J Skin Cancer. 2016; 2016: 4632037.

Published online 2016 Feb 29. doi: 10.1155/2016/4632037

PMCID: PMC4789471

Inflammatory Bowel Disease and Skin Cancer: An Assessment

of Patient Risk Factors, Knowledge, and Skin Practices
Jessica N. Kimmel, 1 , * Tiffany H. Taft, 1 and Laurie Keefer 1 , 2

Author information ► Article notes ► Copyright and License information ►

Abstract
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1. Introduction
Skin cancer is the most common form of cancer in the United States and causes significant
morbidity and mortality [1]. Inflammatory bowel disease (IBD) is a chronic autoimmune
condition that is associated with increased risk of development of skin cancer. Proposed
mechanisms predisposing IBD patients to skin cancer include chronic inflammation, cellular
damage, and underlying immune dysfunction leading to altered tumor surveillance [2–4].
Use of immunosuppressants in IBD patients has been shown to lead to a 4–7-fold increased
risk of skin cancer and approximately half of IBD patients are exposed to these medications
within 5 years of diagnosis [3]. Specifically, the use of biologic and immunomodulating
agents increases skin cancer risk [2–6]. Similarly, immunosuppression has been shown to
accelerate the development of skin cancer in transplant patients; thus, routine skin exams are
recommended [3, 4]. According to the United States Preventive Service Task Force, there is
insufficient evidence to assess the risk versus benefit for general skin cancer screening [7]. In
addition, there is a lack of data to support that early detection of skin cancer reduces
morbidity and mortality [5]. However, patients with IBD have different risk factors for skin
cancer development compared to the general population. Thus, these skin cancer screening
recommendations may not be applicable to IBD patients. Despite the lack of specific
standardized guidelines for screening, there is general consensus among gastroenterologists
that IBD patients should protect themselves from the sun and that annual skin cancer
surveillance should be considered, especially for patients on biologic and immunomodulating
agents [5, 8, 9].
Thus, it is important for IBD patients to be aware of their risk of skin cancer and to adopt
preventive strategies for modifiable risk factors. The aims of this study are to assess IBD
patients' risk factors for and knowledge of skin cancer. In addition, we will assess patients'
current skin protection practices. We anticipate that this survey will help to identify gaps in
patient education regarding skin cancer prevention in the IBD population.
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2. Methods

2.1. Patients
Patients 18 years of age or older with a diagnosis of inflammatory bowel disease were
eligible for inclusion in the study. Due to the study design, a diagnosis of IBD was via self-
report. Patients were recruited via email, by online sources, and by healthcare providers in
gastroenterology offices at Northwestern Medicine. All subjects gave informed, signed
consent prior to study registration. Eligible patients who agreed to participate were
forwarded to an online, confidential, anonymous survey. Data was collected using Adobe
FormsCentral. Study design was approved by the Northwestern University Institutional
Review Board.

2.2. Survey Design

A cross-sectional research questionnaire queried patients about baseline demographics and
IBD-related information, including medications, complications, and extent of their IBD. In
addition, study participants were questioned about their individual skin cancer risk factors,
sun exposure and skin protection practices, behaviors in the event that they identified a mole,
and general skin cancer knowledge. Topics addressed in this study were compiled after
critical review of published literature on skin cancer and its risk factors and included a
compilation of questions in formats derived from other validated skin cancer assessments
[6, 10–16]. Answers were formatted with Likert scales, true/false, and multiple-choice
responses (Table 1). Questions were reviewed by dermatologists prior to administration.

Table 1
Categorized questions and answers for skin cancer variables (skin cancer prevention,
awareness, knowledge, skin protection, and sun exposure).

2.3. Statistical Analyses

All responses were exported from the online system into SPSS v.22 for analysis. Data were
tested for normal distribution. Descriptive statistics (percentages, mean (SD)) analyzed the
demographic and clinical characteristics of the study sample. Scores for each skin cancer
category were summed to produce total scores for skin cancer prevention (out of 28),
awareness (out of 40), knowledge (out of 4), protection (out of 32), and exposure (out of 24).
Each score was compared by demographic and clinical variables via a series of independent
samples t-tests and one-way analysis of variance (ANOVA). Relationships between
continuous variables were evaluated via Pearson's correlations while categorical variables
were analyzed via Chi Square. Statistical significance was set to P ≤ 0.01 for t-tests and
ANOVA to control for type I error due to multiple comparisons.
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3. Results
A total of 164 patients with inflammatory bowel disease completed the online survey. Patient
demographics are reported in Table 2. The mean age of participants was 43.5 years and 63%
of patients were female. The majority of study participants were Caucasian (94%, n = 153)
and non-Hispanic (98%, n = 161). Crohn's disease was reported in 67% of patients,
ulcerative colitis in 31%, and indeterminate colitis in 2%. Ninety-five percent of patients
were currently receiving IBD treatment at the time of survey response. Approximately two-
thirds (n = 105) of patients reported either current or past treatment with immunomodulators
(which include Imuran/Azathioprine and 6-mercaptopurine) and approximately two-thirds
with biologics (n = 103).

