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

The role of public health advocacy in achieving an outright ban on commercial tanning beds in Australia

Although many countries still face opposition to the legislation of artificial tanning beds, all Australian states and territories have announced a total ban on commercial tanning beds. A combination of epidemiological and policy-centered research, powerful personal stories, and the active advocacy of prominent academics, cancer organizations, and grassroots community campaigners contributed to the decisions to first legislate standards and then ban all commercial tanning beds. We have illustrated that incremental change can be an effective pathway to securing substantial public health reforms.

Calcidiol [25(OH)D3]: from diagnostic marker to therapeutical agent

OBJECTIVE

Osteoporosis is a skeletal disorder characterized by diminished bone strength, which results in an increased risk of fracture. Currently, osteoporosis is a public health priority due to the large number of individuals affected and the detrimental effect on quality of life. Primary osteoporosis, the most common form, usually results from age-related reduction in bone mineral strength. Over time, the individual's capacity to build bone is impaired, as the synthesis of vitamin D, the hormone responsible for calcium absorption, tends to decline. As serum calcium levels decrease, metabolic control serves to increase the removal of calcium from the skeleton to make up for the deficit. The synthesis of the 'hormone' vitamin D and its control therefore become central to intervention in involutional osteoporosis syndromes. In humans, plain vitamin D (cholecalciferol), also called parental or native vitamin D, is photosynthesized in the skin and then hydroxylated in the liver into the vitamin D analog calcidiol [25(OH)D3], which is hydroxylated again in the kidney into the vitamin D analog calcitriol [1,25(OH)2D3]. The advantage of administering vitamin D analogs is that the pro-drug calcidiol avoids the effect of declines in hepatic function, while calcitriol avoids the effect of declines in hepatic and kidney function. A strategy to enhance [25(OH)D3] levels to the optimal threshold of vitamin D is supplementation with the calcidiol metabolite itself. The goal of this paper is to review published studies on the efficacy of the calcidiol metabolite in increasing 25(OH)D3 serum levels and improving skeletal health parameters in humans.

METHODS

A library search of published papers in the area of use of calcidiol in humans from 1967 to 2013 was performed (key words: calcidiol, 25-hydroxy-vitamin D3, vitamin D supplementation, vitamin D metabolism, osteomalacia).

RESULTS AND CONCLUSION

The results of the survey made it possible to conclude that calcidiol is characterized by a number of features that make the compound ideal in conditions that require supplementation with a 25-hydroxylated metabolite.

Using research data to impact consumer protection legislation: lessons learned from CITY100 dissemination efforts

The Correlates of Indoor Tanning in Youth (CITY100) project evaluated individual, built-environmental, and policy correlates of indoor tanning by adolescents in the 100 most populous US cities. After CITY100's completion, the research team obtained supplemental dissemination funding to strategically share data with stakeholders. The primary CITY100 dissemination message was to encourage state-level banning of indoor tanning among youth. We created a user-friendly website to broadly share the most relevant CITY100 data. Journalists were a primary target audience, as were health organizations that would be well positioned to advocate for legislative change. CITY100 data were used to pass the first US state law to ban indoor tanning among those under 18 (CA, USA), as well as in other legislative advocacy activities. This paper concludes with lessons learned from CITY100 dissemination activities that we hope will encourage more health researchers to proactively address policy implications of their data and to design relevant, effective dissemination strategies.

A pilot study of genetic variants in dopamine regulators with indoor tanning and melanoma

Many people frequently tan indoors despite being aware of the increased risk of melanoma. Ultraviolet radiation is hypothesized to modify biological reward pathways, for example, through the dopamine neurotransmitter system, to reinforce tanning behaviour. In this pilot study, we relied on questionnaire and DNA data from a recently completed case-control study to examine 67 single-nucleotide polymorphisms (SNPs) and related haplotypes in five dopamine receptor and drug metabolism genes in relation to indoor tanning among controls. We also examined the association between individual SNPS and likelihood of melanoma, adjusting for or stratifying on indoor tanning status. In candidate and haplotype gene analyses, variants only in the DRD2 dopamine receptor and ANKK1 signalling genes were positively associated with indoor tanning use among controls; only associations for ANKK1 remained statistically significant (P < 0.05) after adjustment. Several SNPs in ANKK1 and DRD2 associated with indoor tanning among controls were also found to be associated with increased risk of melanoma. Upon stratifying for indoor tanning status, one ANKK1 SNP was positively associated with melanoma among non-tanners, while three DRD2 SNPS were positively associated with melanoma among tanners or non-tanners, depending on the SNP. These alleles represent important genomic regions to further explore addictive tanning behaviour.

