Public awareness regarding UV risks and vitamin D--the challenges for UK skin cancer prevention campaigns

Since 1970s, incidence rates for malignant melanoma have been among the fastest rising of all cancers in the UK. Compared to other cancers, melanoma affects disproportionately more young people, and non-melanoma skin cancers are the most commonly diagnosed, with over 100,000 new cases estimated in the UK annually. Government targets to reduce skin cancer incidence have led working groups and prevention campaigns to be set up in the belief that moderating UV exposure will help. An increased awareness of skin cancer has clearly played a role in curbing mortality from the disease, but translating knowledge into behaviour change in this context is a slow and complex process, and campaigns need to be sustained if they are to impact on incidence. A growing body of literature suggesting a cancer protective role for vitamin D and sun exposure presents further challenges for skin cancer prevention campaigns, no more so than when exaggerated claims for the health benefits of sunbathing make the media spotlight. The UK population tend to need little encouragement to make the most of sunshine, and this is especially true for the younger generation who most need to take care. Public health messages to avoid the midday sun, not to burn and to protect children should not adversely affect outdoor activity or population vitamin D levels, but it is important that they are targeted to those most at risk and are consistent. More research is required to establish optimal levels of vitamin D and how to safely achieve them in a heterogeneous population. In the meantime, hasty alterations of public health messages are likely to prove counterproductive.     

Acquired melanocytic nevi as risk factor for melanoma development. A comprehensive review of epidemiological data

Acquired melanocytic nevi (MN) in Caucasian populations are important markers for the risk of melanoma development. The total number of MN on the whole body is the most important independent risk factor for melanoma and the risk of melanoma development increases almost linearly with rising numbers of MN. Additionally, the presence of atypical MN and of actinic lentigines are likewise independent risk factors for melanoma. Atypical mole syndrome should be defined by the presence of many acquired MN and a threshold number of atypical MN. Acquired MN develops mainly during childhood and adolescence in the first two decades of life. The number of acquired nevi seems to be related to hereditary factors and nevus-prone families exist. The amount of sun exposure is the most important environmental risk factor for nevus development, particularly in early childhood. Interestingly, sunburns may play a role in nevus development, but seem not to be required, and even moderate sun exposure promotes the process. Therefore, preventive measures for nevus and melanoma development should target young children and adolescents.     

The impact of skin cancer prevention efforts in New South Wales,Australia: Generational trends in melanoma incidence and mortality

BackgroundIn Australia, skin cancer awareness campaigns have focused on raising the awareness and consequences of skin cancer and highlighting the importance of utilising sun protection.MethodsTrends in melanoma incidence and mortality have been explored elsewhere in Australia and this study sought to examine the trends in NSW. Anonymised incidence and mortality data for in situ and invasive melanoma from 1988 to 2014 were obtained from the NSW Cancer Registry. Trends of melanoma incidence and mortality were analysed using segmented regression to allow for changes over time. Birth cohort patterns were assessed using age–period–cohort models.ResultsOver the period, incidence of in situ melanoma increased in all age groups although the rates were lowest in those under 40 years of age. Incidence of invasive melanoma was either stable or decreased in people under 60, while it increased in those aged 60 and above, particularly in men. Age–period–cohort analysis revealed decreasing age-specific incidence of invasive melanoma under 40 years of age. Melanoma mortality over the period was stable or decreased in all groups except in men aged 60 or over. Overall, mortality rates generally declined or remained stable particularly in recent years.ConclusionIt is encouraging that rates of invasive melanoma are declining in the younger age cohorts – which could be attributed to both primary prevention efforts with individuals protecting their skin as well as early detection through self assessment and clinician performed skin checks. In addition, whilst it is important to monitor the increasing rates of in situ melanoma, the increase is likely due to early detection and treatment of melanoma that could have progressed to invasive melanoma and therefore detection whilst still in situ is an improved outcome. Overall, the results demonstrate the need to continue to improve the understanding of and compliance with primary skin cancer prevention measures in order to reduce population UVR exposure and overall melanoma incidence.     

Tanning Devices – Fast Track to Skin Cancer?

