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Although the harmful effects of smoking after a cancer diagnosis have been clearly demonstrated, many patients continue to smoke cigarettes during treatment and beyond. The NCCN Guidelines for Smoking Cessation emphasize the importance of smoking cessation in all patients with cancer and seek to establish evidence-based recommendations tailored to the unique needs and concerns of patients with cancer. The recommendations contained herein describe interventions for cessation of all combustible tobacco products (eg, cigarettes, cigars, hookah), including smokeless tobacco products. However, recommendations are based on studies of cigarette smoking. The NCCN Smoking Cessation Panel recommends that treatment plans for all patients with cancer who smoke include the following 3 tenets that should be done concurrently: (1) evidence-based motivational strategies and behavior therapy (counseling), which can be brief; (2) evidence-based pharmacotherapy; and (3) close follow-up with retreatment as needed.

The NCCN Guidelines for Central Nervous System (CNS) Cancers focus on management of the following adult CNS cancers: glioma (WHO grade 1, WHO grade 2–3 oligodendroglioma [1p19q codeleted, IDH-mutant], WHO grade 2–4 IDH-mutant astrocytoma, WHO grade 4 glioblastoma), intracranial and spinal ependymomas, medulloblastoma, limited and extensive brain metastases, leptomeningeal metastases, non–AIDS-related primary CNS lymphomas, metastatic spine tumors, meningiomas, and primary spinal cord tumors. The information contained in the algorithms and principles of management sections in the NCCN Guidelines for CNS Cancers are designed to help clinicians navigate through the complex management of patients with CNS tumors. Several important principles guide surgical management and treatment with radiotherapy and systemic therapy for adults with brain tumors. The NCCN CNS Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel’s most recent recommendations regarding molecular profiling of gliomas.

Differentiated thyroid carcinomas is associated with an excellent prognosis. The treatment of choice for differentiated thyroid carcinoma is surgery, followed by radioactive iodine ablation (iodine-131) in select patients and thyroxine therapy in most patients. Surgery is also the main treatment for medullary thyroid carcinoma, and kinase inhibitors may be appropriate for select patients with recurrent or persistent disease that is not resectable. Anaplastic thyroid carcinoma is almost uniformly lethal, and iodine-131 imaging and radioactive iodine cannot be used. When systemic therapy is indicated, targeted therapy options are preferred. This article describes NCCN recommendations regarding management of medullary thyroid carcinoma and anaplastic thyroid carcinoma, and surgical management of differentiated thyroid carcinoma (papillary, follicular, Hürthle cell carcinoma).

The NCCN Guidelines for Hepatobiliary Cancers focus on the screening, diagnosis, staging, treatment, and management of hepatocellular carcinoma (HCC), gallbladder cancer, and cancer of the bile ducts (intrahepatic and extrahepatic cholangiocarcinoma). Due to the multiple modalities that can be used to treat the disease and the complications that can arise from comorbid liver dysfunction, a multidisciplinary evaluation is essential for determining an optimal treatment strategy. A multidisciplinary team should include hepatologists, diagnostic radiologists, interventional radiologists, surgeons, medical oncologists, and pathologists with hepatobiliary cancer expertise. In addition to surgery, transplant, and intra-arterial therapies, there have been great advances in the systemic treatment of HCC. Until recently, sorafenib was the only systemic therapy option for patients with advanced HCC. In 2020, the combination of atezolizumab and bevacizumab became the first regimen to show superior survival to sorafenib, gaining it FDA approval as a new frontline standard regimen for unresectable or metastatic HCC. This article discusses the NCCN Guidelines recommendations for HCC.

The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic focus primarily on assessment of pathogenic or likely pathogenic variants associated with increased risk of breast, ovarian, and pancreatic cancer and recommended approaches to genetic testing/counseling and management strategies in individuals with these pathogenic or likely pathogenic variants. This manuscript focuses on cancer risk and risk management for BRCA-related breast/ovarian cancer syndrome and Li-Fraumeni syndrome. Carriers of a BRCA1/2 pathogenic or likely pathogenic variant have an excessive risk for both breast and ovarian cancer that warrants consideration of more intensive screening and preventive strategies. There is also evidence that risks of prostate cancer and pancreatic cancer are elevated in these carriers. Li-Fraumeni syndrome is a highly penetrant cancer syndrome associated with a high lifetime risk for cancer, including soft tissue sarcomas, osteosarcomas, premenopausal breast cancer, colon cancer, gastric cancer, adrenocortical carcinoma, and brain tumors.

The NCCN Guidelines for Central Nervous System (CNS) Cancers focus on management of adult CNS cancers ranging from noninvasive and surgically curable pilocytic astrocytomas to metastatic brain disease. The involvement of an interdisciplinary team, including neurosurgeons, radiation therapists, oncologists, neurologists, and neuroradiologists, is a key factor in the appropriate management of CNS cancers. Integrated histopathologic and molecular characterization of brain tumors such as gliomas should be standard practice. This article describes NCCN Guidelines recommendations for WHO grade I, II, III, and IV gliomas. Treatment of brain metastases, the most common intracranial tumors in adults, is also described.