Invited commentary: are dietary intakes and other exposures in childhood and adolescence important for adult cancers?

In this issue of the Journal, Nimptsch et al. (Am J Epidemiol. 2013;178(2):172-183) report significant associations between female adolescents' poultry consumption in high school and subsequent reduced risk of colorectal adenomas in adulthood. Consumption of red meat or fish was not related to risk, but replacement with poultry reduced the risk of later adenomas. Most epidemiologic studies of adult diseases lack exposure data from the distant past. By focusing on a cancer precursor lesion and using a variety of methods to assess data quality, the investigators address concerns about the quality of distant recall. These findings add to the growing evidence that links childhood and adolescent lifestyle and environmental exposures with subsequent risk of cancers arising in adulthood. Highlights of the literature on this topic and methodological challenges are summarized. Future studies would benefit from incorporating measures of lifestyle, diet, environmental exposures, and other risk factors from early in life and from validation and other data quality checks of such measurements. Sources of historical data on children's and adolescents' exposures should be sought and evaluated in conjunction with subsequent exposures in relationship to adult-onset cancers.

Sunbed use, attitudes, and knowledge after the under-18s ban: a school-based survey of adolescents aged 15 to 17 years in Sandwell, United Kingdom

BACKGROUND

Sunbed use in childhood increases risk of melanoma. The under-18s sunbed ban was introduced in England, April 2011. Impact on use has not been investigated since. This cross-sectional study estimates the prevalence of under-18s' use in Sandwell after the commercial ban and identifies factors associated with use/intention.

METHODS

Adolescents aged 15 to 17 years in schools were surveyed using self-completed anonymous questionnaires. Data collected include demographics, sunbed use, tanning attitudes, knowledge of risks and ban awareness. All Sandwell schools were approached; adolescents available on the survey days were included.

RESULTS

Five out of 22 schools participated, 407 adolescents responded (95.1%). Twenty participants (5.3%; 95% confidence interval [CI] = 3.4-8.0) had used sunbeds, of who 16 reported use in commercial settings. After exclusion of one school cohort with atypical use (possibly associated with beauty vocational course and European migrants), the prevalence of use was 1.7% (95% CI = 0.7-3.9, n = 5). Less than half of all were aware of the ban (48.2%; 95% CI = 43.2-53.3). Users/potential users were less aware of associated risks. Being female, having family/friends who use sunbeds increased use/intention 2- to 4-fold.

CONCLUSION

Strategies targeting parents, stricter enforcement, and greater publicity of the ban are needed. Further research exploring the possible association between certain vocational courses, migrants, and sunbed use is required.

Preventing skin cancer through reduction of indoor tanning: current evidence

Exposure to ultraviolet radiation from indoor tanning devices (tanning beds, booths, and sun lamps) or from the sun contributes to the risk of skin cancer, including melanoma, which is the type of skin cancer responsible for most deaths. Indoor tanning is common among certain groups, especially among older adolescents and young adults, adolescent girls and young women, and non-Hispanic whites. Increased understanding of the health risks associated with indoor tanning has led to many efforts to reduce use. Most environmental and systems efforts in the U.S. (e.g., age limits or requiring parental consent/accompaniment) have occurred at the state level. At the national level, the U.S. Food and Drug Administration and the Federal Trade Commission regulate indoor tanning devices and advertising, respectively. The current paper provides a brief review of (1) the evidence on indoor tanning as a risk factor for skin cancer; (2) factors that may influence use of indoor tanning devices at the population level; and (3) various environmental and systems options available for consideration when developing strategies to reduce indoor tanning. This information provides the context and background for the companion paper in this issue of the American Journal of Preventive Medicine, which summarizes highlights from an informal expert meeting convened by the CDC in August 2012 to identify opportunities to prevent skin cancer by reducing use of indoor tanning devices.

Strategies to reduce indoor tanning: current research gaps and future opportunities for prevention

Exposure to ultraviolet radiation from indoor tanning device use is associated with an increased risk of skin cancer, including risk of malignant melanoma, and is an urgent public health problem. By reducing indoor tanning, future cases of skin cancer could be prevented, along with the associated morbidity, mortality, and healthcare costs. On August 20, 2012, the CDC hosted a meeting to discuss the current body of evidence on strategies to reduce indoor tanning as well as research gaps. Using the Action Model to Achieve Healthy People 2020 Overarching Goals as a framework, the current paper provides highlights on the topics that were discussed, including (1) the state of the evidence on strategies to reduce indoor tanning; (2) the tools necessary to effectively assess, monitor, and evaluate the short- and long-term impact of interventions designed to reduce indoor tanning; and (3) strategies to align efforts at the national, state, and local levels through transdisciplinary collaboration and coordination across multiple sectors. Although many challenges and barriers exist, a coordinated, multilevel, transdisciplinary approach has the potential to reduce indoor tanning and prevent future cases of skin cancer.

