International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review

UV Driven Tanning Salons: Danger on Main Street

Appearing in the early 1980s, at a time when UVA was considered as relatively safe, the tanning industry has substantially developed in occidental countries, especially in Northern European countries. In Europe, the erythemally-weighted irradiance of a modern sunbed should not exceed 0.3 W/m², equivalent to an UV index of 12, i.e. to a tropical midday sun, but increased in recent years, the UV spectrum emitted by sunbeds had evolved towards higher UVA irradiance and solariums UV had become even less similar to natural sun.

Cutaneous melanoma: From pathogenesis to therapy (Review)

In less than 10 years, melanoma treatment has been revolutionized with the approval of tyrosine kinase inhibitors and immune checkpoint inhibitors, which have been shown to have a significant impact on the prognosis of patients with melanoma. The early steps of this transformation have taken place in research laboratories. The mitogen‑activated protein kinase (MAPK) pathway, phosphoinositol‑3‑kinase (PI3K) pathway promote the development of melanoma through numerous genomic alterations on different components of these pathways. Moreover, melanoma cells deeply interact with the tumor microenvironment and the immune system. This knowledge has led to the identification of novel therapeutic targets and treatment strategies. In this review, the epidemiological features of cutaneous melanoma along with the biological mechanisms involved in its development and progression are summarized. The current state‑of‑the‑art of advanced stage melanoma treatment strategies and the currently available evidence of the use of predictive and prognostic biomarkers are also discussed.

Patterns of Ultraviolet Radiation Exposure and Skin Cancer Risk: the E3N-SunExp Study

BACKGROUND

While ultraviolet (UV) radiation exposure is a recognized risk factor for skin cancer, associations are complex and few studies have allowed a direct comparison of exposure profiles associated with cutaneous melanoma, basal-cell carcinoma (BCC), and squamous-cell carcinoma (SCC) within a single population.

METHODS

We examined associations between UV exposures and skin cancer risk in a nested case-control study within E3N, a prospective cohort of 98,995 French women born in 1925-1950. In 2008, a lifetime UV exposure questionnaire was sent to all reported skin cancer cases and three controls per case, which were matched on age, county of birth, and education. Analyses were performed using conditional logistic regression and included 366 melanoma cases, 1,027 BCC cases, 165 SCC cases, and 3,647 controls.

RESULTS

A history of severe sunburns <25 years was associated with increased risks of all skin cancers (melanoma: OR 2.7; BCC: OR 1.7; SCC: OR 2.0 for ≥6 sunburns vs. none), while sunburns ≥25 years were associated with BCC and SCC only. While high-sun protection factor sunscreen use before age 25 was associated with lower BCC risk (Ptrend = 0.02), use since age 25 and reapplication of sunscreen were associated with higher risks of all three types of skin cancer. There were positive linear associations between total UV score and risks of BCC (Ptrend = 0.01) and SCC (Ptrend = 0.09), but not melanoma. While recreational UV score was strongly associated with BCC, total and residential UV scores were more strongly associated with SCC.

CONCLUSIONS

Melanoma, BCC, and SCC are associated with different sun exposure profiles in women.

Mechanisms and prevention of UV-induced melanoma

Melanoma is the deadliest form of skin cancer and its incidence is rising, creating a costly and significant clinical problem. Exposure to ultraviolet (UV) radiation, namely UVA (315-400 nm) and UVB (280-315 nm), is a major risk factor for melanoma development. Cumulative UV radiation exposure from sunlight or tanning beds contributes to UV-induced DNA damage, oxidative stress, and inflammation in the skin. A number of factors, including hair color, skin type, genetic background, location, and history of tanning, determine the skin's response to UV radiation. In melanocytes, dysregulation of this UV radiation response can lead to melanoma. Given the complex origins of melanoma, it is difficult to develop curative therapies and universally effective preventative strategies. Here, we describe and discuss the mechanisms of UV-induced skin damage responsible for inducing melanomagenesis, and explore options for therapeutic and preventative interventions.

Counseling on Sun Protection and Indoor Tanning

BACKGROUND

The US Preventive Services Task Force recommends clinical counseling for individuals ages 10 to 24 years to decrease skin cancer risk.

METHODS

A national, random sample of US American Academy of Pediatrics members practicing primary care in 2002 (response rate 55%) and 2015 (response rate 43%). Surveys explored attitudes and experiences regarding sun protection counseling; indoor tanning questions were added in 2015. χ² tests compared demographics and counseling responses across years, and multivariable logistic regression models examined counseling predictors.

RESULTS

More pediatricians in 2015 (34%) than in 2002 (23%) reported discussing sun protection during recent summer months with ≥75% of patients. This pattern held across all patient age groups (each P <.001). Female and suburban pediatricians counseled more; those in the South and West counseled less. More pediatricians in 2015 than in 2002 named time as a barrier. Sun protection ranked lowest among preventive topics in both years. In 2015, approximately one-third of pediatricians reported discussing indoor tanning at least once with 10 to 13 year-old patients; approximately half discussed this with older adolescents. Most (70%) did not know if their states had laws on minors' indoor tanning access; those stating they knew whether a law existed counseled more.

CONCLUSIONS

Although improved, sun protection counseling rates remain low. Indoor tanning counseling can be improved. Because early-life exposure to UV radiation increases risk and clinician counseling can positively impact prevention behaviors, pediatricians have an important role in skin cancer prevention; counseling may save lives. Time constraints remain a barrier.

Teens, Tweets, and Tanning Beds: Rethinking the Use of Social Media for Skin Cancer Prevention

The incidence of skin cancer is rising in the U.S., and melanoma, the deadliest form, is increasing disproportionately among young white women. Indoor tanning is a modifiable risk factor for all skin cancers and continues to be used at the highest rates in young white women. Adolescents and young adults report personal appearance-based reasons for using indoor tanning. Previous research has explored the influences on tanning bed use, including individual factors as well as relationships with peers, family, schools, media influences, legislation, and societal beauty norms. Adolescents and young adults also have high rates of social media usage, and research is emerging on how best to utilize these platforms for prevention. Social media has the potential to be a cost-effective way to reach large numbers of young people and target messages at characteristics of specific audiences. Recent prevention efforts have shown that comprehensive prevention campaigns that include technology and social media are promising in reducing rates of indoor tanning among young adults. This review examines the literature on psychosocial influences on indoor tanning among adolescents and young adults, and highlights ways in which technology and social media can be used for prevention efforts.