The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic provide recommendations for genetic testing and counseling for hereditary cancer syndromes, and risk management recommendations for patients who are diagnosed with syndromes associated with an increased risk of these cancers. The NCCN panel meets at least annually to review comments, examine relevant new data, and reevaluate and update recommendations. These NCCN Guidelines Insights summarize the panel’s discussion and most recent recommendations regarding criteria for high-penetrance genes associated with breast and ovarian cancer beyond BRCA1/2, pancreas screening and genes associated with pancreatic cancer, genetic testing for the purpose of systemic therapy decision-making, and testing for people with Ashkenazi Jewish ancestry.

Histiocytic neoplasms are rare hematologic disorders accounting for less than 1% of cancers of the soft tissue and lymph nodes. Clinical presentation and prognosis of these disorders can be highly variable, leading to challenges for diagnosis and optimal management of these patients. Treatment often consists of systemic therapy, and recent studies support use of targeted therapies for patients with these disorders. Observation (“watch and wait”) may be sufficient for select patients with mild disease. These NCCN Guidelines for Histiocytic Neoplasms include recommendations for diagnosis and treatment of adults with the most common histiocytic disorders: Langerhans cell histiocytosis, Erdheim-Chester disease, and Rosai-Dorfman disease.

Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers provide treatment recommendations for cancers of the lip, oral cavity, pharynx, larynx, ethmoid and maxillary sinuses, and salivary glands. Recommendations are also provided for occult primary of the head and neck (H&N), and separate algorithms have been developed by the panel for very advanced H&N cancers. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding the increase in human papillomavirus-associated oropharyngeal cancer and the availability of immunotherapy agents for treatment of patients with recurrent or metastatic H&N cancer.

Distress is defined in the NCCN Guidelines for Distress Management as a multifactorial, unpleasant experience of a psychologic (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Early evaluation and screening for distress leads to early and timely management of psychologic distress, which in turn improves medical management. The panel for the Distress Management Guidelines recently added a new principles section including guidance on implementation of standards of psychosocial care for patients with cancer.

BACKGROUND: The goal of this study was to investigate the association of health literacy with skin cancer risk and protective behaviors among young adults at moderate to high risk of skin cancer, the most common cancer. METHOD: A US national sample of 958 adults, 18–25 years old, at moderate to high risk of developing skin cancer, completed a survey online. Behavioral outcomes were ultraviolet (UV) radiation exposure (e.g., indoor and outdoor tanning, sunburn) and protective (e.g., sunscreen use, sunless tanning) behaviors. Multivariable regression analyses were conducted to determine whether health literacy (a four-item self-report measure assessing health-related reading, understanding, and writing) was associated with behavioral outcomes while controlling for demographic factors. RESULTS: Higher health literacy was independently associated with less sunbathing, odds ratio (OR) = 0.77, 95% confidence interval (CI) = 0.60–0.98; less indoor tanning, OR = 0.38, CI = 0.31–0.48; and less use of tanning oils, OR = 0.54, CI = 0.43–0.69. However, health literacy was also associated with a lower likelihood of wearing long pants, OR = 0.76, CI = 0.58–0.99, or a hat, OR = 0.68, CI = 0.53–0.87, when outdoors. On the other hand, higher health literacy was associated with higher incidental UV exposure, OR = 1.69, CI = 1.34–2.14, and a greater likelihood of ever having engaged in sunless tanning, OR = 1.50, CI = 1.17–1.92. CONCLUSION: Interestingly, higher health literacy was associated with lower levels of intentional tanning yet also higher incidental UV exposure and lower skin protection among US young adults. These findings suggest that interventions may be needed for young adults at varying levels of health literacy as well as populations (e.g., outdoor workers, outdoor athletes/exercisers) who may be receiving large amounts of unprotected incidental UV.

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel’s discussion and updated recommendations regarding systemic therapy for first-line and subsequent-line treatment of patients with hepatocellular carcinoma.

Skin cancer is the most common cancer, and its incidence is increasing. Young adults expose themselves to large amounts of ultraviolet radiation (UV) and engage in minimal skin protection, which increases their risk. Internet interventions are effective in modifying health behaviors and are highly disseminable. The current study's purpose was to test an Internet intervention to decrease UV exposure and increase skin protection behavior among young adults.RCT conducted in 2014, with data analyzed in 2015.A national sample of adults aged 18-25 years at moderate to high risk of developing skin cancer by a self-report measure was recruited online.Participants were randomized to one of three intervention conditions: assessment only, the website of a skin cancer organization, or a tailored interactive multimedia Internet intervention program (UV4.me) based on the Integrative Model of Behavioral Prediction.Self-reported overall UV exposure and skin protection assessed at 3 and 12 weeks after baseline. Secondary outcomes were self-reported intentional and incidental UV exposure, sunburns, sunscreen use, and skin cancer screening.For the intervention arm, there were significant decreases in UV exposure and increases in skin protection at both follow-up time points compared with the assessment-only condition (p0.001). The effect sizes (Cohen's d) comparing the experimental and assessment-only arm for exposure behaviors were 0.41 at 3-week follow-up and 0.43 at 12-week follow-up. The effect sizes for protection behaviors were 0.41 at 3-week follow-up and 0.53 at 12-week follow-up. The control condition was not significantly different from the assessment only condition. All three conditions exhibited decreased exposure and increased protection at both follow-ups (p0.01), but the effect was much stronger in the intervention group. Secondary outcomes were generally also significantly improved in the intervention condition compared with the other conditions.This is the first published report describing the results of an RCT of an Internet intervention to modify skin cancer risk behaviors among young adults. The UV4.me intervention significantly improved self-reported skin cancer prevention behaviors. Future research will investigate mechanisms of change and approaches for dissemination.This study is registered at www.clinicaltrials.gov NCT02147080.