Table 2
Patient demographics.
Sunburn and skin cancer history were assessed and reported in Table 3. Twelve percent of
patients (n = 19) reported a personal history of skin cancer, of which 7% were basal cell
carcinoma, 2% squamous cell carcinoma, 1% melanoma, and 4% multiple types of skin
cancer. Additionally, 34% (n = 55) reported having a first-degree relative with skin cancer.
Sixty-two percent (n = 102) of patients had three or more episodes of bad sunburns. The
majority of patients (70%) had seen a dermatologist, with 35% of patients receiving a full
skin exam once per year, 30% less than once per year, and 24% having never received a skin
exam. Half of patients (51%, n = 84) were self-referred to a dermatologist;
gastroenterologists referred 13% of patients for dermatology consultation and primary care
referred 17%.
Table 3
Patient skin cancer information.
Patient responses to standardized questions of skin cancer prevention, awareness, knowledge,
protection, and sun exposure are reported in Table 1. Average scores for skin cancer
prevention, awareness, knowledge, skin protection, and sun exposure were 16.24/28,
34.34/40, 2.93/4, 16.1/32, and 6.15/24, respectively. Patients over 40 years of age scored
higher on prevention (17.45/28) compared to patients 40 years old or younger (15.35/28, P =
0.03). Females scored higher on skin protection (16.94/32 compared to 14.53/32 for
males, P = 0.02) and awareness (35.16/40 compared to 32.98/40 for males, P= 0.03, Table
4). There were no statistically significant differences in scores between participants with or
without exposure to immunomodulators. There was a difference in knowledge scores
between those currently treated with biologic agents (3.01/4) compared to those with prior
biologic exposure (2.91/4) or no exposure (2.85/4, P ≤ 0.01). Additionally, those who had a
personal history of skin cancer scored better on both skin protection (21.47/32) and
prevention (20.56/28) questions compared to those without a personal history (15.33/32,
15.75/28, resp., P ≤ 0.001). In addition, those with a family history scored higher on skin
protection questions (18.46/32) compared to those without a first-degree relative with skin
cancer (14.03/32, P ≤ 0.001). When asked if IBD and its treatment increase the risk of skin
cancer, 61% of patients agreed with the statement and 38% responded neutrally or disagreed
(Table 5); patients currently or previously treated with immunomodulators scored higher
than those who were not on these medications (P = 0.000).

Table 4
Mean differences for skin cancer variables by various demographics and treatment.
Table 5
Patient responses to the following question: “Are you at increased risk of having skin cancer
because of your IBD and the medications that you take for the treatment of IBD?”
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4. Discussion and Conclusion