The use of UVB and/or UVA emitting devices for cosmetic tanning is widespread in Western populations including young people and is especially prevalent in females. Several epidemiological studies, although not all, have shown a significant relationship between the use of tanning devices and malignant melanoma after, in some cases, adjustment for confounding factors such as solar ultraviolet radiation (UVR) exposure. A relationship between solar exposure, especially intermittent exposure, and malignant melanoma is well established so it is not surprising that a similar connection has been reported for the use of tanning devices. Several epidemiological studies show that childhood exposure to sunlight is a risk factor for malignant melanoma and this may also be the case for the use of tanning devices, especially if sunburns are obtained. Some studies have evaluated the relationship between the use of tanning devices and non‐melanoma skin cancer and at least one has suggested an association. The use of tanning devices by a substantial minority of young people is a worrying trend in terms of a likely increased incidence of malignant melanoma, and possibly non‐melanoma cancers in the future. Although two recent reviews by epidemiologists conclude that a clear link between tanning devices and malignant melanoma is yet to be proven, there is a strong case for effective legislation to prohibit the use of tanning devices by people under 18 yr of age.     

Tanning devices--fast track to skin cancer?

The use of UVB and/or UVA emitting devices for cosmetic tanning is widespread in Western populations including young people and is especially prevalent in females. Several epidemiological studies, although not all, have shown a significant relationship between the use of tanning devices and malignant melanoma after, in some cases, adjustment for confounding factors such as solar ultraviolet radiation (UVR) exposure. A relationship between solar exposure, especially intermittent exposure, and malignant melanoma is well established so it is not surprising that a similar connection has been reported for the use of tanning devices. Several epidemiological studies show that childhood exposure to sunlight is a risk factor for malignant melanoma and this may also be the case for the use of tanning devices, especially if sunburns are obtained. Some studies have evaluated the relationship between the use of tanning devices and non-melanoma skin cancer and at least one has suggested an association. The use of tanning devices by a substantial minority of young people is a worrying trend in terms of a likely increased incidence of malignant melanoma, and possibly non-melanoma cancers in the future. Although two recent reviews by epidemiologists conclude that a clear link between tanning devices and malignant melanoma is yet to be proven, there is a strong case for effective legislation to prohibit the use of tanning devices by people under 18 yr of age.     

Incidence and thickness of primary tumours and survival of patients with cutaneous malignant melanoma in relation to socioeconomic status.

OBJECTIVE--To study incidence of and survival from cutaneous malignant melanoma in relation to socioeconomic status. DESIGN--Application of Carstairs deprivation score to all malignant melanoma patients diagnosed in a geographically defined area over a 15 year period. SETTING--West of Scotland (area population 2,716,900). SUBJECTS--3142 patients first diagnosed with malignant melanoma in the period 1979-93. INTERVENTIONS--Surgical excision of primary malignant melanoma with additional treatment as appropriate and follow up until December 1994. MAIN OUTCOME MEASURES--Malignant melanoma incidence, primary tumour thickness and five year survival by socioeconomic status. RESULTS--From 1979 to 1993, the age standardised incidence rate for cutaneous malignant melanoma was 9.1/100,000 for the most affluent men and 2.4/100,000 for the least affluent men and 16.1/100,000 and 5.0/100,000 respectively for most and least affluent women (P < 0.001 for trend in both). The incidence increased steadily over time in both sexes in all socioeconomic groups. Good prognosis tumours ( < 1.5 mm thick) were most common in the most affluent men and women, and over the study period the proportion of such tumours increased most in the intermediate affluence group (both sexes) and in the least affluent women. Five year disease free survival from melanoma for the sexes combined was 81% for most affluent, 77% for intermediate, and 73% for least affluent groups. Even after adjustment for known prognostic factors of tumour thickness, ulceration, age, and body site of primary melanoma, the more affluent the group, the better the survival. CONCLUSION--Although the incidence of cutaneous malignant melanoma is higher among more affluent people, the prognosis is better in this group than for less affluent individuals. Early diagnosis campaigns should be targeted particularly to less affluent men and primary prevention campaigns should emphasise the greater risk in more affluent women.     