The NCCN Guidelines for Head and Neck (H&N) Cancers provide treatment recommendations for cancers of the lip, oral cavity, pharynx, larynx, ethmoid and maxillary sinuses, and salivary glands. Recommendations are also provided for occult primary of the H&N, and separate algorithms have been developed by the panel for very advanced H&N cancers. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding evaluation and treatment of nasopharyngeal carcinoma.

We aimed to further the understanding of the low rates of sun protection in young women at risk for skin cancer. Six-hundred-sixty-one daily diary entries were received via text message over 14 days from 56 young women at moderate to high risk of developing skin cancer. Women reported whether or not they used sun protection and also listed what their reasons were for using protection or not using sun protection each day. Multi-level modeling was used to examine the influence of study variables when predicting daily sun protection or lack of protection. The number of days in which sun protection was reported was positively associated with “habit” and “prevention” as reasons for protection and negatively associated with “not-needed” and “unprepared” as reasons for non-protection. Self-reported sun protection increased over the 14-day study period. Results of this study suggest the potential value of interventions aimed at motives for sun-protection behaviors.

Tanning during adolescence increases skin cancer risk. Relatively few studies have examined the association between thinness attitudes and tanning attitudes and behaviors. The purpose of the current study was to examine psychosocial predictors of sunbathing and tanning bed use, specifically thin ideal internalization (TII) and motives for tanning among high school girls. Adolescent girls (N = 229) completed a 10-minute questionnaire designed to assess sunbathing and indoor tanning, TII and motives to tan (appearance, social and well-being). Hierarchical regression analyses showed that TII, β = .05, p

Background With the growing popularity of waterpipe smoking (WPS), it is important to understand how WPS may impact health. The aim of this study was to systematically review the literature to identify potential health effects of WPS, specifically on the head and neck region. Types of Studies Reviewed The authors systematically reviewed published articles that focused on WPS and head and neck conditions identified from the following databases: PubMed and MEDLINE, PsycInfo, and Google Scholar. Results The authors included 20 articles in the review. Ten of the articles pertained to oral tissue outcomes, 7 to head and neck cancer, and 3 to the voice and middle ear. The authors found that WPS was associated with greater inflammation, Candida , periodontitis, dry socket, blood chromium and nickel levels, premalignant lesions, oral cancer, esophageal squamous cell carcinoma, attic retraction, edema in the vocal cords, and lower habitual vocal pitch and voice turbulence index. Conclusions and Practical Implications WPS is associated with various head and neck conditions. Educational and policy approaches may be required to limit the spread of WPS and its potentially deleterious effects.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colorectal Cancer Screening provide recommendations for selecting individuals for colorectal cancer screening, and for evaluation and follow-up of colon polyps. These NCCN Guidelines Insights summarize major discussion points of the 2015 NCCN Colorectal Cancer Screening panel meeting. Major discussion topics this year were the state of evidence for CT colonography and stool DNA testing, bowel preparation procedures for colonoscopy, and guidelines for patients with a positive family history of colorectal cancer.

Indoor tanning is currently a $5 billion per year industry in the US with more than 40,000 indoor tanning establishments.1,2 Thirty million Americans indoor tan each year, and one million tan indoors each day.3 Hoerster and colleagues found more indoor tanning facilities in each of 116 large US cities than the number of Starbucks coffee shops and McDonald's restaurants in those cities.4 The Social Ecological Model has been used to help understand the various influences on health behaviors and includes intrapersonal, interpersonal, organizational, community, and public policy factors.5 Most research on indoor tanning thus far has focused on intrapersonal and interpersonal factors, indicating that individuals are motivated to tan most commonly for appearance-enhancement reasons.6 However, some individuals tan indoors due to social or normative factors or in order to improve mood or reduce stress.6 Much less attention has been paid to organizational, community, and public policy contextual factors. As is the case with tobacco use and obesity, contextual factors such as accessibility, governmental regulation, marketing, or cost may also be associated with the prevalence of indoor tanning. Salon accessibility, for example, having a higher density of tanning facilities and living within 2 miles of a tanning facility, has been found to be associated with indoor tanning in the last year.7 However, indoor tanning has been found to be unrelated to state tanning regulations, likely due to low levels of enforcement,7-11 suggesting that community norms and other factors may be more important in influencing indoor tanning behavior currently. Other contextual factors that have been found to encourage more frequent and continuous indoor tanning among tanning salon patrons include reasonable prices and the convenience of being able to tan anytime including at night.12 Ultraviolet radiation (UV) such as that emitted by indoor tanning devices is known to definitively increasing skin cancer risk.13-16 However, there are additional contextual issues related to indoor tanning that may contribute to even greater levels of risk than would otherwise exist. UV-related guidelines and regulations regularly go un-enforced.8-11 For example, very fair-skinned individuals at high risk for burning are often permitted to tan when they shouldn't be, and tanning session length guidelines based on skin types (ie, sensitivity to burning) are not followed. Additionally, many tanning devices are not monitored adequately and therefore may emit more UV than guidelines recommend. Salon staff sometimes do not even know what type or how much UV is emitted from their devices,9 thus, they would be unlikely to be able to follow Food and Drug Administration (FDA) or other guidelines regarding UV exposure. Moreover, indoor tanners are often adolescents and college-aged individuals, thus potentially leading to high levels of lifetime UV exposure.17,18 Besides contextual factors, an additional intrapersonal reason for frequent tanning is tanning dependence or addiction, colloquially referred to as “tanorexia”.19 Although tanning dependence in not an official disorder according to the American Psychiatric Association's Diagnostic and Statistical Manual,20 tanning dependence has been defined based on traditional substance dependence criteria and measures (ie, tolerance, withdrawal, difficulty controlling the behavior despite negative consequences). A number of studies have provided evidence for the phenomenon of tanning dependence, with plausible biologic underpinnings, primarily related to the opioid system.19 The prevalence of tanning dependence varies by population and measurement strategy. Rates range from 22% to 45% among college indoor tanners and 18% among college sunbathers.21-24 Among general college student samples in the US, rates range from 5% to 27%.21-25 Tanning dependent individuals may tan frequently and put themselves at even greater risk of skin cancer than other tanners. There are elements of the current indoor tanning context that may contribute to tanning dependence such as easy accessibility, lack of regulation/enforcement, marketing efforts by salons, and the relatively low cost of indoor tanning. Although seemingly important, relatively few studies have focused on such contextual factors related to indoor tanning. These studies have been focused on adolescents rather than college-aged individuals, and the results have been mixed in terms of the impact of state indoor tanning laws and indoor tanning behaviors.26 The purpose of the current study was to investigate the association of college-aged women's perceptions of contextual factors such as tanning salon accessibility, regulations, marketing, or cost and indoor tanning behavior or tanning dependence. We hypothesized that individuals who had tanned indoors in the last 30 days and/or women who scored higher on a measure of tanning dependence would be more likely to report greater salon accessibility, looser tanning regulations, more promotional efforts, and lower cost of individual indoor tanning sessions, yet more trouble paying for their tanning habit than others. Understanding the factors associated with more frequent indoor tanning may help inform policy and public health programming efforts. For example, the impact on young women's skin cancer risk of additional regulation and enforcement of contextual factors associated with frequent or dependent tanning could be investigated.

