning beds.1-5 Skin cancer is the most common of all cancers, accounting for nearly half of all cancers in the United States.5 As skin cancer is primarily preventable through public education and behavior change,6 the importance for skin cancer awareness in public health programs is obvious. One of the ways in which skin cancer awareness is circulated, whether by federal agencies, cancer organizations, or other associations, is through the mass media. The media is a popular source of medical and health information.7,8 Received from the Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (MKH, ACH, SAO) and New York University School of Medicine, Department of Dermatology, New York, NY (CH). Supported by K07 CA94002 from the National Institutes of Health (SAO). Address correspondence and reprint requests to: Susan A. Oliveria, Dermatology Service, Memorial Sloan-Kettering Cancer Center, 160 East 53rd Street, 2nd Floor, New York, NY 10022; phone: (212) 610-0767; fax: (212) 308-0530; e-mail: .

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MATERIALS AND METHODS To obtain the most comprehensive information on skin cancer issues in the print media, a we performed a preliminary search across selected newspapers and included The Washington Post, USA Today, and The New York Times. The New York Times was selected as the best surrogate publication because (1) The New York Times sold a total of 2,801,640 copies in the 6-month period of April to September 2004,28 (2) The New York Times has given significant coverage of health and medical news since 1978 in the Science Times section,29 and (3) The New York Times newspaper had a searchable archived database for the time period studied. We utilized the ProQuest® online content repository database, a subscription-based search engine that covers a wide array of news articles on current events, legal business, and medical issues to identify and quantify articles related to skin cancer in The New York Times over a 25-year period (1980-2004). We performed a main search with the key words skin cancer. Inclusion criteria required that articles had at least 1 mention of the words skin cancer in the text. Articles that were excluded were birth notices, classifieds, comics, display advertisements, editorial articles, editorial cartoons, legal notices, letters, lottery numbers, marriages, obituaries, photographs, real estate, stock quotes, table of contents, and weather. Within the selected articles on skin cancer, we conducted an advanced focus search using key words melanoma, squamous cell carcinoma, basal cell carcinoma, sunscreen, tanning, sunbathing, and tanning salon. This search strategy proved to be the most comprehensive compared to other methods such as searching for articles with skin cancer in the title, which only revealed 47 documents over the 25-year period. Thus, the articles collected and analyzed are likely to represent most of the skin cancer related news coverage found in The New York Times during the period examined.

The total number of articles identified during this same time period that were related to cancer as a broader subject was 42,185. Thus, skin cancer articles represented about 2% (n = 874) of all articles that were cancer related. We observed considerable variation in the quantity of skin cancer related coverage each year, ranging from a peak of 56 articles in 1987 to a low of 13 articles in both 1981 and 1984 (Figure 1). There was a slight increase in the frequency of skin cancer related articles over time. There were also apparent fluctuations in the frequency of articles related to melanoma, squamous cell carcinoma, and basal cell carcinoma over the 25-year period examined (Figure 2). Similarly, fluctuations in the frequency of articles pertaining to sunscreen, tanning, sunbathing, and tanning salon were noted over time, whereas sunscreen and tanning were discussed more frequently than sunbathing and tanning salons in most years (data not shown). There was additional variation in the dominant themes of the articles (Figure 3). Melanoma was the overriding subject of the 874 articles, with 29% (n=253) of the articles focusing on some aspect of melanoma. Coverage of other major subjects included sunscreen (11%, n=92), tanning (9%, n=80), basal cell carcinoma (7%, n=65), squamous cell carcinoma (3%, n=30), sunbathing (2%, n=16), and tanning salons (2%, n=15). The remaining 37% (n=323) mentioned skin cancer in general, but the main focus of the article tended not to be about 1 type of skin cancer in particular; these articles only briefly contained a statement or 2 about skin cancer. Specifically, over half of these remaining articles (n=234) were related to environmental risks such as ozone depletion, which has lead to diminished ultraviolet radiation protection and a higher risk of getting skin cancer.