An integrated model of skin cancer risk in sexual minority males

Sexual minority males are an at-risk group for developing skin cancer. Elevated rates of skin cancer among this population are thought to be driven by excess indoor tanning; however, motivations to indoor tan among this population are unknown. Theoretically, appearance-based and affect regulation motives may be proximal predictors of increased indoor tanning in this population. The current study tests an integrated biopsychosocial model of indoor tanning behaviors and future intentions among a sample of sexual minority males. Participants were 231 sexual minority males, between the age of 14 and 35 years, residing in San Diego County, California, who completed a battery of self-report questionnaires online. Constructs assessed included skin tone, perceived susceptibility to skin cancer, sociocultural pressures to tan, appearance-based motives to tan, affect regulation in regard to indoor tanning, indoor tanning behaviors over the previous 3 months, and future intentions to indoor tan. The three proposed proximal predictors of indoor tanning all displayed significant pathways; however, results varied depending upon the specific outcome measure modeled. Affect regulation was significantly associated with increased odds of indoor tanning, and future intentions to indoor tan. Increased appearance reasons to tan were significantly associated with future intentions to indoor tan, while increased appearance reasons not to tan were significantly associated with fewer number of indoor tanning sessions. Results underscore the unique pathways of affect regulation and appearance-based motives in indoor tanning behaviors. Skin cancer prevention programs focusing on sexual minority males may wish to address affect and appearance concerns.

Opportunities for Skin Cancer Prevention Education among Individuals Attending a Community Skin Cancer Screening in a High-Risk Catchment Area

Despite the highly preventable nature of skin cancer, it remains the most commonly diagnosed form of cancer in the United States. Recommendations for a complete skin cancer prevention regimen include engaging in photoprotection (e.g., sunscreen use), avoiding skin cancer risk behaviors (e.g., tanning), and receiving total body skin exams from a health care provider. The current study examined reported engagement in these behaviors among participants attending a community skin cancer screening (N = 319) in a high-risk catchment area to assess the need for increased health education on skin cancer prevention. Participants' responses indicate a history of suboptimal avoidance of skin cancer risk behaviors. Over half of participants (52%) reported four or more blistering sunburns before age 20, and 46% reported indoor tanning at least one during their lifetime. There is a need among this population for education regarding a complete skin cancer prevention regimen, which could improve adherence to photoprotection and avoidance of skin cancer risk behaviors, thereby reducing morbidity and mortality due to skin cancer.

Prevalence of Indoor Tanning and Association With Sunburn Among Youth in the United States

Importance

Indoor tanning and sunburns, particularly during adolescence and young adulthood, increase the risk of developing skin cancer.

Objective

To examine the trends in the prevalence of indoor tanning and the association between indoor tanning and sunburn among US high school students.

Design, Setting, and Participants

This study pooled and examined cross-sectional data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Survey. During 2009, 2011, 2013, and 2015, the overall response rates were 71%, 71%, 68%, and 60%, respectively, and unweighted sample sizes were 16 410, 15 425, 13 538, and 15 624, respectively. It included nationally representative samples of US high school students. Data were collected during the spring semester (January to June) in each survey cycle beginning February 9, 2009, through June 18, 2015.

Main Outcomes and Measures

Prevalence of indoor tanning in the past year from 2009 to 2015 and its association with sunburn in 2015.

Results

Among high school students in the United States, the prevalence of indoor tanning decreased from 15.6% (95% CI, 13.7%-17.6%) in 2009 to 7.3% (95% CI, 6.0%-8.9%) in 2015. Decreases in indoor tanning were found among male (from 6.7% in 2009 to 4.0% in 2015) and female (from 25.4 % in 2009 to 10.6 % in 2015) students overall, non-Hispanic white (from 21.1 % in 2009 to 9.4% in 2015) and Hispanic (from 8.2% in 2009 to 4.7% in 2015) students overall, and all age groups. Among non-Hispanic white female students, the prevalence decreased from 37.4% (95% CI, 33.6%-41.4%) in 2009 to 15.2% (95% CI, 11.7%-19.5%) in 2015. In 2015, indoor tanning was associated with sunburn in the adjusted model: 82.3% (95% CI, 77.9%-86.0%) of indoor tanners had at least 1 sunburn during the preceding year compared with 53.7% (95% CI, 48.9%-58.4%) of those who did not engage in indoor tanning (P < .001).

Conclusions and Relevance

Despite declines in the prevalence of indoor tanning from 2009 to 2015 among high school students nationwide, indoor tanning remains commonplace among certain subgroups, especially non-Hispanic white female students. Three-quarters of those who engaged in indoor tanning had experienced at least 1 sunburn. Efforts by the public health and medical communities are needed to further reduce the prevalence of indoor tanning and sunburn and thus prevent future cases of skin cancer.

Commercial tanning salons and melanoma risk

There have been many case-control studies of melanoma and the use of indoor tanning equipment. A recent meta analysis of 8 credible studies in North America estimated an overall significant odds ratio of 1.23. Three of these 8 studies also reported separately on commercial use and home use of indoor tanning equipment. For home use the overall odds ratio was a significant 1.53 while for commercial use there was a non significant 1.05.

Cutaneous melanoma in women

BACKGROUND

Gender disparity in melanoma outcome is consistently observed, suggesting that gender is as an important prognostic factor. However, the source of this gender disparity in melanoma remains unclear.

OBJECTIVE

This article reviews advances in our understanding of gender differences in melanoma and how such differences may contribute to outcomes.

METHODS

A broad literature search was conducted using the PubMed database, with search terms such as 'gender differences in melanoma' and 'sex differences in melanoma.' Additional articles were identified from cited references.

RESULTS

Herein, we address the gender-linked physiologic differences in skin and melanoma. We discuss the influence of estrogen on a woman's risk for melanoma and melanoma outcomes with regard to pregnancy, oral contraceptives, hormone replacement therapy, and UV tanning.

CONCLUSIONS

The published findings on gender disparities in melanoma have yielded many advances in our understanding of this disease. Biological, environmental, and behavioral factors may explain the observed gender difference in melanoma incidence and outcome. Further research will enable us to learn more about melanoma pathogenesis, with the goal of offering better treatments and preventative advice to our patients.

Friendly tanning: young adults' engagement with friends around indoor tanning

Indoor tanning (IT), particularly during early adulthood, increases risk for melanoma and is exceedingly common among youth. Social influence, including social norms, promotes IT but little is known about young adults' engagement with friends around tanning. We examined IT behaviors and tanning-related communication with friends at three universities. Of 837 participants, 261 (31%) reported ever tanning (90% female, 85% White). Of those, 113 (43%) were former tanners and 148 (57%) current tanners. Current tanners reported more social tanning and discussions with friends about tanning, more frequent outdoor tanning, high propensity to tan, and greater lifetime IT exposure than former tanners. Risks-to-benefits discussion ratios were greater for former tanners. In adjusted analyses, current tanners were more likely to make plans to tan and to talk about tanning benefits with friends. Findings confirm IT is a social experience. Future work should examine social tanning's role in the promotion and reduction of IT among youth.