Ductal adenocarcinoma and its variants account for most pancreatic malignancies. High-quality multiphase imaging can help to preoperatively distinguish between patients eligible for resection with curative intent and those with unresectable disease. Systemic therapy is used in the neoadjuvant or adjuvant pancreatic cancer setting, as well as in the management of locally advanced unresectable and metastatic disease. Clinical trials are critical for making progress in treatment of pancreatic cancer. The NCCN Guidelines for Pancreatic Adenocarcinoma focus on diagnosis and treatment with systemic therapy, radiation therapy, and surgical resection.

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding locoregional therapy for treatment of patients with hepatocellular carcinoma.

The elevated rates of ultraviolet radiation (UVR) exposure and low rates of sun protection in young adult women indicate a need for age- and gender-appropriate interventions that address these behaviors.To examine the effects of daily behavior tracking and individually tailored text messages on sun protection and UVR exposure behaviors in young adult women at moderate to high risk of developing skin cancer.One hundred and four young adult women at risk of skin cancer were randomized to receive the behavior-tracking intervention only, tailored text messages only, both interventions, or neither. Outcomes were self-reported UVR exposure and sun protection behaviors.Those who received the behavior-tracking intervention reported significantly fewer UVR exposure behaviors at 4-week follow-up, relative to those who did not receive behavior tracking. At 4-week follow-up, those who received daily tailored text messages reported significantly greater UVR exposure behaviors but were more likely to report wearing a hat as a form of sun protection, relative to those who did not receive tailored messages.Daily behavior tracking may be repetitive, but repetition may facilitate cognitive processing and the development of healthy habits. Health messages that are less interactive, on the other hand, need to be adequately tailored and delivered with the most advantageous timing to be impactful.Future research should continue to examine how these interventions differentially affect behavior and how they can be adapted to apply to other health behaviors.

The NCCN Clinical Practice Guidelines in Oncology for Genetic/Familial High-Risk Assessment: Breast and Ovarian provide recommendations for genetic testing and counseling for hereditary cancer syndromes and risk management recommendations for patients who are diagnosed with a syndrome. Guidelines focus on syndromes associated with an increased risk of breast and/or ovarian cancer. The NCCN Genetic/Familial High-Risk Assessment: Breast and Ovarian panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. The NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding risk management for carriers of moderately penetrant genetic mutations associated with breast and/or ovarian cancer.

Purpose. Indoor tanning (IT) increases risk for melanoma and is particularly common among young adult women. IT has also been linked with some psychiatric symptoms, and frequent tanning may indicate tanning dependence (addiction) associated with endorphin release during ultraviolet radiation exposure. The objective of the current study was to investigate associations between IT, tanning dependence, and psychiatric and substance use symptoms in young adult women. Design. Cross-sectional survey and psychiatric interview. Setting. Online, except for the Mini International Neuropsychiatric Interview (MINI), which was completed over the telephone. Subjects. Participants were 306 female university students aged 18 to 25 years. Measures. MINI, Seasonal Scale Index, tanning dependence scales, reporting ever having used a tanning bed or booth with tanning lamps (single item), reporting smoking a cigarette in the last 30 days (single item). Analysis. Descriptive statistics, χ2 analysis, multivariate logistic regression. Results. Forty-six percent of the sample reported a history of IT, and 25% were classified as tanning dependent. Multivariate logistic regression analyses showed that IT was significantly associated with symptoms of alcohol use disorders, generalized anxiety, and not having social anxiety. Tanning dependence was associated with symptoms of alcohol use disorders. Conclusion. Tanning is of concern not only for its association with skin cancer but for its association with psychiatric and substance use symptoms. Young women with certain psychological problems may seek relief from their symptoms by IT. These findings suggest that indoor tanners may benefit from health behavior and other psychosocial interventions.