Patients with inflammatory bowel disease are at increased risk of development of skin cancer
compared to the general population, independent of the use of immunosuppressants [2, 3].
Thus, this questionnaire aimed to assess IBD patients' actual and perceived risk factors for
and knowledge of skin cancer as well as general skin protection strategies. Overall, we found
that IBD patients are well informed about skin cancer and are cognizant of worrisome skin
features. Despite this insight, they often practice suboptimal skin protection and prevention.
According to the social-cognitive theory of health behavior, knowledge of risk alone is
insufficient for behavior change; patients also require the perception of personal risk and
skills training to change their habits [17]. This study highlights a potential opportunity for
health professionals to teach and reinforce skin cancer prevention in IBD.
Other than treating the underlying inflammatory state of IBD, many of the factors that place
these patients at additional risk of skin cancer development, including effective IBD
treatments and early age at diagnosis, are not easily modifiable. However, similar to the
general population, behavioral changes, such as avoidance of sun exposure and tanning beds
and skin protection with use of sunscreen and protective clothing, can prevent or decrease the
risk of skin cancer. One's perceived risk of skin cancer encourages these protective
behaviors. On the contrary, a lack of awareness of skin cancer risk serves as a barrier to
adoption of protective behaviors [14]. Overall, we found that IBD patients do have a modest
understanding of skin cancer and are aware of worrisome signs and risk factors for skin
cancer occurrence. In addition, our patient cohort does not report significant sun exposure.
However, despite their knowledge and awareness, our patient population does not practice
optimal sun protection or prevention strategies if they were to find a new mole.
Furthermore, when asked if IBD and its treatment increase one's skin cancer risk, 61% of
patients agreed with this statement. Those with exposure to immunomodulators, which have
been shown to increase the risk of skin cancer, did score higher for this variable. A
proportion of our IBD population still does not recognize that their IBD increases their
personal risk of skin cancer. Individuals adopt protective behavior (such as sun protection) if
they perceive a health threat (such as skin cancer) [18, 19]. According to the health behavior
model, if IBD patients do not perceive a personal risk of skin cancer development, they may
not adopt effective skin protection behaviors [18]. Thus, it is our role as clinicians to discuss
this topic with our patients. Furthermore, patients must understand that the proposed
behavioral changes can mitigate this threat and that they can overcome barriers to achieving
this [17, 18]. Accordingly, this highlights the importance of not only teaching patients about
their own risk but also providing them with ways to minimize this risk with methods to
protect oneself from the sun and its negative effects.
Moreover, we found that patients with a personal and family history of skin cancer tend to
address worrying skin lesions with more vigilance and practice better sun protection than
those without such histories. This further highlights that one's perceived risk of skin cancer
development motivates one to adopt appropriate skin protection strategies. We found that
females practice more appropriate sun protection and are better informed about skin cancer
risk factors and worrisome skin features, which is consistent with prior studies [11]. Previous
reports have found that young age is associated with high-risk behavior for skin cancer
development, less knowledge about skin cancer, and increased incidence of skin cancer,
especially melanoma [3, 11–14]. We found that patients over 40 years of age are more
cognizant of when to seek medical attention for worrisome skin features. IBD patients often
present in early adulthood, thus increasing the cumulative risk of skin cancer development.
Specifically, younger men with Crohn's disease have an increased risk of nonmelanoma skin
cancer; therefore, this is a particularly important group to target [3].
Our study has a few limitations. There is inherent reporter bias associated with the study
design. The questionnaire format may both over- and/or underestimate skin cancer risk
factors and skin practices. The participatory nature inherent in a research questionnaire leads
to selection bias. Furthermore, given the anonymous nature of the survey, a diagnosis of IBD
was self-reported and not confirmed via chart review. In addition, this study is limited by a
sample primarily recruited in GI clinics at one large academic medical center. Thus, the
study population may not be representative of all patients with inflammatory bowel disease.
In addition, questionnaire items were compiled based on prior literature and skin cancer
surveys; however, this specific survey has not been validated. Furthermore, some findings
were statistically significant using a P value of <0.05 instead of 0.01; thus there is the
possibility of a type I statistical error.
Our study shows that the majority of survey participants did recognize the connection
between skin cancer and IBD. Comparatively, quality improvement studies have found even
lower vaccination rates in the IBD population. Encouragingly, several studies have
demonstrated remarkable improvements in vaccination rates with implementation of
educational programs and increased access to vaccines [20–22]. As in vaccination studies,
physician recommendations for skin cancer prevention may not be sufficient for behavioral
change. Our study demonstrates that despite general knowledge about skin cancer and an
overall understanding that they are at increased risk of skin cancer development, our IBD
population continues to practice suboptimal skin protection. Educational modules may be
necessary for IBD patients to further understand their personal risk of skin cancer
development and to provide more information regarding appropriate preventive and
protective behaviors. According to the social-cognitive theory of health behavior, in addition
to knowledge of risk, patients also require guidance in tools to minimize this risk. Given the
young age at IBD diagnosis, there is ample opportunity to intervene, educate, and reduce the
cumulative risk of skin cancer development in this population.
This study supports the hypothesis that primary prevention of skin cancer in the IBD
population is suboptimal and emphasizes a potential opportunity for healthcare professionals
to highlight this population's risk and reinforce skin cancer prevention strategies.
Implementation for improvement includes clinical reminders at each visit and educational
modules on proper skin protection techniques.
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Acknowledgments
The authors thank all of the patients who participated in this study. They also thank Amanda
Nolan who contributed to patient recruitment.
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Conflict of Interests
Dr. Keefer received a one-time consulting fee from Abbvie in 2014.
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Authors' Contribution
All authors have made substantial contributions to the study design and concept, as well as
data acquisition, analysis, and interpretation. Jessica N. Kimmel contributed to study concept
and design, data acquisition, interpretation of data, and drafting and critical revision of the
paper. Tiffany H. Taft contributed to data analysis and interpretation and revised the paper
critically. Laurie Keefer contributed to study concept and design and revised the paper
critically. All authors approve the final version.
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