Correlates of intentional tanning among adolescents in the United States: a systematic review of the literature

PURPOSE

Exposure to ultraviolet radiation and a history of sunburn in childhood contribute to risk of skin cancer in adolescence and in adulthood, but many adolescents continue to seek a tan, either from the sun or from tanning beds (i.e., intentional tanning). To understand tanning behavior among adolescents, we conducted a systematic review of the literature to identify correlates of intentional tanning in the United States.

METHODS

We included articles on original research published in English between January 1, 2001, and October 31, 2011, that used self-reported data on intentional tanning by U.S. adolescents aged 8 to 18 years and examined potential correlates of tanning behaviors. Thirteen articles met our criteria; all used cross-sectional survey data and quantitative methods to assess correlates of intentional tanning.

RESULTS

Results indicate that multiple factors influence tanning among adolescents. Individual factors that correlated with intentional tanning include demographic factors (female sex, older age), attitudes (preferring tanned skin), and behaviors (participating in other risky or appearance-focused behaviors such as dieting). Social factors correlated with intentional tanning include parental influence (having a parent who tans or permits tanning) and peer influence (having friends who tan). Only four studies examined broad contextual factors such as indoor tanning laws and geographic characteristics; they found that proximity to tanning facilities and geographic characteristics (living in the Midwest or South, living in a low ultraviolet area, and attending a rural high school) are associated with intentional tanning.

CONCLUSIONS

These findings inform future public health research and intervention efforts to reduce intentional tanning.

An intervention to decrease adolescent indoor tanning: a multi-method pilot study

PURPOSE

Indoor tanning usually begins during adolescence, but few strategies exist to discourage adolescent use. We developed and tested a parent-teenager intervention to decrease indoor tanning use.

METHODS

Through focus groups, we identified key messages to enhance parent-teenager communication about indoor tanning, and then developed a pamphlet for parents and postcards for adolescents to use in a direct mail experiment with randomly selected households. Two weeks after the mailing, we asked intervention parents (n = 87) and adolescents (n = 69) and nonintervention parents (n = 31) and adolescents (n = 28) about intervention receipt and content recall, parental concern, monitoring, parent-teenager conversations, and indoor tanning intention.

RESULTS

In intervention households, 54% of mothers and 56% of girls recalled receipt and reported reading materials, but few boys and no fathers did. Among mothers, 57% in intervention households indicated concern about daughters' indoor tanning, and 25% would allow daughters to tan indoors, whereas 43% of nonintervention mothers had concerns and 46% would allow indoor tanning. Fewer girls in intervention households than in nonintervention households thought parents would allow indoor tanning (44% vs. 65%), and fewer intended to tan indoors (36% vs. 60%). Most mothers and daughters who read the intervention materials also reported discussions about indoor tanning. Moreover, the less likely girls were to think that their mothers would allow indoor tanning, the less likely it was that they intended to tan indoors, a relationship mediated by perceptions of maternal monitoring.

CONCLUSIONS

A systematic qualitative and quantitative research approach yielded well-received indoor tanning prevention messages for mothers and female adolescents. Enhancing maternal monitoring has potential to decrease adolescent indoor tanning.

Teens and indoor tanning: a cancer prevention opportunity for pediatricians

In October 2011, California became the first US state to ban indoor tanning for minors under age 18 years. Vermont followed in May 2012. Increasingly, scientific evidence shows that artificial tanning raises the risk of skin cancer, including melanoma, a common cancer in adolescents and young adults and the type most likely to result in death. The World Health Organization, the American Academy of Pediatrics, the American Academy of Dermatology, the American Medical Association, and other organizations strongly recommend legislation to ban minors under age 18 from indoor tanning. Several nations have banned teen tanning. Yet, tanning in salons is still a prevalent practice in the United States, especially among teen girls, where rates for the oldest teens approach 40%. There is no federal legislation to restrict minors from salon tanning. More than 60% of states have some kind of legislation regarding minors' use of tanning salons, but only California and Vermont have passed complete bans of indoor tanning for minors. The Indoor Tanning Association, an industry advocacy group, has vigorously opposed legislative efforts. Pediatricians can play key roles in counseling families and with legislative efforts. In this update, we review the prevalence of salon tanning, association with skin cancer risk, tanning addiction, the roles of the federal and state governments in regulation and legislation, and responses to arguments created by industry to oppose legislation. Preventing exposure to artificial tanning may save lives, including young lives, and is a key cancer prevention opportunity for pediatricians.