The challenge resulting from positive and negative effects of sunlight: how much solar UV exposure is appropriate to balance between risks of vitamin D deficiency and skin cancer?

There is no doubt that solar ultraviolet (UV) exposure is the most important environmental risk factor for the development of non-melanoma skin cancer. Therefore, sun protection is of particular importance to prevent these malignancies, especially in risk groups. However, 90% of all requisite vitamin D has to be formed in the skin through the action of the sun-a serious problem, for a connection between vitamin D deficiency and a broad variety of independent diseases including various types of cancer, bone diseases, autoimmune diseases, hypertension and cardiovascular disease has now been clearly indicated in a large number of epidemiologic and laboratory studies. An important link that improved our understanding of these new findings was the discovery that the biologically active vitamin D metabolite 1,25(OH)(2)D is not exclusively produced in the kidney, but in many other tissues such as prostate, colon, skin and osteoblasts. Extra-renally produced 1,25(OH)(2)D is now considered to be an autocrine or paracrine hormone, regulating various cellular functions including cell growth. We and others have shown that strict sun protection causes vitamin D deficiency in risk groups. In the light of new scientific findings that convincingly demonstrate an association of vitamin D deficiency with a variety of severe diseases including various cancers, the detection and treatment of vitamin D deficiency in sun-deprived risk groups is of high importance. It has to be emphasized that in groups that are at high risk of developing vitamin D deficiency (e.g., nursing home residents or patients under immunosuppressive therapy), vitamin D status has to be monitored. Vitamin D deficiency should be treated, e.g., by giving vitamin D orally. Dermatologists and other clinicians have to recognize that there is convincing evidence that the protective effect of less intense solar UV radiation outweighs its mutagenic effects. Although further work is necessary to define an adequate vitamin D status and adequate guidelines for solar UV exposure, it is at present mandatory that public health campaigns and recommendations of dermatologists on sun protection consider these facts. Well-balanced recommendations on sun protection have to ensure an adequate vitamin D status, thereby protecting people against adverse effects of strict sun protection without significantly increasing the risk of developing UV-induced skin cancer.     

Genetic and environmental factors in cutaneous malignant melanoma

Cutaneous malignant melanoma (CMM) is an interesting example of multifactorial disease, where both genetic and environmental factors are involved and interact. Major risk factors include a personal and familial history of melanoma, cutaneous and pigmentary characteristics, sun exposure and reactions to sun exposure. Phenotypic risk factors are likely to be genetically determined. Two high-risk melanoma susceptibility genes-CDKN2A and CDK4-have been identified to date, with a third gene p14(ARF) also being suspected of playing a role. Other high-risk genes are anticipated by the existence of 9p21-unlinked families. A low-risk melanoma-susceptibility gene-MC1R-has also been identified. Current studies aim to identify other susceptibility genes as well as to determine the respective contributions and interactions of the various genetic and environmental factors of CMM and associated phenotypes.     

Pigmentation and skin reaction to sun as risk factors for cutaneous melanoma: Western Canada Melanoma Study.

Between 1 April 1979 and 31 March 1981, 904 residents of the four western provinces of Canada (population 6.5 million), were diagnosed as suffering from primary cutaneous malignant melanoma. Of 801 patients aged 20-79 years, 665 (83%) were interviewed along with control subjects chosen at random from the general population and matched for age, sex, and province. After exclusion of 70 subjects with lentigo maligna or acral lentiginous melanoma, comparisons of the 595 case-control pairs showed that light hair, skin, and eye colour, a history of heavy freckling in adolescence, and a tendency to burn readily and tan poorly in the sun were significant risk factors for melanoma. The strongest primary associations were with blond hair (relative risk 7.1 compared with black hair), light colour of unexposed skin (relative risk 2.4), and severe freckling (relative risk 2.1). These associations were independent of ethnic origin and of recorded amount of exposure to the sun and were somewhat stronger for superficial spreading than for nodular melanoma. This study is the largest and most detailed of an incident series of melanomas to be published to date. The results were consistent with other studies reporting associations between melanoma and poor tanning ability, a tendency to burn easily, and a history of sunburn and showed that light hair colour was the strongest risk factor for the disease.     

