Discussion
The present study aimed to directly address an evidence gap by evaluating the age-specific lifetime prevalence and risk of skin cancer in Australian golf participants compared with a general population-based sample. More golf participants had been diagnosed with skin cancer (27%) compared with the general population (7%). After adjusting for age, sex, education and smoking status, the relative risk of skin cancer was 2.42 times higher among golf participants than the general population.
Previous research has found that playing golf is likely to bring physical and mental health benefits for players.12 13 Nevertheless, playing golf can also expose players to potentially harmful levels of UVR and thus associated skin problems such as skin cancer. A scoping review found that golf participants are likely at higher risk of skin cancer than non-golf participants,12 and an international consensus agreed on the statement: ‘While moderate sun exposure can offer benefits, golf participants can be exposed to increased risk of skin cancer associated with excess sun exposure if appropriate care and consideration are not taken’.20 The findings of the current study that golf participants have a higher relative risk of skin cancer than the general population add further evidence to the emerging golf and health literature.
Previous UVR dosimetry studies suggest that golf exposes players to a UVR dose greater than or similar to tennis, sailing6 16 and gardeners.21 In addition, a modelling study estimated that men’s golf at the Tokyo 2020 Olympics had the second highest UVR exposure of the 144 Olympic sports.22 Interestingly, a UVR dosimetry study estimated that the relative risk of golf participants developing basal cell carcinoma and squamous cell carcinoma compared with indoor workers was 1.11 on the forearm and 1.16 on the back.23 This risk is notably lower than the relative risk of skin cancer identified in our study compared with a general population-based sample.10 22 There are a number of potential explanations for this. First, golf participants could be more likely to develop skin cancer in other locations (such as the legs, face or head); however, we did not collect data on skin cancer location. Second, the risk was calculated on UVR dosimetry, as a proxy for confirmed skin cancer diagnosis, which may have underestimated the prevalence of skin cancer in the previous study.
The only previous study to have collected data on skin cancer diagnosis in golf participants15 investigated point prevalence of skin cancer and associated risk factors (ie, UVR exposure) for professional and amateur female golf participants in the USA. Professional golf participants in their study were exposed to five times as much sunlight as amateur golf participants mainly due to the requirement to practise and play during the peak UVR exposure times during the day. Approximately 15% of all the golf participants had been diagnosed with skin cancer, lower than the findings of the current study. Although some of the golf participants developed skin cancer much earlier (~25 years old), the average age of those who had been diagnosed with skin cancer was 50.9 years, more in keeping with the findings of our current study. However, the study is limited in its generalisability as a general population comparison group was not used.
Interestingly, a study by Dixon et al24 found that Australian golf participants’ sun protection practices declined from 1992 to 2002 in terms of clothing cover and concluded SunSmart campaigns may be failing to reach golf participants. A cross-sectional study of individuals living in Copenhagen21 found that the median number of episodes of sunburn per year was lower for golf participants than for children, adolescents and indoor workers in a cross-sectional study. However, it is unclear if skin cancer prevention campaigns had any impact on these findings. Further research is needed to investigate the effectiveness of skin cancer prevention programmes on changing skin protection behaviours among golf participants.
This study represents an advancement in the evidence available on the risk of skin cancer for golf participants. This is only the second study to collect data on history of skin cancer diagnosis in golf participants, and to the best of our knowledge, this is the first study to assess the prevalence of skin cancer in golf participants compared with a general population comparator group. This study’s strengths are seen in its relatively large and nationwide Australian setting and the large general population sample size. In addition, the sample of golf participants can be thought of as representative of the Australian golfing population. The data obtained on golf participants are consistent with previously reported data on golf populations where age, gender, playing history and education status have been reported (eg, refs 8 13 25). Furthermore, the data from our comparator sample were obtained from a large random sample of Australians. The findings of the present study are therefore likely to be generalisable to the wider Australian context.
Despite these strengths, this study possesses limitations that should be acknowledged. The data are cross-sectional and we did not have information about when participants were diagnosed with skin cancer, so we cannot infer causation in terms of the relationship between golf and risk of skin cancer diagnosis. Variables related to ethnicity were not available within the AHS and were unable to be included in the analysis. Ethnicity and exposed skin colour are known risk factors for skin cancer,26 whereby those with fairer skin have an increased risk of developing skin cancer. Our results may have been influenced by the absence of these variables. In addition, the possibility that surveillance bias may explain some of the higher risk for golf participants should also be considered. Surveillance bias occurs when some individuals may have more diagnostic tests performed than others.27 In this case, it may be that golf participants are more likely to have regular skin checks than the general population due to public information campaigns on the risks associated with increased sun exposure. Self-report bias has been shown to underestimate the true prevalence of medical conditions.28 It is possible that the true prevalence of skin cancer was underestimated in both the sample of golf participants and the general population-based sample. Larger prospective studies with more information on potential confounders and objective skin cancer data are needed to confirm the results of this study.
Clinical implications
The findings of this analysis have key implications for golf participants with regard to sun protection practices. Matthews et al’s29 recent narrative review concluded that while definitive evidence exists to indicate that golf participants are exposed to potentially harmful levels of UVR during play, epidemiological studies are required to understand more about the risks to skin health that golf participants face from this exposure. Although causation cannot be established from our study, the findings provide greater insight into morbidity related to sun exposure for golf participants than previous studies in this field have provided to date. Given that we have found a more than twofold increase in lifetime risk of skin cancer golf participants, our findings support the need for golf participants to reduce their UVR exposure during play. Golf industry, golf facilities and the wider public health community have a role in supporting golf participants to reduce their UVR exposure and to engage regularly with health providers for regular skin checks. Specifically, golf participants should use high-Sun Protection Factor (SPF) sunscreen reapplied regularly, wear clothing that protects high-exposure areas such as arms, legs, neck and ears and wear broad brimmed hats rather than peaked caps. Strategies such as these are particularly important for junior golfers, who may be less aware of the risk of skin cancer, and the need to use skin protection from an early age to reduce the risk of developing skin cancer in later life. If applying insect repellent, timing of application should be considered to allow sufficient absorption of sunscreen. Golfers at high risk of skin cancer, such as those with family history, a history of cancer and those needing to avoid UV exposure due to medication and/or treatment, should consider playing at times during the day when UVR exposure is lower. Since Australia is a popular tourist destination for golfing, golfing tourists should also be informed of these risks, especially those from colder climates.30