DISCUSSION The results of this analysis provide the first identification, content assessment, and trend examination of skin cancer issues in The New York Times newspaper. The total number of skin cancer related articles identified (n=874) 60 50 Number of Articles

creates public awareness of current issues and also helps define the way people think about skin cancer as a health problem. Given the magnitude of the potential influence that media coverage may have on the general public, it is important to recognize how skin cancer issues are being discussed in the media. The overall aim of this study was to understand and quantify skin cancer issues in the print media, specifically The New York Times newspaper, over a 25-year period from 19802004. The major aims were to (1) identify the number of published articles related to skin cancer, (2) assess the content of the articles related to skin cancer, and (3) examine the trends in skin cancer coverage over time.

40 30 20 10

RESULTS 0

We identified 874 published articles relating to skin cancer in The New York Times from January 1, 1980, through December 31, 2004. This represents an average of almost 35 articles per year, or just less than 3 articles per month. 100

1980

1985

1990

Year

1995

2000

2005

FIGURE 1. The frequency of newspaper articles related to skin cancer in The New York Times from 1980-2004. HENEGHAN et al. ■ News Coverage of Skin Cancer

18 16

Number of articles

14 12 Melanoma

10

BCC

8

SCC

6 4 2 0

1980

1982

1984

1986

1988

1990

1992 Year

1994

1996

1998

2000

2002

2004

FIGURE 2. The frequency of newspaper articles related to skin cancer with a focus on melanoma, basal cell carcinoma (BCC), or squamous cell carcinoma (SCC) in The New York Times from 1980-2004. melanoma 29%

other 37%

SCC 3%

tanning salon 2%

BCC 7%

sunbathing 2% tanning 9%

sunscreen 11%

FIGURE 3. The dominant themes of newspaper articles related to skin cancer in The New York Times from 19802004. “Other” category represents articles that contained key words skin cancer, but the main focus of the article was not skin cancer. BCC indicates basal cell carcinoma; SCC, squamous cell carcinoma.

reflects an average of just under 3 articles per month. To put this in perspective, cancer in general was discussed in over 42,000 articles over the 25-year period. Therefore, skin cancer represents a small portion of all cancer related articles or just above 2%. This percentage is much lower than the percentage of all cancer patients who specifically have been diagnosed with skin cancer (nearly 50%).5 Furthermore, as the majority (37%) of skin cancer related articles was not exclusively about skin cancer, the total number of articles solely pertaining to skin cancer is overestimated. Given this, the news media is not accurately representing skin cancer issues. In fact, in a similar study by Stryker et al,30 a content analysis of skin cancer articles released by the Associated Press from 1979 to 2003 revealed that media attention to skin cancer has not increased since 1986, the Journal of Cancer Education 2007, Volume 22, Number 2

media pays little attention to skin cancer, and stories often lack important educational information.30 The New York Times is a media outlet extending to 4,928,200 readers during the week and 6,871,700 readers on Sundays,28 and exposing millions of readers to more frequent skin cancer issues might be important to further public awareness and knowledge. Over the time examined, there was a slight increase in the number of articles published, which might reflect the ongoing efforts of skin cancer prevention programs, many of which were established in 1983.31,32 In particular, since 1985, the AAD’s national program, Melanoma/Skin Cancer Detection and Prevention, has annually produced extensive print, radio, and television coverage about the dangers of sun exposure and benefits of sun protection.32 The AAD has also implemented free annual skin cancer screening programs throughout the United States since 1985. This program in which dermatologists perform free skin examinations and provide educational materials to the public has had a direct influence on the number of skin cancer related articles that have been published by the media.33 The goal of AAD and many other programs is to reduce the incidence and mortality of skin cancer through heightening awareness and knowledge of melanoma and nonmelanoma skin cancers among members of the general public and the health care community. Although the finding that only about 2% of all cancer related articles focus on skin cancer might be of concern for skin cancer prevention advocates, the slight increase in the quantity of articles over time is hopeful for increasing public exposure and awareness. The considerable fluctuation in the coverage of skin cancer suggests that skin cancer related issues and news coverage has varied over the years. Public attention does not remain concentrated on any 1 issue over long periods of time; instead, public attitudes and behavior are influenced by the “issue-attention cycle” in which public problems remain prominent for a short period of time and then begin 101

to fade from the center of attention.34 This, in addition to competing with other health news, presents a challenge to skin cancer prevention advocates who seek to permanently be on the media’s agenda.30 Research on advertising efforts has indicated that frequency of exposure is important in terms of educating and informing the public35; the greater consistency and more frequent exposure the news media provides, the more successful media advocacy will be in disseminating skin cancer information. Several of the peaks in skin cancer related articles can be attributed to the announcement of a skin cancer diagnosis in a public figure, particularly in politicians. The high number of skin cancer related articles between 1985 and 1988, for instance, is associated with the multiple diagnoses and treatments of skin cancer received by President Ronald Reagan. Overall, we identified 24 articles relating to President Reagan’s diagnoses of skin cancer between 1985 and 1988. President Reagan’s skin cancer diagnoses also explains the relatively high volume of articles related to basal cell carcinoma, his specific type of skin cancer. Likewise, there was a high number of articles related to melanoma in 2000 at the time when Senator John McCain was being diagnosed and treated. Of the 17 total melanoma articles in 2000, 7 were regarding his melanoma treatment. Clearly, the media portrays the diagnosis of skin cancer in public political figures as an important subject to cover. Research has indicated that the disclosure of an illness from a public figure can influence health care behaviors.36-42 Studies based on Katie Couric’s promotion of colon cancer awareness and screening after her husband died of the disease,43 Nancy Reagan’s public announcement of her breast cancer treatment,40,41 and Magic Johnson’s declaration of being HIV positive and his promotion of AIDS awareness,44-47 have suggested that a celebrity spokesperson can influence public participation in preventive care programs. With this said, celebrity role models with personal experiences of skin cancer should be encouraged to promote awareness; they have the potential to help shape news coverage and positively influence the health behavior of millions of people. The way in which the focus themes of skin cancer have been portrayed by the news media also has important public health implications. Melanoma was the major topic of all skin cancer related articles identified. Melanoma is the most fatal of all skin cancers, accounting for 79% of all skin cancer deaths.5 The number of new melanomas that will be diagnosed in 2007 is estimated to be about 59,940, and it is predicted that about 8,110 of these cases will be deadly.48 Basal cell carcinoma and squamous cell carcinoma are much more common than melanoma, as more than 1 million cases of nonmelanoma skin cancers are diagnosed annually in the United States;5 however, media attention to these 2 types of skin cancer is lacking. Moreover, in 1988, there was an unusually high number of articles related to sunscreen, which could be due to the advent of sunless tanning lotion and/or the controversy about whether a high sun protection factor has any real value. 102

Newspapers can be an important source of medical information, but they have the potential to be inaccurate. Journalists may not have specialized knowledge of medicine or science, and their opinion of reporting can differ from a scientist’s perspective.49-51 The lack of skin cancer coverage over time may be because journalists might not consider skin cancer as health “news.” The mission of The New York Times is to report news and inform the public correctly. However, journalists and media outlets often have a priority of entertaining the public rather than promoting health and disease prevention. When a famous person is diagnosed with cancer, for example, it often makes headlines, which can be misleading to draw attention to them. Likewise, skin cancer experts may be unable, or may refuse, to communicate with journalists. Cancer physicians and educators are often contacted by journalists when a famous person is diagnosed and an expert statement is needed. This presents an important opportunity for experts to use the media as a personal launch window to promote skin cancer awareness. Although these factors might make it difficult to achieve good health journalism, The New York Times generally provides accurate reporting, particularly in the Science Times section. In a detailed text study of the Science Times, it was determined that journalists do not actively obfuscate science; but instead, journalists try to integrate science and scientific work in a broader context.52 This analysis does not serve as a critique of The New York Times but rather identifies and considers the potential implications skin cancer coverage has on informing the general public. There are several limitations of this study. First, The New York Times, although very widely distributed, was the only paper we examined. The New York Times might not accurately reflect how skin cancer issues are being portrayed in other print media publications. By narrowing the focus solely on skin cancer articles, we recognize that these findings may not be generalizable to other newspapers or media outlets. In the context of this study and the resources available, it was not possible to examine other print media outlets such as additional newspapers and magazines. Second, assessing the content of the skin cancer articles and the classification of these articles into subcategories such as melanoma, basal cell carcinoma, and squamous cell carcinoma is a somewhat subjective process. The analysis of the trends in the media could be extended in a number of ways to provide a broader understanding of how the media has portrayed skin cancer over a 25-year span. Multiple newspapers could be studied along with other media outlets such as magazines, television, or the radio. Interviews and/or surveys could be conducted with public health reporters or health sector spokespersons. Such work could be justified given the high incidence of skin cancer and the importance of information for the public and the media on the control of the disease. In summary, consistent and more frequent media coverage of skin cancer remains crucial; maintaining a high frequency of skin cancer related issues in the media should be 1 goal of advocacy efforts. The findings support the need HENEGHAN et al. ■ News Coverage of Skin Cancer