Indoor Tanning and Melanoma Risk: Long-Term Evidence From a Prospective Population-Based Cohort Study

Indoor tanning is associated with increased risk of melanoma, but most evidence comes from case-control studies. Using data from the Norwegian Women and Cancer Study, a large prospective cohort study, we investigated the associations of age at initiation of indoor tanning, duration of tanning-device use, and dose response with melanoma risk and examined the role of indoor tanning in age at melanoma diagnosis. We used Poisson regression to estimate relative risks and 95% confidence intervals for the relationship of indoor tanning to melanoma risk and linear regression to examine age of indoor tanning initiation in relation to age at diagnosis. During follow-up of 141,045 women (1991-2012; mean duration follow-up = 13.7 years), 861 women were diagnosed with melanoma. Melanoma risk increased with increasing cumulative number of tanning sessions (for highest tertile of use vs. never use, adjusted relative risk = 1.32, 95% confidence interval (CI): 1.08, 1.63); P-trend = 0.006. Age at initiation <30 years was associated with a higher risk in comparison with never use (adjusted relative risk = 1.31, 95% CI: 1.07, 1.59). Moreover, women who started indoor tanning prior to 30 years of age were 2.2 years (95% CI: 0.9, 3.4) younger at diagnosis, on average, than never users. This cohort study provides strong evidence of a dose-response association between indoor tanning and risk of melanoma and supports the hypothesis that vulnerability to the harmful effects of indoor tanning is greater at a younger age.

Non-genetic risk factors for cutaneous melanoma and keratinocyte skin cancers: An umbrella review of meta-analyses

BACKGROUND

Skin cancers have a complex disease mechanism, involving both genetic and non-genetic risk factors. Numerous meta-analyses have been published claiming statistically significant associations between non-genetic risk factors and skin cancers without applying a thorough methodological assessment.

OBJECTIVE

The present study maps the literature on the non-genetic risk factors of skin cancers, assesses the presence of statistical biases and identifies the associations with robust evidence.

METHODS

We searched PubMed up to January 20, 2016 to identify systematic reviews and meta-analyses of observational studies that examined associations between non-genetic factors and skin cancers. For each meta-analysis, we estimated the summary effect size by random-effects and fixed-effects models, the 95% confidence interval and the 95% prediction interval. We also assessed the between-study heterogeneity (I2 metric), evidence for small-study effects and excess significance bias.

RESULTS

Forty-four eligible papers were identified and included a total of 85 associations. Twenty-one associations were significant at P<10-6. Fifty-two associations had large or very large heterogeneity. Evidence for small-study effects and excess significance bias was found in fifteen and thirteen associations, respectively. Overall, thirteen associations (actinic keratosis, serum vitamin D, sunburns, and hair color for basal cell carcinoma and density of freckles, eye color, hair color, history of melanoma, skin type, sunburns, premalignant skin lesions, common and atypical nevi for melanoma) presented high level of credibility.

CONCLUSION

The majority of meta-analyses on non-genetic risk factors for skin cancers suffered from large between-study heterogeneity and small-study effects or excess significance bias. The associations with convincing and highly suggestive evidence were mainly focused on skin photosensitivity and phenotypic characteristics.

Engaging Moms on Teen Indoor Tanning Through Social Media: Protocol of a Randomized Controlled Trial

BACKGROUND

Indoor tanning elevates the risk for melanoma, which is now the most common cancer in US women aged 25-29. Public policies restricting access to indoor tanning by minors to reduce melanoma morbidity and mortality in teens are emerging. In the United States, the most common policy restricting indoor tanning in minors involves parents providing either written or in person consent for the minor to purchase a tanning visit. The effectiveness of this policy relies on parents being properly educated about the harms of indoor tanning to their children.

OBJECTIVE

This randomized controlled trial will test the efficacy of a Facebook-delivered health communication intervention targeting mothers of teenage girls. The intervention will use health communication and behavioral modification strategies to reduce mothers' permissiveness regarding their teenage daughters' use of indoor tanning relative to an attention-control condition with the ultimate goal of reducing indoor tanning in both daughters and mothers.

METHODS

The study is a 12-month randomized controlled trial comparing 2 conditions: an attention control Facebook private group where content will be relevant to teen health with 25% focused on prescription drug abuse, a topic unrelated to tanning; and the intervention condition will enter participants into a Facebook private group where 25% of the teen health content will be focused on indoor tanning. A cohort of 2000 mother-teen daughter dyads will be recruited to participate in this study. Only mothers will participate in the Facebook groups. Both mothers and daughters will complete measures at baseline, end of intervention (1-year) and 6 months post-intervention. Primary outcomes include mothers' permissiveness regarding their teenage daughters' use of indoor tanning, teenage daughters' perception of their mothers' permissiveness, and indoor tanning by both mothers and daughters.

RESULTS

The first dyad was enrolled on March 31, 2016, and we anticipate completing this study by October 2019.

CONCLUSIONS

This trial will deliver social media content grounded in theory and will test it in a randomized design with state-of-the-art measures. This will contribute much needed insights on how to employ social media for health behavior change and disease prevention both for indoor tanning and other health risk behaviors and inform future social media efforts by public health and health care organizations.

CLINICALTRIAL

Clinicaltrials.gov NCT02835807; https://clinicaltrials.gov/ct2/show/NCT02835807 (Archived by WebCite at http://www.webcitation.org/6mDMICcCE).

State of the science on prevention and screening to reduce melanoma incidence and mortality: The time is now

Answer questions and earn CME/CNE Although overall cancer incidence rates are decreasing, melanoma incidence rates continue to increase about 3% annually. Melanoma is a significant public health problem that exacts a substantial financial burden. Years of potential life lost from melanoma deaths contribute to the social, economic, and human toll of this disease. However, most cases are potentially preventable. Research has clearly established that exposure to ultraviolet radiation increases melanoma risk. Unprecedented antitumor activity and evolving survival benefit from novel targeted therapies and immunotherapies are now available for patients with unresectable and/or metastatic melanoma. Still, prevention (minimizing sun exposure that may result in tanned or sunburned skin and avoiding indoor tanning) and early detection (identifying lesions before they become invasive or at an earlier stage) have significant potential to reduce melanoma incidence and melanoma-associated deaths. This article reviews the state of the science on prevention and early detection of melanoma and current areas of scientific uncertainty and ongoing debate. The US Surgeon General's Call to Action to Prevent Skin Cancer and US Preventive Services Task Force reviews on skin cancer have propelled a national discussion on melanoma prevention and screening that makes this an extraordinary and exciting time for diverse disciplines in multiple sectors-health care, government, education, business, advocacy, and community-to coordinate efforts and leverage existing knowledge to make major strides in reducing the public health burden of melanoma in the United States. CA Cancer J Clin 2016;66:460-480. © 2016 American Cancer Society.