The dysplastic nevus: recognition and management

The recognition of atypical or dysplastic nevomelanocytic nevi potentially provides clinicians with another means of identifying individuals at increased risk for cutaneous malignant melanoma. However, a great deal of controversy still surrounds these lesions, their significance, and the clinical and histologic criteria needed for their diagnosis at present. In general, dysplastic nevi tend to be asymmetrical and larger (greater than 5 mm) than ordinary acquired nevi, have a macular component, irregular and ill-defined borders, and haphazard (variegate) coloration. A clinical diagnosis of dysplastic nevi must be confirmed by histopathology, since not all clinically atypical nevi are dysplastic. While precise histopathologic criteria for dysplastic nevi are lacking, most authorities agree that an abnormal nevomelanocytic proliferative pattern as manifested by increased numbers of basilar melanocytes and/or abnormal junctional nevomelanocytic nesting in the setting of lentiginous epidermal hyperplasia, variable degrees of nevomelanocytic nuclear atypia, and a lymphocytic host response are consistent with a histologic diagnosis of dysplastic nevi. Current data for individuals with dysplastic nevi and a family history of cutaneous malignant melanoma (at least two family members with cutaneous malignant melanoma) indicate a relative risk for cutaneous malignant melanoma about 148 times that of the general population. In comparison, cutaneous malignant melanoma risk seems lower for individuals with familial dysplastic nevi (but without familial cutaneous malignant melanoma) and "sporadic" dysplastic nevi. With respect to progression to melanoma, probably the vast majority of dysplastic nevi remain stable or possibly regress. Management of individuals with histologically confirmed dysplastic nevi involves periodic skin examinations. Regional overview and life-size photography are helpful in following these patients. Patients should also be instructed in the examination of their own skin. While a definite relationship between sun exposure and dysplastic nevi remains unproved, the use of sunscreens and avoidance of unnecessary sun exposure are advised. Examination of family members for atypical melanocytic lesions is also recommended.     

Melanoma Prevention: Is It Possible to Change a Population's Behavior in the Sun?

With the highest incidence and mortality rates of melanoma in the world, Australia has been running carefully designed primary prevention programs for more than 10 years. These have included public education programs aimed at all ages but concentrating particularly on young people. The programs have also included structural changes such as provision of shade in open space, rescheduling work and sport activities, removal of sales tax from approved sunscreens, and provision of cheap sunscreens. There have been substantial changes in knowledge, attitudes, and beliefs about melanoma, sunlight, and suntans. There have been significant increases in sun protective behavior reflected in the reduced proportions of people sunburnt at the weekend in summer in recent years. The incidence rate of melanoma continues to rise, as expected. Although there has been considerable success so far, we still have a long way to go.     

Sun exposure and skin cancer,and the puzzle of cutaneous melanoma: A perspective on Fears et al. Mathematical models of age and ultraviolet effects on the incidence of skin cancer among whites in the United States. American Journal of Epidemiology 1977; 105: 420–427

Sunlight has been known as an important cause of skin cancer since around the turn of the 20th Century. A 1977 landmark paper of US scientists Fears, Scotto, and Schneiderman advanced a novel hypothesis whereby cutaneous melanoma was primarily caused by intermittent sun exposure (i.e. periodic, brief episodes of exposure to high-intensity ultraviolet radiation) while the keratinocyte cancers, squamous cell carcinoma and basal cell carcinoma, were primarily caused by progressive accumulation of sun exposure. With respect to cutaneous melanoma, this became known as the intermittent exposure hypothesis. The hypothesis stemmed from analysis of measured ambient ultraviolet radiation and age-specific incidence rates of melanoma and keratinocyte cancers collected as an extension to the US Third National Cancer Survey in several US States. In this perspective paper, we put this novel hypothesis into the context of knowledge at the time, and describe subsequent epidemiological and molecular research into melanoma that elaborated the intermittent exposure hypothesis and ultimately replaced it with a dual pathway hypothesis. Our present understanding is of two distinct biological pathways by which cutaneous melanoma might develop; a nevus prone pathway initiated by early sun exposure and promoted by intermittent sun exposure or possibly host factors; and a chronic sun exposure pathway in sun sensitive people who progressively accumulate sun exposure to the sites of future melanomas.     