for greater advocacy partnerships between the media and health educators as a means of informing the public about the prevention of skin cancer. Because the print media portrays the diagnosis of skin cancer in public figures as an important subject to cover, such instances can be considered public health opportunities the media and skin cancer experts can take advantage of to promote public awareness. Understanding which skin cancer issues are most likely to be covered and the content of the coverage about them provides valuable feedback for federal agencies and cancer organizations and may ultimately promote further prevention and education to decrease the incidence of skin cancer. References 1. Cantor M, Rosseel K, Rutsch L. The United States Environmental Protection Agency sunwise school program. Health Educ Behav. 1999;26:303-304. 2. The Skin Cancer Foundation. Public service announcement campaigns. New York: The Skin Cancer Foundation; 2005. Available at: http://www.skincancer.org/psaindex.php. Accessed January 15, 2005. 3. Jorgensen CM, Wayman J, Green C, et al. Using health communication for primary prevention of skin cancer: CDC’s Choose Your Cover Campaign. J Women Health Gender-Based Med. 2000;9:471-475. 4. Lim HW, Cooper K. The health impact of solar radiation and prevention strategies: report of the Environment Council, American Academy of Dermatology. J Am Acad Dermatol. 1999;42:81-99. 5. American Cancer Society. Skin cancer facts: What is the American Cancer Society doing about skin cancer? Atlanta, GA: American Cancer Society; 2005. Available at: http://www.cancer.org/docroot/ PED/content/ped_7_1_What_You_Need_To_Know_About_Skin_ Cancer.asp?sitearea=PED. Accessed April 15, 2005. 6. Hill D, White V, Marks R, et al. Melanoma prevention: behavioral and nonbehavioral factors in sunburn among an Australian urban population. Prev Med. 1992;21:654-669. 7. Moyer A, Greene S, Beauvais J, et al. Accuracy of health research reported in the popular press. Health Commun. 1994;7:147-161. 8. Clarke J, Robinson J. Testicular cancer: medicine and machismo in the media (1980-94). Health Educ Behav. 1999;3:263-282. 9. Doherty C, ed. Online News Audience Larger, More Diverse: News Audiences Increasingly Politicized. Pew Research Center Biennial News Consumption Survey; 2004. Washington, DC: The Pew Research Center for the People and the Press News Release. 10. Carson NJ, Rodriguez D, Audrain-McGovern J. Investigation of mechanisms linking media exposure to smoking in high school students. Prev Med. 2005;41:511-520. 11. Elder RW, Shults RA, Sleet DA, et al. Effectiveness of mass media campaigns for reducing drinking and driving and alcohol-involved crashes. Am J Prev Med. 2004;27:57-65. 12. Corbett JB, Mori M. Medicine, media, and celebrities: media coverage of breast cancer, 1960-1995. Journalism Mass Commun Q. 1999;76:229-249. 13. Gutman J. Physicians’ exposure to health topics through mass media: an avenue for improving the dietitian’s image. J Am Diet Assoc. 1977;71:505-509. 14. Meissner HI, Potosky AL, Convissor R. How sources of health information relate to knowledge and use of cancer screening exams. J Community Health. 1992;17:153-165. 15. O’Keefe MT. The mass media as sources of medical information for doctors. Journal Q. 1970;47:95-100. 16. Phillips DP, Kanter EJ, Bednarczyk B, et al. Importance of the lay press in the transmission of medical knowledge to the scientific community. N Engl J Med. 1991;325:1180-1183.

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HENEGHAN et al. ■ News Coverage of Skin Cancer