Background Indoor tanning has been found to be addictive. However, the most commonly used tanning dependence measures have not been well validated. Objective The study's purpose was to explore the psychometric characteristics of and compare the modified Cut-down, Annoyed, Guilty, Eye-opener Scale (mCAGE), modified Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition – Text Revised (mDSM-IV-TR) and Tanning Pathology Scale (TAPS) measures of tanning dependence and provide recommendations for research and practice. Methods This study was a cross-sectional online survey with 18- to 25-year-old female university students. The main outcome variable was tanning dependence measured by the mCAGE, mDSM-IV-TR and TAPS. Results Internal consistency of the TAPS subscales was good but was poor for the mCAGE and mDSM-IV-TR, except when their items were combined. Agreement between the mCAGE and mDSM-IV-TR was fair. Factor analysis of the TAPS confirmed the current four-factor structure. All of the tanning dependence scales were significantly correlated with one another. Likewise, most of the tanning dependence scales were significantly correlated with other measures of tanning attitudes and behaviours. However, the tolerance to tanning TAPS subscale was not significantly correlated with any measure of tanning attitudes or behaviours and had the lowest subscale internal reliability and eigenvalues. Conclusion Based on the data and existing literature, we make recommendations for the continued use of tanning dependence measures. Intervention may be needed for the approximately 5% of college women who tend to be classified as tanning dependent across measures. Monitoring of individuals reporting tanning dependence symptoms is warranted.

This is a focused update highlighting the most current NCCN Guidelines for diagnosis and management of Lynch syndrome. Lynch syndrome is the most common cause of hereditary colorectal cancer, usually resulting from a germline mutation in 1 of 4 DNA mismatch repair genes (MLH1, MSH2, MSH6, or PMS2), or deletions in the EPCAM promoter. Patients with Lynch syndrome are at an increased lifetime risk, compared with the general population, for colorectal cancer, endometrial cancer, and other cancers, including of the stomach and ovary. As of 2016, the panel recommends screening all patients with colorectal cancer for Lynch syndrome and provides recommendations for surveillance for early detection and prevention of Lynch syndrome-associated cancers.

Indoor tanning (IT) has been linked with psychiatric and addictive symptoms, and frequent tanning may indicate tanning dependence (addiction). The current study evaluated the effects of an IT episode on mood states and the association of these effects with psychiatric and addictive symptoms among young adult female indoor tanners. One-hundred thirty-nine female university students aged 18-25 years who had indoor tanned completed an online survey including the Positive and Negative Affects Scales and a standardized psychiatric interview (the MINI International Neuropsychiatric Interview) via telephone. Psychiatric and addictive symptoms were relatively common among these young adult female indoor tanners. Overall, participants reported significant decreases in both negative (upset, scared, irritable, nervous, jittery, afraid) and positive (feeling interested) mood states after their most recent tanning episode. Multivariable linear regression analyses showed that more frequent indoor tanning in the past month and symptoms of illicit drug use disorders were associated with decreases in negative mood, and symptoms of generalized anxiety disorder were associated with a decrease in feeling interested. In summary, indoor tanners report relatively high rates of psychiatric and substance use symptoms, including symptoms of tanning dependence, and indoor tanning appears to alter mood. Women with certain substance use and psychiatric characteristics may be more vulnerable to such mood changes after tanning indoors. Further research is needed to clarify the relationships among these variables.

Thirdhand smoke (THS) refers to tobacco smoke contaminants and by-products that remain in the environment after a cigarette is extinguished. The purpose of this study was to assess beliefs and behaviors regarding THS among healthcare professionals, and to examine associations among smoking attitudes/beliefs, provider demographics, and THS beliefs and behaviors. Healthcare professionals (N = 204) at a comprehensive cancer center and affiliated general hospital in a northeastern urban area completed online questionnaires. About one third of the respondents had heard of THS before completing the survey, and more than two thirds of the sample believed that THS issues do not receive enough attention. Being female, likelihood of discussing THS with others, endorsing the belief that smoking affects the quality of parenting, and support for government action towards smoking bans were significantly associated with providers’ belief that THS is harmful. Endorsing the belief that smoking affects the quality of parenting and belief that THS is harmful were significantly associated with the likelihood of discussing THS with others. Findings shed light on THS beliefs and behaviors of healthcare providers (a group of individuals that could be trained to educate and advise patients about THS) and inform recommendations for new tobacco policies and clinical guidelines for best practices in tobacco control and prevention.

Sustainability is a key challenge facing society in the twenty-first century, although its implementation at heritage sites can present some significant challenges for the custodians. This paper investigates progress in the adoption of sustainable practices in the management of a sample of 416 heritage properties and sites in Devon and Cornwall. The findings are based on the compilation of an inventory of selected heritage resources; an extensive questionnaire survey of managers of historic houses, churches and museums, which investigated the extent of, and opinions about, sustainable management approaches; and targeted, semi-structured, face-to-face interviews with a small number of heritage managers that probed key issues in greater depth. The results indicate that very few heritage sites produce sufficient surpluses to facilitate investment in sustainable practices that might ultimately enhance their financial viability and fund enhanced conservation activities. It is argued that future strategies for ...