Practices of unregulated tanning facilities in Missouri: implications for statewide legislation

BACKGROUND

The incidence of skin cancer has increased in the United States, concomitant with increased UV radiation (UVR) exposure among young adults. We examined whether tanning facilities in Missouri, a state without indoor-tanning regulations, acted in accordance with the Food and Drug Administration's recommendations and consistently imparted information to potential clients about the known risks of UVR.

METHODS

We conducted a statewide telephone survey of randomly selected tanning facilities in Missouri. Each tanning facility was surveyed twice, in the morning (7 am-3 pm) and evening (3-10 pm), on different days, to determine intrasalon consistency of information provided to potential clients at different times.

RESULTS

On average, 65% of 243 tanning-facility operators would allow children as young as 10 or 12 years old to use indoor-tanning devices, 80% claimed that indoor tanning would prevent future sunburns, and 43% claimed that there were no risks associated with indoor tanning. Intrasalon inconsistencies involved allowable age of use, and UVR exposure type and duration. Morning tanning-facility employees were more likely to allow consumers to start with maximum exposure times and UV-A-emitting devices (P < .001), whereas evening employees were more likely to allow 10- or 12-year-old children to use indoor-tanning devices (P = .008).

CONCLUSIONS

Despite increasing evidence that UVR exposure in indoor-tanning devices is associated with skin cancer, ocular damage, and premature photoaging, tanning facilities in Missouri often misinformed consumers regarding these risks and lack of health benefits and inconsistently provided information about the Food and Drug Administration's guidelines for tanning devices.

Psychosocial correlates of frequent indoor tanning among adolescent boys

The aim of the current study was to assess psychosocial correlates (i.e., perceived weight, weight control strategies, substance use, and victimization) of frequent indoor tanning in adolescent boys-a group at high risk for developing skin cancer. Participants (N=7,907) were drawn from a nationally representative sample of adolescent boys attending high school in the United States. Binary logistic regression revealed that extreme weight control strategies, particularly steroid use (odds ratio=3.67) and compensatory vomiting (odds ratio=2.34), along with substance use and victimization, were significantly related to frequent indoor tanning. These results highlight the role of appearance-changing, and health-risk behaviors in the context of frequent indoor tanning. Skin cancer prevention interventions may benefit from adopting approaches that integrate the treatment of body dissatisfaction and subsequent maladaptive behaviors.

A melanoma risk score in a Brazilian population

BACKGROUND

Important risk factors for cutaneous melanoma (CM) are recognized, but standardized scores for individual assessment must still be developed.

OBJECTIVES

The objective of this study was to develop a risk score of CM for a Brazilian sample.

METHODS

To verify the estimates of the main risk factors for melanoma, derived from a meta-analysis (Italian-based study), and externally validate them in a population in southern Brazil by means of a case-control study. A total of 117 individuals were evaluated. Different models were constructed combining the summary coefficients of different risk factors, derived from the meta-analysis, multiplied by the corresponding category of each variable for each participant according to a mathematical expression.

RESULTS

the variable that best predicted the risk of CM in the studied population was hair color (AUC: 0.71; 95% CI: 0.62-0.79). Other important factors were freckles, sunburn episodes, and skin and eye color. Consideration of other variables such as common nevi, elastosis, family history, and premalignant lesions did not improve the predictive ability of the models.

CONCLUSION

The discriminating capacity of the proposed model proved to be superior or comparable to that of previous risk models proposed for CM.

Immunotherapy in the management of melanoma: current status

As the rate of melanoma continues to increase, so does the need for more effective and durable therapies. Despite considerable research, the management of advanced disease remains challenging. Numerous therapies are being investigated, many of which aim at upregulating the immune system’s innate ability to attack the tumor. Cytotoxic T lymphocyte antigen 4 antibodies are immune stimulants that act as negative regulators of the immune system by modifying an antitumor T-cell response. Ipilimumab, one such cytotoxic T lymphocyte antigen 4 antibody, and vemurafenib, a BRAF competitive inhibitor, were approved as first-line therapies in 2011 due to improved survival rates versus standard chemotherapy. Allovectin-7 is a lipid plasmid that encodes for major histone compatibility complex DNA sequences. It has led to increases in cytotoxic T-cell production, which subsequently attacks the tumor. OncoVEX, an oncolytic herpes virus, and PV-10, a chemoablative agent, have yielded promising results in metastatic lesions and have demonstrated a unique “bystander” phenomenon. In this paper we review the basics of melanoma from the pathophysiology, risk factors, signs, diagnostic approaches, and current status of immunologic management of melanoma.

