Introduction

Military veterans are an important yet understudied group at increased risk for skin cancer, including fatal melanomas [1]. This elevated risk is likely attributable to numerous factors, including: intermittent high ultraviolet radiation exposure from the sun during active duty; barriers to engaging in sun protection during military operations; high sunburn rates; elevated exposure to in-flight cosmic ionizing radiation; and over-representation of older White men among veterans [1]. Thus, there have been recommendations for military veterans to receive periodic, routine physician screenings for skin cancer [1–3]. The U.S. Preventive Services Task Force has not recommended skin cancer screening for the average-risk U.S. population, despite some controversy and experiences of other countries that have administered national skin cancer screening programs such as the German SCREEN program [4–7]. Little is known about receipt of skin cancer screening by military veterans. The primary goal of the current study was to examine the prevalence and correlates of physician skin cancer screening among military veterans.

Materials and methods

Statistical analyses

We used SAS 9.4 to carry out the analyses, which took into account the complex sample survey data that included sample weights and post-stratification adjustments. We conducted a multivariable logistic regression analysis to examine factors associated with ever having had a physician skin exam. The independent variables included in the multivariable logistic regression analysis are shown in Table 1. All percentages reported are weighted and all sample sizes are unweighted. A cutoff of P < 0.05 was used to determine statistical significance.

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Table 1. Sample characteristics, physician skin exam screening rates, and multivariable correlates of receipt of a physician skin exam among 2,826 U.S. military veterans, 2015 National Health Interview Survey.

https://doi.org/10.1371/journal.pone.0251785.t001

Results

Consistent with the U.S. veteran population, the sample was comprised largely of non-Hispanic white, middle-aged and older men (See Table 1). Almost two-thirds of veterans had either TRICARE or private health insurance. Fewer than a third (30.88%) of veterans reported ever having a physician skin exam. Among those reporting having a physician skin exam, half (51.60%) indicated that they had this exam in the past year. Results of the multivariable logistic regression analysis identified numerous factors that were significantly associated with a higher rate of physician skin cancer screening, including: older age; a higher level of education; being non-Hispanic white; living in the Northeast compared to the Midwest; having TRICARE health insurance; receiving preventive health care at a doctor’s office or health maintenance organization; having skin that is more sensitive to the sun; engaging in more sun protection behaviors; and being more physically active.

Discussion

Just under a third of military veterans in the current study reported that a physician had ever screened them for skin cancer. This figure is higher than the overall rate of 21.3% in the U.S. population in 2015 [10]. Higher rates of screening were found among individuals with one or more skin cancer risk factors, which is consistent with research conducted with non-veteran populations [10,12].

Screening rates were higher among more physically active individuals, who are at elevated risk for melanoma, which has been attributed to increased ultraviolet radiation-related skin damage from outdoor physical activity [13]. Skin cancer screening rates varied by veterans’ insurance status, with the highest screening rates among those with TRICARE insurance, which covers skin cancer exams, and the lowest rates among uninsured veterans. This finding is consistent with prior research reporting higher rates of provision of other preventive care services in VA medical facilities compared to non-VA settings [14]. The higher physician skin cancer screening rate among individuals who reported more frequently engaging in sun protection behaviors may reflect these individuals’ greater awareness and motivation with regard to skin cancer prevention. In general, however, previous research has shown that military veterans may not perceive themselves as being at increased risk for skin cancer [15,16]. In a study of military veterans who had been deployed to Iraq or Afghanistan, 63% reported having a sunburn during deployment and 29% reported that they noticed a changing mole after deployment, both of which are skin cancer risk factors. However, only 23% reported that the U.S. military made them very aware of the risks of skin cancer [17].

The strengths of this study include the use of a probability-based sample with a sample size of nearly 3,000 military veterans. The limitations include an inability to stratify results according to military branch, lack of information regarding additional potentially relevant skin cancer risk factors (e.g., lifetime history of sunburns), and the self-report nature of the data, which is subject to recall bias. However, several reports note recall bias for melanoma-related factors such as skin examinations and sunburns to be minimal [18–21]. Overall, the study results provide valuable insights on skin cancer screening rates among at-risk military veterans and opportunities for improvements.

Conclusions

Future research is warranted to test clinician screening interventions targeted for military veterans who are at increased risk for skin cancer. Further, such research should be accompanied by systematic efforts to improve skin cancer prevention, treatment, and outcomes among military service members and veterans, such as that supported by the Department of Defense Melanoma Research Program [22].

Acknowledgments

The authors gratefully acknowledge the National Center for Health Statistics (NCHS) for collecting the study data. The statistical analyses, interpretations, and conclusions drawn in this paper are attributable to the authors and do not necessarily represent the views of the NCHS.