Having one’s physical appearance scrutinized is a common experience for women. We examined 274 Northeastern American undergraduate women’s responses to having their appearance evaluated 1) by themselves or by another student, and 2) in comparison to the appearance of female peers or without comparison. As hypothesized, comparison to peers and evaluation by another predicted poorer views of the self and of one’s appearance, but only in conjunction with being overweight, endorsing thinness ideals, or their combination. Endorsement of thinness ideals and being overweight also independently predicted lower appearance state self-esteem. Few effects on mood were found. Results underscore the power of appearance evaluation to influence women’s self-perceptions, particularly in those whose appearance deviates from culturally prescribed standards of beauty.

Despite its known association with skin cancer, tanning remains popular among young adult women. Indoor tanning behavior has been found to be associated with affective and addictive disorders. To better understand potential psychological and biological mechanisms of tanning behavior, we investigated associations between tanning and medication (psychotropic and other) use among young women. Two hundred and fifty-three women age 18-29 years old were recruited from two northeastern university campus communities. Women self-reported tanning frequency and chronic medication use. In both univariate and multivariate analyses, indoor tanning ≥12 times last year was significantly associated with use of psychotropic medication and anti-depressants in particular. Sunbathing was not associated with medication use. Potential reasons for associations between tanning and psychotropic medication use are discussed. Indoor tanners should be warned that some psychotropic medications are photosensitizing, thus increasing risk for burns and other skin damage from indoor tanning.

As the vision of mobile health (mHealth) is beginning to be realized, rigorous intervention development protocols are needed in order to draw optimal efficacy and effectiveness to support patient-centered oncology care. The purpose of the current study was to conduct a review of published articles that describe the development process of mHealth interventions for patients’ cancer care self-management. The review search yielded 11 interventions, reported by 14 manuscripts. The following trends emerged: importance of stakeholder engagement during the development process, addressing the unique needs and experiences of cancer patients and care providers, ensuring user satisfaction with the system, and identifying perceived benefits and limitations of the system. This review provides practical suggestions for mHealth intervention development. Assessments of user perceptions should be both qualitative and quantitative, and researchers should follow an established framework when developing a randomized controlled trial employing mHealth.

Identification of risk factors for indoor tanning may ultimately aid the development of better indoor tanning prevention strategies, which is pertinent given the association between indoor tanning and skin cancer. This study aimed to examine the relationship between seasonal sleep change and indoor tanning. Female tanners ( N = 139) completed self-report measures including items relating to seasonal sleep changes, seasonal affective disorder (SAD), reasons for tanning, tanning during the winter months, and the Tanning Pathology Scale (TAPS), which measures problematic tanning motives and symptoms of tanning dependence. It was hypothesized that seasonal sleep change and SAD would be associated with greater indoor tanning during the winter, more tanning to improve mood and to relax, and higher scores on the TAPS. Findings indicated that more seasonal sleep change was associated with tanning to improve mood and higher scores on the TAPS. Similarly, the presence of SAD was related to tanning to improve mood, tanning to relax, and more problematic tanning.

Skin cancer is the most common cancer in the US, with almost three million individuals being diagnosed annually [1]. Both melanoma and non-melanoma (or keratinocyte) skin cancer (NMSC) incidence rates have been increasing in recent decades [2]-[4]. In 2012, melanoma is predicted to be the fifth most common cancer among US men and the sixth most common cancer among women [2]. Risk factors for melanoma and NMSC include male sex, age over 50 years, personal or family history of melanoma or NMSC, red hair, blue or green eyes, Fitzpatrick skin type I (very fair skin sensitive to ultraviolet radiation [UV]) with freckles, actinic keratosis on the head, familial atypical mole-melanoma syndrome, or numerous (i.e., > 100) moles [2], [5]-[15]. Additionally, many melanomas and NMSCs can be attributed to UV exposure such as via outdoor occupations, one blistering sunburn prior to age 18, multiple sunburns at any age, or indoor tanning [15]-[21].

Skin cancer is an increasingly common disease, particularly among young adult women. Sunburn early in life is a risk factor for skin cancer. Few studies have reported on psychosocial correlates of sunburn. The current study consisted of an online survey of undergraduate women from a university in the northeastern part of the USA. A logistic regression demonstrated that young women who reported a history of four or more sunburns were significantly more likely to report fair skin, higher perceived susceptibility to skin cancer, greater perceived benefits of tanning (e.g., appearance enhancement), lower perceived control over skin protection, and more frequent sunscreen use. Sunbathing was not associated with a greater number of sunburns. These results suggest that young women who sunburn more often possess other skin cancer risk factors, are aware of their susceptibility to skin cancer, and try to use sunscreen, but feel limited control over their skin protection behavior and are not less likely to sunbathe than others. Therefore, interventions are needed to assist high risk young women in asserting more control over their sun protection behavior and perhaps improve the effectiveness of the sunscreen or other skin protection methods they do employ.