The epidemiology of melanoma in young adults

The incidence of melanoma is rising steadily around the world, with varying mortality trends among different populations. Particularly, incidence rates among young adults, below age 40 years, have increased dramatically in the past decades. In young adults, the gender predominance is switched, with the highest incidence occurring in young women. Multiple risk factors are associated with higher risk of developing melanoma. Intermittent sunlight exposure and use of tanning beds early in life increase significantly the risk of melanoma. The prevalence of tanning bed use among young women and adolescents is increasing continuously. This trend may be associated with the increase in melanoma incidence among young women. Efforts to implement new active interventions that will increase public awareness of melanoma and the risks of tanning bed use are crucial; regulations on tanning bed use especially among those underage should be implemented.

Melanoma treatment costs: a systematic review of the literature, 1990-2011

CONTEXT

Melanoma is the most deadly form of skin cancer and an important public health concern. Given the substantial health burden associated with melanoma, it is important to examine the economic costs associated with its treatment. The purpose of the current study was to systematically review the literature on the direct medical care costs of melanoma.

EVIDENCE ACQUISITION

A systematic review was performed using multiple databases including MEDLINE, Embase, CINAHL, and Econlit. Nineteen articles on the direct medical costs of melanoma were identified.

EVIDENCE SYNTHESIS

Detailed information on the study population, study country/setting, study perspective, costing approach, disease severity (stage), and key study results were abstracted. The overall costs of melanoma were examined as well as per-patient costs, costs by phase of care, stage of diagnosis, and setting/type of care. Among studies examining all stages of melanoma, annual treatment costs ranged from $44.9 million among Medicare patients with existing cases to $932.5 million among newly diagnosed cases across all age groups.

CONCLUSIONS

Melanoma leads to substantial direct medical care costs, with estimates varying widely because of the heterogeneity across studies in terms of the study setting, populations studied, costing approach, and study methods. Melanoma treatment costs varied by phase of care and stage at diagnoses; costs were highest among patients diagnosed with late-stage disease and in the initial and terminal phases of care. Aggregate treatment costs were generally highest in the outpatient/office-based setting; per-patient/per-case treatment costs were highest in the hospital inpatient setting. Given the substantial costs of treating melanoma, public health strategies should include efforts to enhance both primary prevention (reduction of ultraviolet light exposure) and secondary prevention (earlier detection) of melanoma.

Vitamin D and melanoma incidence and mortality

The role of vitamin D (25-OH-D, or 25-hydroxyvitamin D) and its potential confounders in relationship to melanoma risk and mortality is discussed. The paradox that ultraviolet radiation (UVR) exposure is the major environmental risk factor for melanoma etiology as well as a major source of vitamin D might be explained by viewing vitamin D levels as the result of a healthy lifestyle rather than a cause of health.

Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis

OBJECTIVE

To synthesise the literature on indoor tanning and non-melanoma skin cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed (1966 to present), Embase (1974 to present), and Web of Science (1898 to present).

STUDY SELECTION

All articles that reported an original effect statistic for indoor tanning and non-melanoma skin cancer were included. Articles that presented no data, such as review articles and editorials, were excluded, as were articles in languages other than English.

DATA EXTRACTION

Two investigators independently extracted data. Random effects meta-analysis was used to summarise the relative risk of ever use versus never use of indoor tanning. Dose-response effects and exposure to indoor tanning during early life were also examined. The population attributable risk fraction for the United States population was calculated.

RESULTS

12 studies with 9328 cases of non-melanoma skin cancer were included. Among people who reported ever using indoor tanning compared with those who never used indoor tanning, the summary relative risk for squamous cell carcinoma was 1.67 (95% confidence interval 1.29 to 2.17) and that for basal cell carcinoma was 1.29 (1.08 to 1.53). No significant heterogeneity existed between studies. The population attributable risk fraction for the United States was estimated to be 8.2% for squamous cell carcinoma and 3.7% for basal cell carcinoma. This corresponds to more than 170 000 cases of non-melanoma skin cancer each year attributable to indoor tanning. On the basis of data from three studies, use of indoor tanning before age 25 was more strongly associated with both squamous cell carcinoma (relative risk 2.02, 0.70 to 5.86) and basal cell carcinoma (1.40, 1.29 to 1.52).