Vitamin D production in UK Caucasian and South Asian women following UVR exposure

BACKGROUND

It is known that skin pigmentation reduces the penetration of ultraviolet radiation (UVR) and thus photosynthesis of 25-hydroxvitamin D (25(OH)D). However ethnic differences in 25(OH)D production remain to be elucidated.

OBJECTIVE

The aim of this study was to investigate differences in vitamin D production between UK South Asian and Caucasian postmenopausal women, in response to a defined and controlled exposure to UVR.

DESIGN

Seventeen women; 9 white Caucasian (skin phototype II and III), 8 South Asian women (skin phototype IV and V) participated in the study, acting as their own controls. Three blood samples were taken for the measurement of vitamin D status during the run in period (9days, no sunbed exposure) after which, all subjects underwent an identical UVR exposure protocol irrespective of skin colour (9 days, 3 sun bed sessions, 6, 8 and 8min respectively with approximately 80% body surface exposed). Skin tone was measured four times during the study.

RESULTS

Despite consistently lower 25(OH)D levels in South Asian women, they were shown to synthesise vitamin D as efficiently as Caucasians when exposed to the same dose of UVR. Interestingly, the baseline level of vitamin D rather than ethnicity and skin tone influenced the amount of vitamin D synthesised.

CONCLUSIONS

This study have found no ethnic differences in the synthesis of 25(OH)D, possibly due to the baseline differences in 25(OH)D concentration or due to the small population size used in this study. Applying mixed linear model, findings indicated no effect of ethnicity and skin tone on the production of vitamin D; baseline level and length of exposure were the critical factors. To confirm that ethnicity and skin tone has no effect on 25(OH)D production, a larger sample size study is required that considers other ethnic groups with highly pigmented skin. Initial vitamin D status influences the amount of UVB needed to reach equal serum concentrations.

Theory-Driven Longitudinal Study Exploring Indoor Tanning Initiation in Teens Using a Person-Centered Approach

BACKGROUND

Younger indoor tanning initiation leads to greater melanoma risk due to more frequent and persistent behavior. Despite this, there are no published studies exploring the predictors of indoor tanning initiation in teen populations.

PURPOSE

This longitudinal study uses latent profile analysis to examine indoor tanning initiation in indoor tanning risk subgroups from a national sample of female adolescents.

METHODS

Latent profile analysis used indoor tanning beliefs and perceptions to identify indoor tanning initiation risk subgroups. The teens in each subgroup were reassessed on indoor tanning initiation after a year.

RESULTS

Three subgroups were identified: a low risk, anti-tanning subgroup (18.6 %) characterized by low scores on positive indoor tanning belief scales and high scores on beliefs about indoor tanning dangers; a moderate risk aware social tanner subgroup (47.2 %) characterized by high scores on positive indoor tanning belief scales but also high scores on beliefs about indoor tanning dangers; and a high risk risky relaxation tanner subgroup (34.2 %) characterized by high scores on positive indoor tanning belief scales and low scores on beliefs about indoor tanning dangers. Teens in the aware social tanner and risky relaxation tanner subgroups were significantly more likely to initiate indoor tanning in the following year.

CONCLUSIONS

These findings highlight the need to identify teens at risk for indoor tanning initiation and develop tailored interventions that will move them to the lowest risk subgroup. Subgroup correlates suggest parent and peer-based interventions may be successful.

Tanning among Ontario adolescents pre-legislation: Prevalence and beliefs

To establish adolescent tanning beliefs and behaviors, prevalence and location of UV tanning device (beds/lamps) use, awareness of risk and restriction signage, and frequency of tanning service refusal, noting differences by grade and sex, prior to a ban on UV tanning device use among those under 18 in Ontario, Canada. Data were collected May 5 to 20 of 2014. Children in grades 7 to 12, and under age 18 completed an on-line questionnaire that asked their age, sex, grade, methods used to tan, frequency, length and location of UV tanning device use, if services were refused and why, awareness and content of signs/warning labels, tanning beliefs and knowledge, and use of eye protection. Of 1561 participants (10% response rate), 49% were male, 51% female. There were significant differences between the sexes regarding tanning behaviors (e.g. not tanning, tanning outside). Seven percent (108) had 'ever' used UV tanning devices, females more than males (p=0.0026). Over half (57%) of the 104 using UV tanning devices in the past 12months noticed warning signs/labels, of which most noticed that UV tanning devices can cause cancer (65%), and that UV exposure can contribute to premature aging (67%). While most (66%) tanned at tanning salons/studios and beauty salons/studios, gyms/fitness clubs (35%) and home use were common (25%). A relatively low proportion of adolescents used UV tanning devices prior to the ban, with use more common among females and those in higher grades.

Tanning bed use and melanoma: Establishing risk and improving prevention interventions

PURPOSE

Exposure to ultraviolet radiation (UVR) from indoor tanning devices is thought to cause melanoma and other negative health consequences. Despite these findings, the practice of indoor tanning in the United States remains prevalent. In this paper we aim to present a clear discussion of the relationship between indoor tanning and melanoma risk, and to identify potential strategies for effective melanoma prevention by addressing indoor tanning device use.

BASIC PROCEDURES

We reviewed relevant literature on the risks of indoor tanning, current indoor tanning legislation, and trends in indoor tanning and melanoma incidence. Study was conducted at the University of Southern California, Los Angeles, CA between the years of 2014 and 2015.

MAIN FINDINGS

Our findings reaffirm the relationship between indoor tanning and melanoma risk, and suggest a widespread public misunderstanding of the negative effects of indoor tanning.

PRINCIPAL CONCLUSIONS

This review argues for an aggressive initiative to reduce indoor tanning in the United States, to design prevention efforts tailored towards specific high risk groups, and the need to better inform the public of the risks of indoor tanning.

Nucleotide excision repair deficiency in melanoma in response to UVA

Background

The causative link between UV exposure and melanoma development is well known, however the mechanistic relationship remains incompletely characterised. UVA and UVB components of sunlight are implicated in melanomagenesis; however the majority of studies have focused on the effects of UVB and UVC light. Interestingly, melanoma tumour sequencing has revealed an overrepresentation of mutations signature of unrepaired UV-induced DNA damage. Repair of UVA-induced DNA damage is thought to occur primarily through the Nucleotide Excision Repair (NER) pathway, which recognises and repairs damage either coupled to transcription (Transcription Coupled Repair; TCR), or through global genome scanning (Global Genome Repair; GGR). Current literature suggests NER is deficient in melanoma, however the cause of this remains unknown; and whether reduced NER activity in response to UVA may be involved in melanoma development remains uncharacterised. In this study we aimed to determine if melanoma cells exhibit reduced levels of NER activity in response to UVA.