UV radiation: what we know and do we protect ourselves adequately?

Chronic sun exposure causes degenerative changes in the skin that are recognized as photoaging, immunosuppression and photocarcinogenesis. Sun is necessary for life, so total sun avoidance is impossible. Sun exposure during the first 15 years of life and blistering sunburns before age 20 have been linked to an increased risk of melanoma. Individuals who have outdoor lifestyles, live in sunny climates, and are lightly pigmented will experience the greatest degree of photoaging. In our study, performed four years ago, we have shown the knowledge of more than 4000 people about the effects of UV rays on the skin. The results show us that sun exposure is still exaggerated and uncontrolled due to the lack of knowledge about this topic. Encouraging photoprotection and improving the awareness of the general public about the harmful effects of too much sun exposure must be the leading preventative health strategy.     

Signaling pathways mediating melanogenesis.

Pigmentation of the skin, due to the synthesis and dispersion of melanin in the epidermis, is of great cosmetic and societal significance. It is also the key physiologic defense against sun-induced injuries such as sunburn, photocarcinogenesis and photoaging. During recent decades, there has been a dramatic increase in skin cancers, including melanoma, due to habitual sun exposure (Rigel, 1992; Weinstock, 1989). At present, in the United States, about one in 75 individuals is projected to develop malignant melanoma during his or her lifetime (Rigel, 1992). Unfortunately, progress in preventing sun-related injuries has been slow, in part due to lack of understanding of the molecular mechanisms involved in pigmentation. This article reviews recent progress in identifying signal transduction pathways that mediate melanogenesis.     

New option in photoprotection

All the people are exposed to solar ultraviolet radiation. Exposure to sun with living in an oxygen-rich atmosphere causes unwanted photodemage. Sunburned skin is a leading risk factor for melanoma and non-melanoma cancers. UV exposure causes immunosuppression via multiple mechanisms in the skin. In this review the main topic is to mention new or alternative ways of photoprotection. Sunscreens are commonly used as protection against sun damage. They reduce the penetration of damaging solar UV wavelengths in skin by reflecting or absorbing them. Sunscreens are very valuable, but they have limitations. They have to be used properly to gain the full effect (application a little while before UV exposure, at frequent time points and in adequate amounts). Also, they have the problem of photoinactivation, which is the degeneration of the UV-filter due to exposure to UV rays resulting in the loss of absorbing capacity. Products with immune protection factor contain DNA-repair enzymes and antioxidants that may reduce mutations and enable the immune system to combat photodamage. The use of antioxidants and polyphenols may exert an anti-aging effect by preventing and even reversing sun damage. Adequate photoprotection is essential to control photocarcinogenesis and photoaging.     

Skin cancer--primary and secondary prevention (information campaigns and screening)--with a focus on children & sunbeds

Solar and artificial (sunbed) UV-exposure is the main risk factor for the development of epithelial skin cancer (basal cell carcinoma, BCC, and squamous cell carcinoma, SCC) as well for malignant melanoma (MM). UV exposure in childhood and adolescence is especially important. Therefore, adequate methods of primary prevention have continuously to be used and to be developed further to target these age-groups in order to reduce the risks of intensive UV-exposure. Primary prevention can effectively be combined with secondary prevention (early detection, screening) to reduce the burden of skin cancer and to decrease incidence, morbidity and mortality.     

