Precision Skin Cancer Prevention A Sun Safety Mobile App. David Buller, PhD Senior Scientist & Director of Research Klein Buendel, Inc.

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1 Precision Skin Cancer Prevention A Sun Safety Mobile App David Buller, PhD Senior Scientist & Director of Research Klein Buendel, Inc. PATIENT CENTERED OUTCOMES RESEARCH 8 TH ANNUAL SYMPOSIUM WASHINGTON UNIVERSITY April 25, 2018

2 Disclosures Dr. Buller receives a salary from Klein Buendel, Inc. Dr. Buller s spouse is an owner of Klein Buendel, Inc. Klein Buendel, Inc. owns the mobile app and markets it after this research concluded. Klein Buendel has an active conflict of interest plan in effect.

3 Overview of Presentation 1. Mobile computing and precision prevention of skin cancer. 2. Mobile app and precision skin cancer prevention. 3. Randomized trials on skin cancer prevention mobile app. 4. Implications for using mobile technology for precision prevention. CONTRACT NO. HHSN

4 Promise of Mobile Computing for Precision Prevention Mobile devices are the most common personal computers and networked into users lives. Mobile phones can know a lot about the user and her/his current situation. Communication via mobile devices can be personalized and have high ecological validity.

5 Precision Skin Cancer Prevention NOAA/CPC Forecast UV Index + Geo-spatial Data from Phone + User Supplied Data Sunburn Risk Sun Protection UV Index Vitamin D

6 User-centered Development of Skin Cancer Prevention Mobile App User Expectations App should recommend the best type of sunscreen, cumulative sun exposure, and alerts when it is time to get out of the sun. Ideal features included multiple profiles, alarms & alerts (but not too many), simple advice, a planning feature, and tips.

7 How Mobile App Will Be Used For learning about UV. For sunscreen timing and warnings. At a picnic or other event that is several hours long. While recreating outdoors (running, hiking, water sports, or skiing). At high elevation. With kids. On vacation. Buller et al. Transl Behav Med Practice, 2013;3:

8 Precision Prevention Advice Algorithms

9 Risk of Sunburn Algorithm Based on UV levels and skin type. Displayed as a countdown timer with sunburn risk feedback. Low (>3 hours until sunburn). Moderate (1-3 hours until sunburn). Extreme (<1 hour until sunburn). Adjusted by sunscreen (SPF) and shade use.

10 Sun Protection Practices Algorithm UV 1-2: Take Minimal Precautions (sunglasses, sunscreen, and cover-up clothing). UV 3-7: Take Some Precautions (sunglasses, sunscreen, cover-up clothing, hat, and shade). UV 8 or higher: Take All Precautions (sunglasses, sunscreen, cover-up clothing, hat, shade, and go indoors).

11 Mobile App Home Screen Use the People and Profiles link to run an existing profile, add people, or add a new profile for existing people. Use the Sun Exposure Link to run the app. Use the Planner to plan for an event up to 5 days in the future.

12 Mobile App Feedback Screen This is the person and profile currently active. The Display Screen shows custom-made advice for this profile. This is how much time you have before your skin starts to sunburn, based on the UV level, the active person and profile, and time spent out in the sun. If you go inside, out in the sun or in the shade, press here to tell the mobile app. This is your current danger of being sunburned based on the UV level, active person and profile, and time spent out in the sun. This is how long you have until you should reapply your sunscreen. Press here after you reapply your sunscreen. Press these buttons for more tips to protect yourself from the sun. See how much vitamin D your skin makes when exposed to the sun.

13 User Input Screen The mobile app calculates your skin type to determine how quickly your skin sunburns and makes vitamin D.

14 Warnings & Alerts Warnings will appear in your notifications bar where you can review them later if you miss them.

15 Randomized Trial Buller et al. JAMA Dermatol 2015;151:

16 Profile of Sample Characteristic % Age (mean=38.9; sd=13.2) or older Education High school or less Some college 4-year college or postgraduate degree Diagnosed with skin cancer 30.5 Gender Female 47.9 Race/Ethnicity Skin Phenotypic Index Non-Hispanic White Hispanic White 1-2 (low risk) (high risk)

17 Sun Protection Practices Measure Control Treatment Statistic p Percent of days wearing 34.5% 28.6% F= sunscreen with SPF 15+ while outdoors in midday sun in past 3 months Percent of days staying in the shade while outdoors in the midday sun in past 3 months 33.7% 41.0% F= Note: Adjusted means displayed.