Methods

Melanocyte and melanoma cell lines were UVA-irradiated, and DNA damage levels assessed by immunodetection of Cyclobutane Pyrimidine Dimer (CPD) and (6-4) Photoproduct [(6-4)PP] lesions. Expression of NER pathway components and p53 following UVA treatment was quantified by qPCR and western blot.

Results

UVA did not induce detectable induction of (6-4)PP lesions, consistent with previous studies. Repair of CPDs induced by UVA was initiated at 4 h and complete within 48 h in normal melanocytes, whereas repair initiation was delayed to 24 h and >40 % of lesions remained in melanoma cell lines at 48 h. This was coupled with a delayed and reduced induction of GGR component XPC in melanoma cells, independent of p53.

Conclusion

These findings support that NER activity is reduced in melanoma cells due to deficient GGR. Further investigation into the role of NER in UVA-induced melanomagenesis is warranted and may have implications for melanoma treatment.

Estimation of individual cumulative ultraviolet exposure using a geographically-adjusted, openly-accessible tool

Background

Estimates of an individual’s cumulative ultraviolet (UV) radiation exposure can be useful since ultraviolet radiation exposure increases skin cancer risk, but a comprehensive tool that is practical for use in the clinic does not currently exist.

The objective of this study is to develop a geographically-adjusted tool to systematically estimate an individual’s self-reported cumulative UV radiation exposure, investigate the association of these estimates with skin cancer diagnosis, and assess test reliability.

Methods

A 12-item online questionnaire from validated survey items for UV exposure and skin cancer was administered to online volunteers across the United States and results cross-referenced with UV radiation indices. Cumulative UV exposure scores (CUES) were calculated and correlated with personal history of skin cancer in a case–control design. Reliability was assessed in a separate convenience sample.

Results

1,118 responses were included in the overall sample; the mean age of respondents was 46 (standard deviation 15, range 18 – 81) and 150 (13 %) reported a history of skin cancer. In bivariate analysis of 1:2 age-matched cases (n = 149) and controls (n = 298), skin cancer cases were associated with (1) greater CUES prior to first skin cancer diagnosis than controls without skin cancer history (242,074 vs. 205,379, p = 0.003) and (2) less engagement in UV protective behaviors (p < 0.01). In a multivariate analysis of age-matched data, individuals with CUES in the lowest quartile were less likely to develop skin cancer compared to those in the highest quartile. In reliability testing among 19 volunteers, the 2-week intra-class correlation coefficient for CUES was 0.94. We have provided the programming code for this tool as well as the tool itself via open access.

Conclusions

CUES is a useable and comprehensive tool to better estimate lifetime ultraviolet exposure, so that individuals with higher levels of exposure may be identified for counseling on photo-protective measures.

Electronic supplementary material

The online version of this article (doi:10.1186/s12895-016-0038-1) contains supplementary material, which is available to authorized users.

Incidence of cutaneous malignant melanoma by socioeconomic status in Canada: 1992-2006

BACKGROUND

There are no nationwide studies documenting changes in cutaneous malignant melanoma incidence or association of incidence with socioeconomic status (SES) in Canada. We sought to determine whether melanoma incidence increased from 1992 to 2006 and if there was an association between SES and melanoma incidence. Additionally, we studied whether there was a correlation between province of residence and melanoma incidence.

METHODS

Cases from the Canadian Cancer Registry were reviewed. Demographic and socioeconomic information were extracted from the Canadian Census of Population data. Cases were linked to income quintiles by postal code. A negative binomial regression was performed to identify relationships among these variables.

RESULTS

Overall incidence of melanoma in Canada increased by 67 % from 1992 to 2006 (p < 0.0001). The increase in incidence was greater for melanoma in situ compared with invasive melanoma (136 % versus 52 % [p < 0.0001]). Incidence was positively correlated with higher income quintiles; the incidence rates among patients in the lowest income quintiles were 67 % of that for the highest income quintiles (p < 0.0001).

DISCUSSION

A wide variety of explanations have been postulated for an increased incidence in melanoma among persons of higher SES, including access to and awareness of screening, more access to vacations in sunny climates, and increased leisure time. Variations in incidence of melanoma by urban vs. rural location and province may indicate differences in access to dermatologists across Canada.

CONCLUSIONS

Melanoma incidence is increasing in Canada and is higher among people in high SES groups. This rise is likely due to a combination of factors including a true rise in incidence due to increases in sun exposure, and also an increased detection rate, particularly in those who are more aware of the disease and have access to resources for detection.

Improving outcomes in patients with melanoma: strategies to ensure an early diagnosis

Patients with thin, low-risk melanomas have an excellent long-term prognosis and higher quality of life than those who are diagnosed at later stages. From an economic standpoint, treatment of early stage melanoma consumes a fraction of the health care resources needed to treat advanced disease. Consequently, early diagnosis of melanoma is in the best interest of patients, payers, and health care systems. This review describes strategies to ensure that patients receive an early diagnosis through interventions ranging from better utilization of primary care clinics, to in vivo diagnostic technologies, to new "apps" available in the market. Strategies for screening those at high risk due to age, male sex, skin type, nevi, genetic mutations, or family history are discussed. Despite progress in identifying those at high risk for melanoma, there remains a lack of general consensus worldwide for best screening practices. Strategies to ensure early diagnosis of recurrent disease in those with a prior melanoma diagnosis are also reviewed. Variations in recurrence surveillance practices by type of provider and country are featured, with evidence demonstrating that various imaging studies, including ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging, provide only minimal gains in life expectancy, even for those with more advanced (stage III) disease. Because the majority of melanomas are attributable to ultraviolet radiation in the form of sunlight, primary prevention strategies, including sunscreen use and behavioral interventions, are reviewed. Recent international government regulation of tanning beds is described, as well as issues surrounding the continued use artificial ultraviolet sources among youth. Health care stakeholder strategies to minimize UV exposure are summarized. The recommendations encompass both specific behaviors and broad intervention targets (eg, individuals, social spheres, organizations, celebrities, governments).

Conceptual approach to early melanoma detection: models, tools, issues and challenges

Identification and removal of melanoma early in its development remains the most effective treatment. However, identification of early melanoma remains challenging and may result in unnecessary morbidity due to the excess excision of benign melanocytic nevi. Herein, we present a conceptual model of benign and malignant melanocytic growths. The potential differences in the location of the cell of origin as well as considerations for neoplasm progression are also reviewed. Several of the clinical tools currently available, the integration of information from those different sources, and approaches to set an optimum biopsy threshold are discussed. While early detection remains a challenge, significant progress has been made. Insight into melanoma growth processes and appropriate use of available tools can result in the detection of thinner melanomas while also decreasing overall biopsy rates.