CONCLUSIONS

Indoor tanning is associated with a significantly increased risk of both basal and squamous cell skin cancer. The risk is higher with use in early life (<25 years). This modifiable risk factor may account for hundreds of thousands of cases of non-melanoma skin cancer each year in the United States alone and many more worldwide. These findings contribute to the growing body of evidence on the harms of indoor tanning and support public health campaigns and regulation to reduce exposure to this carcinogen.

Ultraviolet light and skin cancer in athletes

The incidence of melanoma and nonmelanoma skin cancers is increasing worldwide. Ultraviolet light exposure is the most important risk factor for cutaneous melanoma and nonmelanoma skin cancers. Nonmelanoma skin cancer includes basal cell carcinoma and squamous cell carcinoma. Constitutive skin color and genetic factors, as well as immunological factors, play a role in the development of skin cancer. Ultraviolet light also causes sunburn and photoaging damage to the skin.

Changes of melanocytic lesions inducedby Melanotan injections and sun bed use ina teenage patient with FAMMM syndrome

A 16-year-old girl presented with general skin tanning, multiple dark melanocytic nevi and an enlarging nevus in her left groin following self-injections of Melanotan 2 and attending a UV tanning studio. She had been referred by her GP who was concerned that some of the darkened nevi were potentially malignant.

Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis

OBJECTIVE

To estimate the burden of melanoma resulting from sunbed use in western Europe.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, ISI Web of Science (Science Citation Index Expanded), Embase, Pascal, Cochrane Library, LILACS, and MedCarib, along with published surveys reporting prevalence of sunbed use at national level in Europe.

STUDY SELECTION

Observational studies reporting a measure of risk for skin cancer (cutaneous melanoma, squamous cell carcinoma, basal cell carcinoma) associated with ever use of sunbeds.

RESULTS

Based on 27 studies ever use of sunbeds was associated with a summary relative risk of 1.20 (95% confidence interval 1.08 to 1.34). Publication bias was not evident. Restricting the analysis to cohorts and population based studies, the summary relative risk was 1.25 (1.09 to 1.43). Calculations for dose-response showed a 1.8% (95% confidence interval 0% to 3.8%) increase in risk of melanoma for each additional session of sunbed use per year. Based on 13 informative studies, first use of sunbeds before age 35 years was associated with a summary relative risk of 1.87 (1.41 to 2.48), with no indication of heterogeneity between studies. By using prevalence data from surveys and data from GLOBOCAN 2008, in 2008 in the 15 original member countries of the European Community plus three countries that were members of the European Free Trade Association, an estimated 3438 cases of melanoma could be attributable to sunbed use, most (n=2341) occurring among women.

CONCLUSIONS

Sunbed use is associated with a significant increase in risk of melanoma. This risk increases with number of sunbed sessions and with initial usage at a young age (<35 years). The cancerous damage associated with sunbed use is substantial and could be avoided by strict regulations.

Vitamin D and metabolism: facts, myths and misconceptions

Vitamin D is essential for a vast number of physiologic processes, and thus adequate levels are necessary for optimal health. During childhood and adolescence, an adequate vitamin D status is needed due to its important role in cell growth, skeletal development and growth. Vitamin D is a fat-soluble vitamin that is naturally found in very few foods, is added to others, and is available as a dietary supplement. It is produced endogenously when ultraviolet light strikes the skin. The adequate intake and status of vitamin D greatly depends on age, concomitant diseases and the use of some medications that are covered in-depth in the article. Recent epidemiologic and experimental evidence has suggested that low vitamin D concentrations seem to be significantly associated with all-cause mortality, cardiovascular disease, cancer (mainly breast, prostate and colorectal), hypertension, metabolic syndrome, diabetes mellitus type 1 and type 2. However, the data supporting protective effects of vitamin D supplementation on conditions other than skeletal diseases like rickets, osteoporosis and osteomalacia are very weak, and the large, controlled clinical trials that are in progress now should resolve this issue.

Update on the current state of melanoma incidence

The incidence of melanoma is rising worldwide, and in the United States has increased by approximately 2.8% annually since 1981. Melanoma is more common in whites, and is generally more prevalent in men. However, there is a 6.1% annual increase in US incidence of melanomas in white women younger than age 44, with growing concern that increases in skin cancer in younger women may reflect recent trends in indoor tanning. Melanoma incidence is also greater in higher economic groups. Globally, melanoma incidence is highest in Australia, followed by the United States and parts of Europe.