Introduction Many Americans fail to accurately identify themselves as overweight and underestimate their risk for obesity-related diseases. The purpose of this study was to investigate associations between weight perceptions and perceived risk for diabetes and heart disease among overweight or obese women. Methods We examined survey responses from 397 overweight or obese female health center patients on disease risk perceptions and weight perceptions. We derived odds ratios (ORs) and 95% confidence intervals (CIs) from multivariable logistic regression analyses to examine predictors of perceived risk for diabetes and heart disease. We further stratified results by health literacy. Results Perceiving oneself as overweight (OR, 2.78; 95% CI, 1.16-6.66), believing that being overweight is a personal health problem (OR, 2.46; 95% CI, 1.26-4.80), and family history of diabetes (OR, 3.22; 95% CI, 1.53-6.78) were associated with greater perceived risk for diabetes. Perceiving oneself as overweight (OR, 4.33; 95% CI, 1.26-14.86) and family history of heart disease (OR, 2.25; 95% CI, 1.08-4.69) were associated with greater perceived risk for heart disease. Among respondents with higher health literacy, believing that being overweight was a personal health problem was associated with greater perceived risk for diabetes (OR, 4.91; 95% CI, 1.68-14.35). Among respondents with lower health literacy, perceiving oneself as overweight was associated with greater perceived risk for heart disease (OR, 4.69; 95% CI, 1.02-21.62). Conclusion Our findings indicate an association between accurate weight perceptions and perceived risk for diabetes and heart disease in overweight or obese women. This study adds to research on disease risk perceptions in at-risk populations.

Little is known about the consistency of people's reasons for smoking and how these might influence the amount of smoking in individuals. Therefore, we developed a new concept, motivational flexibility, which suggests that a behavior is more common when people have multiple reasons for engaging in it and when the primary reason changes across occurrences of the behavior. The purpose of this study was to examine motivational flexibility in cigarette smokers. We hypothesized that smoking would be associated with greater number of reasons for smoking and greater frequency of change (shifting) in the most important motive for smoking among light smokers. Student cigarette smokers (N = 116) completed daily entries for 14 days: whether they smoked or not and their reasons for doing so, with importance ratings for each reason listed. Multilevel modeling was used to examine the relationship between motivational flexibility and daily cigarette smoking. Shifting among the most important motive over the 14-day assessment was associated with greater frequency of smoking in light but not daily smokers. Also, smoking for craving and social reasons was associated with smoking fewer cigarettes and on fewer days. Results confirm the applicability of the motivational flexibility concept to smoking. The association between motive shifting and greater frequency of smoking may indicate a greater responsiveness to environmental cues. That we found this association in light but not daily smokers who are likely addicted to cigarettes may indicate that light smokers are affected more by triggers for smoking, or that they may rationalize their smoking behavior more than heavier smokers.

Importance Skin cancer is common among older adults. Some national organizations recommend total cutaneous examination (TCE) and skin self-examination (SSE) for skin cancer detection. Although the spousal relationship is a known influence on health behavior, little is known about the level of correspondence in skin screening among couples. Objective To investigate correspondence of TCE and SSE among older couples, demographic correlates of correspondence, and correspondence among barriers to skin examinations. Design, Setting, and Participants Cross-sectional online survey of cohabitating partners 50 years or older performed from June 1, 2010, through July 31, 2010, via the nationally representative GfK (Gesellschaft fur Konsumforschung or Society for Consumer Research) Internet panel. Main Outcomes and Measures Both TCE in the past 3 years and SSE in the past year. Results Correspondence among partners was high. For TCE, both partners had completed TCE in 23.9%, and both partners had not completed TCE in 47.3%. With regard to SSE, both partners had completed SSE in 39.8%, and both partners had not completed SSE in 38.9%. Correlates of both partners not completing TCE include lower household income, larger household size, nonmetropolitan residence, living in the Midwest, and being in a same-sex relationship. Correlates of both members not completing SSE included larger household size and being in a same-sex relationship. Barriers to screening that members of couples reported were similar to one another. Conclusions and Relevance Couples were mostly concordant with regard to engagement in skin examinations. Therefore, dyadic interventions to increase screening rates could be useful. Certain sociodemographic groups should especially be targeted.

Skin cancer is the most common cancer in the US, and incidence continues to increase. Studies have shown that screening is helpful in detecting skin cancer at an earlier more treatable stage and can be done by oneself, with the assistance of a close other, or by a health professional. Many people fail to screen for skin cancer. The purpose of this study was to examine screening rates in married couples, as well as the reasons for failing to screen. Participants were recruited and assessed by KnowledgePanel from Knowledge Networks (http://www.knowledgenetworks.com/). This is a probability-based panel of potential participants for online surveys, designed to be representative of the US population. Married individuals over 50 years of age with another person living in the home were invited to participate. Participants completed an online survey in which both husbands and wives were asked to indicate whether they received a skin exam from a clinician, or performed a skin exam themselves or with the assistance of a partner. If they answered in the negative, they were asked to endorse reasons for failing to screen from a provided list and could write in other reasons. This questionnaire was completed as part of larger study examining other cancer screening behaviors. The questionnaire was completed by 3,048 husbands and 2,942 wives (a 77% response rate). Within husbands, 39% reported receiving a clinical skin exam, while 35% of wives reported doing so. Regarding a self- or partner-assisted skin exam, 47% of husbands reported doing so, as opposed to 49% of wives. Forty-eight percent of couples matched in terms of both failing to receive a clinical skin exam, 28% did not match (i.e., one spouse had an exam, while the other did not), and 25% matched in terms of both having had a clinical skin exam. For self- or partner-assisted skin exam, 40% of married couples matched in terms of neither having an exam, 21% did not match (i.e., one spouse performed an exam, while the other did not), and 39% matched in terms of both partners performing a self- or partner-assisted skin exam. The most commonly endorsed reason among both husbands and wives for failing to obtain a skin exam by a clinician and also not screening oneself is that a doctor did not recommend one, followed by not having any noticeable symptoms of skin cancer, and not perceiving oneself as at risk for skin cancer. Kappa coefficients were calculated to assess husbands' and wives' agreement on the reasons endorsed. Husbands and wives reached moderate agreement for the following reasons for not obtaining a clinical skin exam: healthcare provider hadn't recommended, exam would be inconvenient, did not have noticeable symptoms of skin cancer, would rather have a partner do the exam, and not perceiving oneself as at risk for skin cancer. Similar reasons for not conducting a self- or partner-assisted exam were endorsed and had similar levels of agreement (other than preferring a partner exam), though husbands and wives also had moderate agreement for not conducting an exam due to being too busy. Results show that more than half of individuals over age 50 do not receive clinical or partner skin exams. Most couples matched in terms of both either having or not having had a skin exam and also endorsed similar reasons for not being screened. Based on these similarities and spousal influence on one another, intervening with couples as a unit may be beneficial in increasing skin cancer screening rates. Findings also highlight the role health professionals may play in encouraging screening for skin cancer, as the most highly cited reason for not getting screened is lack of recommendation from a healthcare provider. Finally, results suggest opportunities for education regarding “symptoms of” and risks for skin cancer and the fact that skin cancer may be asymptomatic. Citation Information: Cancer Prev Res 2011;4(10 Suppl):B28.

There are many reasons why people smoke despite widely recognized adverse consequences to health. Little is known, however, about the consistency of people's reasons for smoking and how these might influence the amount of smoking in individuals. We developed a new concept called motivational flexibility, which suggests that a behavior is more common when people have multiple reasons for engaging in it and when the primary reason changes across occurrences of the behavior. We hypothesized that smoking frequency would be associated with greater number of reasons for smoking and greater frequency of change (shifting) in the most important motive for smoking. Differences between light and heavy smokers were examined. We also examined associations between specific motives to smoke and smoking behavior (average number of cigarettes smoked each day and number of days smoked over the assessment period). Student cigarette smokers at a northeastern public university (N = 116) completed online daily entries for 14 days, in which they indicated whether they smoked or not and their reasons for smoking, with importance ratings given for each reason listed. Smoking status (nondaily/light vs. daily/heavy) was assessed at baseline. Reasons listed for smoking were coded by trained research assistants into the following motive categories: 1) stress release, 2) craving, 3) boredom, 4) habit/context, 5) social, and 6) appetite suppression. Multilevel modeling was used to examine the relationship between motivational flexibility (greater number of reasons and shifting) and smoking behavior. Multivariate linear regression was used to assess associations between specific smoking motives and smoking behavior. Results indicated that shifting among the most important motive to smoke over the 14-day assessment was associated with greater frequency of smoking, t(115) = 1.99, p < .05, as hypothesized. When examining light (n = 52) and daily smokers (n = 64) separately, this association was found in light but not daily smokers, t(51) = 2.21, p < .05. The multivariate regression models examining associations between specific motives to smoke and smoking behavior showed that smoking for stress release, t(110) = −2.11, p < .05, craving, t(110) = −2.87, p < .01, and for social reasons, t(110) = −4.06, p < .001, were associated with smoking on fewer of the 14 days. Smoking for craving, t(109) = −2.31, p < .05, boredom, t(109) = −2.81, p < .01, and social reasons, t(109) = −2.36, p < .05, were also associated with smoking fewer cigarettes each day on average over the 14 days. These results illustrate the importance of situational cues to cigarette smoking and help establish the applicability of the motivational flexibility concept to this behavior. The association between motive shifting and greater frequency of smoking may indicate a greater responsiveness to environmental cues: the environment may activate context-specific reasons for smoking. That we found this association in light but not daily smokers who are likely addicted to cigarettes suggests that light smokers may have more triggers that can be activated, which may result in more smoking. Over time, this may contribute to a shift from light to heavier smoking. Daily smokers may not need as many triggers because presumably they smoke everyday out of habit or addiction. It is also possible that light smokers who smoke more often may feel the need to rationalize their behavior, as illustrated by their listing a variety of reasons as being important for each day that they smoked. Smoking cessation interventions and health professionals should be aware of the role of smokers' reasons for smoking in order to encourage healthful behavior change that will reduce cancer risk. Citation Information: Cancer Prev Res 2011;4(10 Suppl):B39.

The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian provide recommendations for genetic testing and counseling and risk assessment and management for hereditary cancer syndromes. Guidelines focus on syndromes associated with an increased risk of breast and/or ovarian cancer and are intended to assist with clinical and shared decision-making. These NCCN Guidelines Insights summarize major discussion points of the 2015 NCCN Genetic/Familial High-Risk Assessment: Breast and Ovarian panel meeting. Major discussion topics this year included multigene testing, risk management recommendations for less common genetic mutations, and salpingectomy for ovarian cancer risk reduction. The panel also discussed revisions to genetic testing criteria that take into account ovarian cancer histology and personal history of pancreatic cancer.