中国汉族人黑色素瘤家系临床特点分析

目的:探讨中国汉族人群恶性黑色素瘤家系发病情况及临床特点。方法:收集4个遗传性黑色素瘤家系进行家系调研和家系图谱绘制,并分析总结临床特点。结果:4个遗传性黑色素瘤家系共33人,确诊黑色素瘤患者10例,死亡2例。确诊患者平均年龄36岁。结论:中国汉族人群黑色素瘤家系具有发病年龄较轻,其中发病年纪越小其恶性程度越高、预后越差,而且黑色素瘤的高侵袭性同样具有明显家族遗传特点。     

Reviews on sun exposure and artificial light and melanoma

Melanoma is the most common form of cancer among young adults aged 25-29 years and the second most common cancer in those aged 15-29 years. We reviewed all the evidence regarding risk factors for melanoma, looking in particular at childhood exposure to ultraviolet radiation (UV). UV radiation is clearly the predominant environmental and thus potentially modifiable risk factor for melanoma. All activities related to tan-seeking behaviour and history of sunburns were shown to be significantly associated to melanoma. Host factors, such as pigmentary characteristics, and genetic predisposition plays also an important role. UV exposure is not only due to the sun but also to indoor tanning devices that have been shown to lead to an elevated risk of melanoma. The strongest evidence for a link between artificial UV and melanoma is found among individuals who had their first exposure to indoor tanning before the age of 30: they have a 75% increase risk of developing melanoma than individuals who had no exposure to indoor tanning. Prevention is very important, especially for children and young adults, as childhood and adolescence are critical periods in the development of later melanoma. Indoor tanning is a widespread practice in most developed countries, particularly in Northern Europe and the USA. In the recent decades more and more people, especially teenagers and women, are exposed to substantially high radiant exposures of UV through artificial sources and these trends raised a considerable concern. In fact the International Agency for Research on Cancer concluded that the association between skin cancer and exposure to solar radiation and the use of UV-emitting tanning devices are causal. Interesting analyses carried out in Iceland showed that when interventions to discourage sunbed use were introduced the incidence of melanoma among women decreased. All this evidence encouraged many countries to introduce regulations on sunbed use to avoid exposure before the age of 18.     

Epidemiological and clinical characteristics of malignant melanoma in area of West Herzegovina from 1997 to 2010

Incidence rate of cutaneous malignant melanoma (MM), one of the most aggressive skin tumours, is increasing nowadays. Etiology of MM has not been fully understood. Various etiological factors are of relevance for the occurrence of the disease. The solar radiation as well as long term exposure to ultraviolet radiation has the greatest impact on development of this skin tumour. Melanoma risk factors have different associations with melanoma on body sites. This study investigates the epidemiological and clinical characteristics of MM such as age, gender, distribution of MM on the body and type of melanoma in the area of West Herzegovina, on the sample of 205 patients. It presents the occurrence of MM in the period from 1997. to 2010. Both, females and males have increased the risk of melanoma on the trunk (45.9%). Different body sites receive various amounts of sun exposure, yet melanomas occur on all parts of the body. This may represent different pathways in the etiology of melanoma based on body location. The most frequent type of MM was superficial spreading melanoma (SSM) 47.8%. According to our investigation incidence rate was 18.6% (per 1000 patients).     

Epidemiologic data of malignant melanoma in Osijek-Baranya County (Eastern Croatia) during the period of 2000-2008

During the past several decades there has been a substantial increase in the incidence of malignant melanoma worldwide. The highest incidences were reported in New Zealand and Australia. In Europe the northern countries generally have a higher incidence. The aim of this retrospective study was to provide the incidence and mortality for all patients with malignant melanoma diagnosed in Osijek-Baranya County, Eastern Croatia, during 2000-2008. In the past 30 years in the Republic of Croatia the incidence of melanoma increased by 337%. During the period of 2000-2006 in Osijek-Baranja County, the incidence of melanoma increased by 13%. The incidence of melanoma increases with age, but in past decades melanoma is more often diagnosed in people aged 25-40. The mortality between 2000 and 2008 increased by 18%. The incidence of melanoma generally increases equally in men and women. The most common localization of skin melanoma in males was trunk and in females the lower extremities. Presently, in Osijek-Baranya County melanoma is 15th on the list of malignant tumors and represent 2% of all malignant tumors. In New Zealand, Australia and European northern countries mortality is reduced, as result of earlier diagnosis and education of risk groups. Unfortunately, in Osijek-Baranya County, in a comparison with these countries, the mortality is higher although incidence is the same or lower.