New approaches to melanoma prevention

Skin cancer is a major public health concern, and tanning remains a modifiable risk factor. Multidimensional influences, including psychosocial, individual, environmental, and policy-related factors, create the milieu for individuals to engage in tanning. Parents and physicians can modify the behavior of teens and young adults using strategies based on harm reduction. Environmental and policy-related factors similar to those used to limit smoking by restricting access of minors to cigarettes in the United States in the 20th century need to be created. Federal regulations can restrict direct advertising and the excise tax can be increased to a prohibitive amount. Social networking may assist with affect regulation.

Ultraviolet radiation and melanoma

Melanoma is a particularly aggressive type of skin cancer, and its incidence has been increasing steadily since the 1970s. This article will review the extensive epidemiologic data demonstrating that ultraviolet radiation (UVR) exposure, from the sun or artificial tanning beds, is the most important environmental risk factor for melanoma; the multiple detrimental effects of UVR on human skin, including DNA damage through the formation of dimeric photoproducts, gene mutations, oxidative stress, inflammation, and immunosuppression, all of which contribute to melanomagenesis; and the evidence that protection from UVR exposure, whether by melanin or by sunscreen, reduces the risk of developing melanoma.

A dermatologist's perspective on vitamin D

Vitamin D is a fat-soluble steroid hormone that is crucial for human health and has recently generated controversy regarding its role in human health and disease. In this Special Article, we discuss our dermatologic perspective on vitamin D in a question-and-answer format. We discuss methods of obtaining vitamin D, including cutaneous photobiosynthesis, diet, and supplements and include the recent US Institute of Medicine recommendations. Other reviewed topics include the associations among skin pigmentation, climate, photoprotection, and vitamin D levels. We also elaborate on the popular interest in sun exposure as a method of normalizing vitamin D levels in the context of the risks of solar and artificial radiation. We also discuss groups at risk for vitamin D inadequacy, the need for testing serum vitamin D levels, and the role of phototherapy in patients with malabsorption conditions and hypervitaminosis D, with a focus on patients with sarcoidosis. Finally, we summarize our recommendations on vitamin D.

Use of tanning beds and incidence of skin cancer

PURPOSE

We sought to evaluate the risk effect of tanning bed use on skin cancers among teenage and young adults. We also expected to determine whether a dose-response relationship was evident.

PATIENTS AND METHODS

We observed 73,494 female nurses for 20 years (from 1989 to 2009) in a large and well-characterized cohort in the United States and investigated whether frequency of tanning bed use during high school/college and at ages 25 to 35 years were associated with a risk of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma. We used Cox proportional hazards models and carefully adjusted for host risk factors, ultraviolet index of residence, and sun exposure behaviors at a young age.

RESULTS

During follow-up, 5,506 nurses were diagnosed with BCC, 403 with SCC, and 349 with melanoma. The multivariable-adjusted hazard ratio (HR) of skin cancer for an incremental increase in use of tanning beds of four times per year during both periods was 1.15 (95% CI, 1.11 to 1.19; P < .001) for BCC, 1.15 (95% CI, 1.01 to 1.31; P = .03) for SCC, and 1.11 (95% CI, 0.97 to 1.27; P = .13) for melanoma. Compared with tanning bed use at ages 25 to 35 years, we found a significantly higher risk of BCC for use during high school/college (multivariable-adjusted HR for use more than six times per year compared with no use was 1.73 during high school/college v 1.28 at ages 25 to 35 years; P for heterogeneity < .001).

CONCLUSION

Our data provide evidence for a dose-response relationship between tanning bed use and the risk of skin cancers, especially BCC, and the association is stronger for patients with a younger age at exposure.

Lifetime history of indoor tanning in young people: a retrospective assessment of initiation, persistence, and correlates

Background

Despite educational and public health campaigns to convey the risks of indoor tanning, many individuals around the world continue to engage in this behavior. Few descriptive studies of indoor tanning have collected information pertaining to the lifetime history of indoor tanning, thereby limiting our ability to understand indoor tanning patterns and potentially target interventions for individuals who not only initiate, but continue to persistently engage in indoor tanning.

Methods

In-person interviews elicited detailed retrospective information on lifetime history of indoor tanning among white individuals (n = 401) under age 40 seen by a dermatologist for a minor benign skin condition. These individuals were controls in a case-control study of early-onset basal cell carcinoma. Outcomes of interest included ever indoor tanning in both males and females, as well as persistent indoor tanning in females - defined as females over age 31 who tanned indoors at least once in the last three or all four of four specified age periods (ages 11-15, 16-20, 21-30 and 31 or older). Multivariate logistic regression was used to identify sociodemographic and lifestyle correlates of ever and persistent indoor tanning in females.