Epidemiological and genetic factors underlying melanoma development in Italy

Among human cancers, melanoma remains one of the malignancies with an ever-growing incidence in white populations. Recent advances in biological and immunological therapeutic approaches as well as increased efforts for secondary prevention are contributing to improve the survival rates. It is likely that a significant fall in mortality rates for melanoma will be achieved by further increase of the early detection through a more accurate selection of the higher-risk individuals (i.e., carriers of predisposing genetic alterations). A similar scenario occurs in Italy. In the present review, we have considered data on incidence, survival and mortality rates of melanoma in Italian population, including evaluation of the main risk factors and genetic mutations underlying disease susceptibility.

Contextual factors, indoor tanning, and tanning dependence in young women

OBJECTIVES

To investigate the association of contextual factors such as cost, tanning accessibility, regulations, or marketing and indoor tanning or tanning dependence.

METHODS

One hundred thirty-nine college-aged female indoor tanners completed a questionnaire between 2009 and 2011.

RESULTS

Higher scores on tanning dependence and assessment in the spring/summer (versus the fall/winter) were associated with more frequent indoor tanning in the last 30 days (ps < .05). More frequent indoor tanning, greater session length, and more trouble paying for tanning were associated with higher scores on tanning dependence (ps < .05).

CONCLUSIONS

Public health research and practice could benefit from attention to such contextual factors as tanning cost and regulations regarding session length.

Cutaneous Melanoma in Women

Background

Gender disparity in melanoma outcome is consistently observed, suggesting that gender is as an important prognostic factor. However, the source of this gender disparity in melanoma remains unclear.

Objective

This article reviews advances in our understanding of gender differences in melanoma and how such differences may contribute to outcomes.

Methods

A broad literature search was conducted using the PubMed database, with search terms such as ‘gender differences in melanoma’ and ‘sex differences in melanoma.’ Additional articles were identified from cited references.

Results

Herein, we address the gender-linked physiologic differences in skin and melanoma. We discuss the influence of estrogen on a woman’s risk for melanoma and melanoma outcomes with regard to pregnancy, oral contraceptives, hormone replacement therapy, and UV tanning.

Conclusions

The published findings on gender disparities in melanoma have yielded many advances in our understanding of this disease. Biological, environmental, and behavioral factors may explain the observed gender difference in melanoma incidence and outcome. Further research will enable us to learn more about melanoma pathogenesis, with the goal of offering better treatments and preventative advice to our patients.

Cutaneous squamous cell carcinoma in Norway 1963-2011: increasing incidence and stable mortality

The incidence of cutaneous squamous cell carcinoma (SCC) is rapidly increasing in white populations, causing high morbidity and health-care costs. Few studies, however, have described the trends for SCC, as population-based data with a long follow-up are limited. In Norway we have this opportunity and we aimed to describe SCC incidence, mortality and survival rates, according to sex, age, stage, primary anatomical location, and geographical region, for the period 1963–2011, for estimation of future health-care needs. Data were retrieved from the Cancer Registry of Norway. Age-adjusted SCC incidence and mortality rates and 5-year relative survival (in percent) were calculated for 5-year calendar periods. A joinpoint regression model identified the annual percentage change (APC) in rates over the 50-year period. The age-adjusted incidence rate increased ninefold in females and sixfold in males from 1963 to 2011, with APCs of 5.6% (95% confidence interval, CI 4.5, 7.3) and 3.3% (95% CI 1.3, 5.3) in females and males, respectively. SCC incidence rose in all age groups, anatomical locations (except ears in females), and geographical regions, though restricted to localized tumors. Most striking increase was seen in the age group 70–79, in face and head locations and among residents in southern Norway. SCC mortality and survival rates remained relatively stable. Our findings underline an increasing need for SCC treatment in Norway, especially considering the aging population. The findings also call for the creation of particular guidelines for primary prevention of SCC.

Decreases in tanning behaviors following a short online survey: Potential for prevention?

OBJECTIVES

To date, tanning prevention programs have led to limited success. The aim of the present study was to investigate potential unexpected prevention effects of completing an online survey focused on tanning attitudes, behaviors, and knowledge among female college tanners.

METHODS

A sample of 92 female undergraduate students from the USA, mean age = 20.09, SD = 1.41 years, who engaged in indoor tanning completed an online survey assessing awareness of tanning-related health risks, appearance-based motivations to tan and not to tan, media literacy related to tanning marketing, and tanning behaviors in 2013. Four months later, participants were invited to complete a follow-up survey assessing tanning intentions and behaviors since completing the initial survey.

RESULTS

Fifty-one participants (55%) completed the follow-up questions, of whom 43 (84.3%) reported having decreased or ceased engaging in indoor tanning. In addition participants provided comments indicating that completing the survey had lead to decreases in their tanning behaviors.

CONCLUSIONS

Our study presents novel and compelling support for using brief online surveys for decreasing health-risk behaviors such as sunbed use. Such measures are extremely cost-effective and easy to disseminate and implement. Replication and extension of these findings are warranted.

Photobiological implications of melanin photoprotection after UVB-induced tanning of human skin but not UVA-induced tanning

Repetitive suberythemal UVA and/or UVB exposures were used to generate comparable UV-induced tans in human skin over the course of 2 weeks. To evaluate the potential photoprotective values of those UVA- and/or UVB- induced tans and to avoid the confounding issue of residual UV-induced DNA damage, we waited 1 week before challenging those areas with a 1.5 MED of UVA+UVB after which we measure DNA damage. The results show that the type of UV used to induce skin pigmentation affects the redistribution of melanin in the skin and/or de novo melanin synthesis. The UVA-induced tans failed to even provide a minimal SPF of 1.5, which suggests that producing a tan with UVA-rich sunlamps prior to a holiday or vacation is completely counterproductive.

Prevalence and Correlates of Indoor Tanning and Sunless Tanning Product Use among Female Teens in the United States

BACKGROUND

Indoor tanning (IT) before the age of 35 increases melanoma risk by 75%. Nevertheless, IT and sunless tanning product (STP) use have gained popularity among youth. However, there are limited data on the prevalence and sociodemographic correlates of both IT and STP use in a representative sample of American teens.

METHODS

Teenage females (N=778) aged 12-18 years were recruited as part of an on-going longitudinal study conducted between May 2011 and May 2013. Descriptive statistics explored IT and STP usage in teen females at baseline. Logistic regression was used to determine sociodemographic correlates of IT and STP use.

RESULTS

Approximately 16% of female teens engaged in IT behavior and 25% engaged in using STPs. Female teens living in non-metropolitan areas were 82% more likely to indoor tan compared to those in metropolitan areas (OR=1.82, 95% CI:1.07-3.10). Age, geographic regions, and race increased the likelihood of IT and STP use.