18 Moderators of Mobile App Effects Sun Safety Outcome Moderator Value of Moderator Experimental Group: Control Treatment Percent of days wearing clothing I think I look % 3.7% that protected the skin from the healthier % 5.9% sun while outdoors in the sun and better 3 6.8% 8.2% between 10 am and 4 pm when I am 4 2.2% 10.4% Self-Efficacy Expectations: Confident can practice sun safety, that is wear sunscreen, protective clothing, a hat, and sunglasses, the next time you go out in the sun? Note: Adjusted means displayed suntanned 5 Income <$25,000 $25,000 - $49,999 $50,000 - $99,999 >$100, % % p- value

19 Use of Mobile App 70 Trial 1 - Daily Feedback Screen Visits /13/2012 8/13/2012 9/13/2012

20 Effect of Use of the Mobile App Measure Used Mobile App Statistic p Hours spent outdoors in midday sun (10 am 4 pm) in the past 3 months Percent of days keeping time in the sun to a minimum while outdoors in the midday sun in past 3 months Percent of days using all sun protection behaviors while outdoors in the midday sun in the past 3 months Note: Adjusted means displayed. No Yes F= % 60.4% F= % 39.4% F=

21 Randomized Trial Buller DB et al. JAMA Dermatol 2015;151:

22 Use of Mobile App 60 Trial 2 - Daily Feedback Screen Visits /4/2013 7/4/2013 8/4/2013

23 Effect of Use of Mobile App Measure Used Mobile App Statistic p Days spent outdoors in midday sun (10 am 4 pm) in past 3 months 7-weeks Posttest Note: Adjusted means displayed. No Yes F=4.04 F=

24 Moderators of Effect of Use of Mobile App Sun Safety Outcome Moderator Value of Moderator Percent of days wearing a hat with a wide brim Percent of days using all sun protection practices Note: Adjusted means displayed Age Gender 7-week interim (past 3 weeks): Posttest (past 3 months): Female Male Used Mobile App No Yes 2.0% 7.9% 13.8% 19.7% 25.5% 42.2% 50.8% 17.9% 17.3% 16.7% 16.2% 15.6% 46.4% 43.3% p- value

25 Conclusions About the Skin Cancer Prevention Mobile App The mobile app appeared to promote sun safety when adults used it. The mobile app may increase shade and hat use and reduce over-reliance on sunscreen. No evidence that precision prevention advice increased high risk behavior (i.e., longer time in the sun).

26 Implications for Precision Prevention on Mobile Devices A mobile devices have the potential to deliver ecologically valid precision prevention advice. Mobile devices can utilize public big data for precision prevention. Users are willing to provide personal information to prevention apps. Privacy concerns in technology-delivered precision prevention need to be considered.

27 Implications (cont.) Actionable prevention advice can be tailored to user characteristics and circumstances and delivered when and where it is needed. User-centered development should focus on use of precision prevention interventions, not just their content.

28 Implications (cont.) Precision prevention is limited by the quality and completeness of existing research evidence. Cost of development, maintenance, and dissemination of precision prevention mobile apps is not trivial.

29 Acknowledgments Collaborators Marianne Berwick, PhD, Univ. of New Mexico Kathleen Lantz, PhD, Univ. of Colorado Boulder and National Oceanic and Atmospheric Administration Mary Klein Buller, MA, Klein Buendel, Inc. Jess Benson, PhD, Univ. of New Mexico Klein Buendel Staff Ilima Kane, MA Lucia Liu, MA James Shane Max Wolf

30 Thank You Buller et al. User-centered development of a smart phone mobile application delivering personalized real-time advice on sun protection. Transl Behav Med Practice, 2013;3: Buller DB, Berwick M, Lantz K, Buller MK, Shane J, Kane I, Liu X. Smartphone mobile application delivering personalized realtime sun protection advice: a randomized clinical trial. JAMA Dermatol 2015;151: Buller DB, Berwick M, Lantz K, Buller MK, Shane J, Kane I, Liu X. Evaluation of immediate and 12-week effects of a smartphone sun-safety mobile application: a randomized clinical trial. JAMA Dermatol 2015;151: