Behaviors associated with ultraviolet radiation exposure in a cohort of adult survivors of childhood and adolescent cancer§

A Report from the Childhood Cancer Survivor Study


  • Presented at the Fourth Biennial Cancer Survivorship Research Conference entitled “Cancer Survivorship Research: Mapping the New Challenges,” Atlanta, GA, June 18-20, 2008.

  • The Childhood Cancer Survivor Study (CCSS) is a collaborative, multi-institutional project, funded as a resource by the National Cancer Institute, of individuals who survived 5 or more years after diagnosis of childhood cancer.

  • §

    CCSS is a retrospectively ascertained cohort of 20,346 childhood cancer survivors diagnosed before age 21 between 1970 and 1986 and approximately 4,000 siblings of survivors, who serve as a control group. The cohort was assembled through the efforts of 26 participating clinical research centers in the United States and Canada. The study is currently funded by a U24 resource grant (NCI grant ‡ U24 CA55727) awarded to St. Jude Children's Research Hospital. Currently, we are in the process of expanding the cohort to include an additional 14,000 childhood cancer survivors diagnosed before age 21 between 1987 and 1999. For information on how to access and use the CCSS resource, visit

  • CCSS Institutions and Investigators: Leslie L. Robison, PhD‡†, Melissa Hudson, MD*†, Greg Armstrong, MD, MSCE†, Daniel M. Green, MD†, St. Jude Children's Research Hospital, Memphis, Tennessee; Lillian Meacham, MD*, Ann Mertens, PhD†, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia; Joanna Perkins, MD, MS*, Children's Hospitals and Clinics of Minnesota Minneapolis, St. Paul, Minnesota; Douglas Hawkins, MD*, Eric Chow, MD, MPH†, Children's Hospital and Medical Center, Seattle, Washington; Brian Greffe, MD*, Children's Hospital, Denver, Colorado; Kathy Ruccione, RN, MPH*, Children's Hospital Los Angeles, California; John Mulvihill, MD*†, Children's Hospital, Oklahoma City, Oklahoma; Leonard Sender, MD*, Children's Hospital of Orange County, Orange, California; Jill Ginsberg, MD*, Anna Meadows, MD†, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Jean Tersak, MD*, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Gregory Reaman, MD*, Roger Packer, MD†, Children's National Medical Center, Washington, District of Columbia; Stella Davies, MD, PhD*†, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Smita Bhatia, MD*†, City of Hope Medical Center, Los Angeles, California; Paul Bowman, MD, MPH*, Cook Children's Medical Center, Ft. Worth, Texas; Lisa Diller, MD*†, Dana-Farber Cancer Institute/Children's Hospital, Boston, Massachusetts; Wendy Leisenring, ScD*†, Fred Hutchinson Cancer Research Center, Seattle, WA; Mark Greenberg, MBChB*, Paul C. Nathan, MD*†, Hospital for Sick Children, Toronto, Ontario, Canada; John Boice, ScD*†, International Epidemiology Institute, Rockville, Maryland; Vilmarie Rodriguez, MD*, Mayo Clinic, Rochester, Minnesota; Charles Sklar, MD*†, Kevin Oeffinger, MD†, Memorial Sloan-Kettering Cancer Center, New York, New York; Jerry Finklestein, MD*, Miller Children's Hospital, Long Beach, California; Roy Wu, PhD†, Nita Seibel, MD†, Preetha Rajaraman, PhD†, National Cancer Institute, Bethesda, Maryland; Amanda Termuhlen, MD*, Sue Hammond, MD†, Nationwide Children's Hospital, Columbus, Ohio; Kimberley Dilley, MD, MPH*, Northwestern University, Chicago, Illinois; Terry A. Vik, MD*, Riley Hospital for Children, Indianapolis, Indiana; Martin Brecher, MD*, Roswell Park Cancer Institute, Buffalo, New York; Robert Hayashi, MD*, St. Louis Children's Hospital, St. Louis, Missouri; Neyssa Marina, MD*, Sarah S. Donaldson, MD†, Stanford University School of Medicine, Stanford, California; Zoann Dreyer, MD*, Texas Children's Hospital, Houston, Texas; Kimberly Whelan, MD, MSPH*, University of Alabama, Birmingham, Alabama; Yutaka Yasui, PhD*†, University of Alberta, Edmonton, Alberta, Canada; Jacqueline Casillas, MD, MSHS*, Lonnie Zeltzer, MD†, University of California-Los Angeles, California; Robert Goldsby, MD*, University of California-San Francisco, California; Jacqueline Casillas, MD, MSHS*, Lonnie Zeltzer, MD†, Tara Henderson, MD, MPH*, University of Chicago, Chicago, IL; Raymond Hutchinson, MD*, University of Michigan, Ann Arbor, MI; Joseph Neglia, MD, MPH*†, University of Minnesota, Minneapolis, MN; Dennis Deapen, DrPH*†, University of Southern California, Los Angeles, California; Daniel Bowers, MD*, University of Texas-Southwestern Medical Center, Dallas, Texas; Louise Strong, MD*†, Marilyn Stovall, MPH, PhD†, University of Texas M. D. Anderson Cancer Center, Houston, Texas. *Institutional Principal Investigator; †Member CCSS Steering Committee; ‡Project Principal Investigator (U24 CA55727).



Previous research from the Childhood Cancer Survivor Study (CCSS) has shown that risk of skin cancer is strongly associated with exposure to radiation therapy. The potential role of ultraviolet radiation exposure in survivors has not been described.


The CCSS is a retrospective cohort study designed to investigate late effects among 5-year survivors of children and adolescents diagnosed with cancer between 1970-1986. Data regarding current sun protection behavior were collected on 9298 survivors and 2950 sibling controls. Median age at follow-up was 31 years (range, 17-54).


In this cohort, childhood cancer survivors and siblings showed similar patterns of sunscreen use (67% vs 66%). Survivors were significantly less likely to report having sunbathed in the previous year (none vs any in previous year: relative risk (RR) = 0.92; 95% confidence interval (CI) = 0.89-0.95) or use artificial tanning (none vs any in previous year: RR = 0.76; 95% CI = 0.70-0.83). Compared with survivors without radiation therapy, survivors with radiation exposure showed increased use of sunscreen (RR = 1.06; 95% CI = 1.03-1.10), and less sunbathing (none vs any in previous year: RR = 0.89; 95% CI = 0.86-0.92) or artificial tanning (none vs any in previous year: RR = 0.62; 95% CI = 0.56-0.69). In adjusted multivariable analysis, statistically significant factors for regular sunscreen use in the past summer (vs never/rarely) in the survivor population were being female, having lighter skin complexions, having previously been examined for skin cancer, and having skin that burned when in the sun unprotected.


Survivors of childhood cancer self-reported lower tanning practices than siblings. However, because of the potential increased risk of skin cancer from therapy-related exposures, future research should be directed at intervention studies to further reduce UV exposures. Cancer 2009;115(18 suppl):4374–84. © 2009 American Cancer Society.