CONCLUSIONS

Results indicate a significant proportion of teen females engage in IT and STP use. There was evidence that in teens that have never used IT before, STP use precedes IT initiation. Given the evidence for increased IT in rural populations, research focused on rural tanning bed use is needed.

Adolescent egocentrism and indoor tanning: is the relationship direct or mediated?

This paper explored how imaginary audience and personal fable ideations contribute to adolescent indoor tanning intentions directly and indirectly through the way they shape pro-tanning attitude and association with peers who use tanning beds. Five hundred and ninety-five male (n = 207) and female (n = 387) adolescents, ranging in age from 11 to 19 (M = 16.87; SD = 1.34) years completed a cross-sectional survey. Measures included imaginary audience, personal fable (three dimensions: invulnerability, uniqueness, and omnipotence), pro-tanning attitude, association with peers who use tanning beds, and tanning bed use intentions. Bootstrapping analyses documented that imaginary audience ideations are indirectly associated with indoor tanning intentions through the mediation of pro-tanning attitude and association with peers who use tanning beds. Of the personal fable ideations, only invulnerability ideation is indirectly associated with indoor tanning intentions through the mediation of association with peers who use tanning beds. Design and evaluation of interventions and campaigns to reduce indoor tanning must be targeted to adolescents varying in imaginary audience ideations differently.

Diversity of biological effects induced by longwave UVA rays (UVA1) in reconstructed skin

Despite their preponderance amongst the ultraviolet (UV) range received on Earth, the biological impacts of longwave UVA1 rays (340–400 nm) upon human skin have not been investigated so thoroughly. Nevertheless, recent studies have proven their harmful effects and involvement in carcinogenesis and immunosuppression. In this work, an in vitro reconstructed human skin model was used for exploring the effects of UVA1 at molecular, cellular and tissue levels. A biological impact of UVA1 throughout the whole reconstructed skin structure could be evidenced, from morphology to gene expression analysis. UVA1 induced immediate injuries such as generation of reactive oxygen species and thymine dimers DNA damage, accumulating preferentially in dermal fibroblasts and basal keratinocytes, followed by significant cellular alterations, such as fibroblast apoptosis and lipid peroxidation. The full genome transcriptomic study showed a clear UVA1 molecular signature with the modulation of expression of 461 and 480 genes in epidermal keratinocytes and dermal fibroblasts, respectively (fold change> = 1.5 and adjusted p value<0.001). Functional enrichment analysis using GO, KEGG pathways and bibliographic analysis revealed a real stress with up-regulation of genes encoding heat shock proteins or involved in oxidative stress response. UVA1 also affected a wide panel of pathways and functions including cancer, proliferation, apoptosis and development, extracellular matrix and metabolism of lipids and glucose. Strikingly, one quarter of modulated genes was related to innate immunity: genes involved in inflammation were strongly up-regulated while genes involved in antiviral defense were severely down-regulated. These transcriptomic data were confirmed in dose-response and time course experiments using quantitative PCR and protein quantification. Links between the evidenced UVA1-induced impacts and clinical consequences of UVA1 exposure such as photo-aging, photo-immunosuppression and cancer are discussed. These early molecular events support the contribution of UVA1 to long term harmful consequences of UV exposure and underline the need of an adequate UVA1 photoprotection.

Indoor tanning among high school students in the United States, 2009 and 2011

IMPORTANCE

Indoor tanning is associated with an increased risk of skin cancer, including melanoma, and is particularly dangerous for younger and more frequent indoor tanners.

OBJECTIVE

To examine the prevalence of indoor tanning and frequent indoor tanning (≥10 times during the 12 months before each survey) and their association with health-related behaviors.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study examined data from the 2009 and 2011 national Youth Risk Behavior Surveys, which used nationally representative samples of US high school students representing approximately 15.5 million students each survey year. The study included 25,861 students who answered the indoor tanning question.

MAIN OUTCOMES AND MEASURES

The prevalence of indoor tanning and frequent indoor tanning were examined as well as their association with demographic characteristics and health-related behaviors using multivariable logistic regression modeling.

RESULTS

The prevalence of indoor tanning was greater among female, older, and non-Hispanic white students. Indoor tanning was highest among female students aged 18 years or older, with 31.5% engaging in indoor tanning in 2011, and among non-Hispanic white female students, with 29.3% engaging in indoor tanning in 2011. Among female students, the adjusted prevalence of indoor tanning decreased from 26.4% in 2009 to 20.7% in 2011. Among female and male students, indoor tanning was associated with other risk-taking behaviors, such as binge drinking (P < .001 and P = .006, respectively), unhealthy weight control practices (P < .001, for both), and having sexual intercourse (P < .001, for both). Additionally, indoor tanning among female students was associated with using illegal drugs (P < .001) and having sexual intercourse with 4 or more persons (P = .03); use among male students was associated with taking steroids without a physician's prescription (P < .001), smoking cigarettes daily (P = .03), and attempting suicide (P = .006). More than half of respondents engaging in indoor tanning reported frequent use of the devices.

CONCLUSIONS AND RELEVANCE

Indoor tanning is common among high school students. Public health efforts are needed to change social norms regarding tanned skin and to increase awareness, knowledge, and behaviors related to indoor tanning. The clustering of risky behaviors suggests a need for coordinated, multifaceted approaches, including primary care physician counseling, to address such behaviors among adolescents.

Indoor tanning in businesses and homes and risk of melanoma and nonmelanoma skin cancer in 2 US case-control studies

BACKGROUND

Indoor tanning increases skin cancer risk. Beyond early research describing melanoma and sun lamps, few recent reports describe where individuals indoor tan and whether skin cancer risk varies by location (business, home-based).

OBJECTIVE

We sought to assess where individuals tanned indoors and skin cancer risk by tanning device location.

METHODS

Multivariate logistic regression was conducted in 2 US case-control studies of melanoma (1161 cases, 1083 controls, ages 25-59 years) and early-onset basal cell carcinoma (375 cases, 382 controls, age<40 years) conducted between 2004 and 2010.

RESULTS

Most indoor tanners (86.4%-95.1%), especially younger individuals, tanned exclusively in businesses. Persons who used indoor tanning exclusively in businesses were at increased risk of melanoma (odds ratio 1.82, 95% confidence interval 1.47-2.26) and basal cell carcinoma (odds ratio 1.69, 95% confidence interval 1.15-2.48) compared with non-users. Melanoma risk was also increased in the small number who reported tanning indoors only at home relative to non-users (odds ratio 4.14, 95% confidence interval 1.75-9.78); 67.6% used sun lamps.

LIMITATIONS

Self-reported tanning and potential recall bias are limitations.

CONCLUSION

Business-only tanning, despite claims of "safe" tanning, was positively associated with a significant risk of melanoma and basal cell carcinoma. Home tanning was uncommon and mostly from sun lamps, which were rarely used by younger participants. Regardless of location, indoor tanning was associated with increased risk of skin cancer.

International prevalence of indoor tanning: a systematic review and meta-analysis

IMPORTANCE

Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known.

OBJECTIVE

To summarize the international prevalence of exposure to indoor tanning.

DATA SOURCES

Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature.

STUDY SELECTION

Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma.

MAIN OUTCOMES AND MEASURES

Ever and past-year exposure to indoor tanning.

RESULTS

The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia.

CONCLUSIONS AND RELEVANCE

Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

The association between demographic and behavioral characteristics and sunburn among U.S. adults - National Health Interview Survey, 2010

OBJECTIVE

To examine the association between demographic and behavioral characteristics and sunburn among U.S. adults.

METHOD

We used 2010 National Health Interview Survey data (N=24,970) to conduct multivariable logistic regressions examining associations with having 1 or more sunburns in the past year and having 4 or more sunburns in the past year.

RESULTS

Overall, 37.1% of adults experienced sunburn in the past year. The adjusted prevalence of sunburn was particularly common among adults aged 18-29years (52.0%), those who repeatedly burn or freckle after 2weeks in the sun (45.9%), whites (44.3%), indoor tanners (44.1%), those with a family history of melanoma (43.9%), and those who are US-born (39.5%). Physical activity, alcohol consumption, and overweight/obesity were positively associated with sunburn (all P<0.001); sun protection behaviors were not significantly associated with sunburn (P=0.35). Among those who were sunburned in the past year, 12.1% experienced 4 or more sunburns.

CONCLUSION

Sunburn is common, particularly among younger adults, those with a more sun-sensitive skin type, whites, those with a family history of melanoma, the highly physically active, and indoor tanners. Efforts are needed to facilitate sun-safety during outdoor recreation, improve the consistency of sun protection practices, and prevent sunburn, particularly among these subgroups.

Skin cancer - an overview for dentists

Skin cancer is common and an increasing problem in the UK. It frequently occurs on the head and neck skin. A significant proportion of the adult population in the UK visits the dentist each year, thus making dental practitioners ideally placed to identify suspicious lesions, which could be skin cancer, as part of their routine extra-oral examination. These patients can then be referred on to hospital or their GP for further management. The dentist can also give advice on risk factors and self-monitoring to patients. This paper aims to describe the risk factors, pathology, presentation and treatments for the three most common forms of skin cancer - basal and squamous cell carcinomas, and malignant melanoma, to give the dental practitioner the knowledge and confidence to examine for and identify these skin cancers.

UV and dietary predictors of serum 25-hydroxyvitamin D concentrations among young shift-working nurses and implications for bone density and skin cancer

OBJECTIVE

In 2011, the U.S. Institute of Medicine updated the definition of vitamin D inadequacy to serum 25-hydroxyvitamin D (25(OH)D) concentration of 30-<50 nmol/l and of deficiency to serum 25(OH)D < 30 nmol/l. We describe the prevalence of these conditions according to these definitions, seasonal variation in 25(OH)D and predictors of serum 25(OH)D concentrations among working, white women.

DESIGN

Participants recorded lifestyle factors and dietary intake and provided fasting blood samples for measurement of serum 25(OH)D in both summer and winter. Predictors of serum 25(OH)D variation were analysed using linear regression and generalized linear mixed models.

SETTING

Kingston General Hospital in Kingston, Ontario, Canada, from April 2008 to July 2009.

SUBJECTS

Female premenopausal nurses (n 83) working full-time rotating shifts.

RESULTS

Deficient or inadequate vitamin D status was observed in 9% of participants following summer/autumn and in 13% following winter/spring. Predictors of serum 25(OH)D concentration were vitamin D supplement use, tanning bed use and season. Tanning bed use increased serum 25(OH)D by 23.24 nmol/l (95% CI 8.78, 37.69 nmol/l, P = 0.002) on average.

CONCLUSIONS

According to the 2011 Institute of Medicine bone health guidelines, over 10% of nurses had deficient or inadequate vitamin D status following winter. Higher serum concentrations were associated with use of tanning beds and vitamin D supplements. As health promotion campaigns and legal restrictions are successful in reducing tanning bed use among women, our data suggest that increased prevalence of vitamin D inadequacy and deficiency may be a consequence, and that low vitamin D status will need to be countered with supplementation.

International prevalence of indoor tanning: a systematic review and meta-analysis

IMPORTANCE

Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known.

OBJECTIVE

To summarize the international prevalence of exposure to indoor tanning.

DATA SOURCES

Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature.

STUDY SELECTION

Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma.

MAIN OUTCOMES AND MEASURES

Ever and past-year exposure to indoor tanning.

RESULTS

The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia.

CONCLUSIONS AND RELEVANCE

Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

Temporal and spatial melanoma trends in Austria: an ecological study

Annual solar ultraviolet radiation (UVR) is mostly determined by latitude and altitude. Over the last decades, increasing UVR ground levels have been observed. Exposure to UVR is associated with a life-time risk to develop melanoma, a malign skin cancer. Thus, we hypothesized that melanoma incidence in Austria is associated with altitude of place of living and time of diagnosis. We investigated this hypothesis in an ecological study by district and year for Austrian melanoma incidence (1990-2010) and mortality (1970-2011) data. As expected, incidence rates increased with altitude (about 2% per 10 m) and year (about 2%). Additionally, melanoma incidence rates were about 50% higher in urban than in rural districts. In contrast, mortality rates decreased with altitude (for males: 0.4% per 10 m, for women: 0.7% per 10 m, respectively). The observed discrepancy between incidence and mortality data could partly be explained by melanoma diagnosis at earlier tumor stage in districts with higher altitude. Possible reasons for this finding include higher awareness of patients, better diagnostic performance of medical professionals working at higher altitudes, or slower tumor growth due to protective effects of sun light-associated vitamin D synthesis.

The molecular pathology of melanoma: an integrated taxonomy of melanocytic neoplasia

Melanomas comprise multiple biologically distinct categories, which differ in cell of origin, age of onset, clinical and histologic presentation, pattern of metastasis, ethnic distribution, causative role of UV radiation, predisposing germ-line alterations, mutational processes, and patterns of somatic mutations. Neoplasms are initiated by gain-of-function mutations in one of several primary oncogenes, which typically lead to benign melanocytic nevi with characteristic histologic features. The progression of nevi is restrained by multiple tumor-suppressive mechanisms. Secondary genetic alterations override these barriers and promote intermediate or overtly malignant tumors along distinct progression trajectories. The current knowledge about the pathogenesis and clinical, histologic, and genetic features of primary melanocytic neoplasms is reviewed and integrated into a taxonomic framework.