Results

Approximately three-quarters (73.3%) of females and 38.3% of males ever tanned indoors, with a median age of initiation of 17.0 and 21.5, respectively. Among indoor tanners, 39.3% of females and 21.7% of males reported being burned while indoor tanning. Female ever indoor tanners were younger, had darker color eyes, and sunbathed more frequently than females who never tanned indoors. Using unique lifetime exposure data, 24.7% of female indoor tanners 31 and older persistently tanned indoors starting as teenagers. Female persistent indoor tanners drank significantly more alcohol, were less educated, had skin that tanned with prolonged sun exposure, and sunbathed outdoors more frequently than non-persistent tanners.

Conclusions

Indoor tanning was strikingly common in this population, especially among females. Persistent indoor tanners had other high-risk behaviors (alcohol, sunbathing), suggesting that multi-faceted behavioral interventions aimed at health promotion/disease prevention may be needed in this population.

Indoor tanning and risk of early-onset basal cell carcinoma

BACKGROUND

Despite an increase in incidence of basal cell carcinoma (BCC) among young people and the ubiquity of indoor tanning in this population, few epidemiologic studies have investigated this exposure-disease relationship.

OBJECTIVE

We sought to evaluate the association between indoor tanning and early-onset BCC.

METHODS

Patients with BCC (n = 376) and control subjects with minor benign skin conditions (n = 390) who were younger than 40 years of age were identified through Yale Dermatopathology. Participants provided information on ever indoor tanning, age of initiation, frequency, duration, burns while tanning, and type of tanning device during an in-person interview. We calculated odds ratios (OR) and 95% confidence intervals (CI) using multivariate logistic regression with never indoor tanners as the referent group.

RESULTS

Ever indoor tanning was associated with a 69% increased risk of early-onset BCC (95% CI 1.15-2.48). This association was stronger among females (OR 2.14, 95% CI 1.31-3.47), for multiple BCCs (OR 2.16, 95% CI 1.26-3.70), and for BCCs on the trunk and extremities (OR 2.81, 95% CI 1.57-5.02). Risk increased dose dependently with years using regular indoor tanning devices (P trend = .003), number of overall burns (P trend < .001), and burns to biopsy site (P trend < .001) from indoor tanning. Approximately one quarter (27%) of early-onset BCCs (or 43% among women) could be prevented if individuals never tanned indoors.

LIMITATIONS

Potential recall bias of indoor tanning by patients and generalizability of the control population suggest replication in other studies is warranted.

CONCLUSIONS

Indoor tanning was a strong risk factor for early-onset BCC, particularly among females. Indoor tanning should continue to be targeted by both policy-based and behavioral interventions, as the impact on BCC-associated morbidity may be substantial.

Host phenotype characteristics and MC1R in relation to early-onset basal cell carcinoma

Basal cell carcinoma (BCC) incidence is increasing, particularly among adults under age 40. Pigment-related characteristics are associated with BCC in older populations, but epidemiologic studies among younger individuals and analyses of phenotype-genotype interactions are limited. We examined self-reported phenotypes and melanocortin 1 receptor gene (MC1R) variants in relation to early-onset BCC. BCC cases (n=377) and controls with benign skin conditions (n=390) under age 40 were identified through Yale’s Dermatopathology database. Factors most strongly associated with early-onset BCC were skin reaction to first summer sun for one hour [severe sunburn vs. tan odds ratio (OR)=12.27, 95% confidence interval (CI)=4.08–36.94] and skin color (very fair vs. olive OR=11.06, 95% CI=5.90–20.74). Individuals with two or more MC1R non-synonymous variants were 3.59 times (95% CI=2.37–5.43) more likely to have BCC than those without non-synonymous variants. All host characteristics and MC1R were more strongly associated with multiple BCC cases status (37% of cases) than single BCC case status. MC1R, number of moles, skin reaction to first summer sun for one hour, and hair and skin color were independently associated with BCC. BCC risk conferred by MC1R tended to be stronger among those with darker pigment phenotypes, traditionally considered to be at low-risk of skin cancer.

Trends in skin cancer knowledge, sun protection practices and behaviours in the Northern Ireland population

BACKGROUND

Sun exposure increases risk of skin cancer, especially melanoma, incidence of which continues to rise. Reported skin cancer knowledge and trends in sun care behaviours are documented in a UK region where there has been 20 years of sun-related health promotion campaigns.

METHODS

In 2000, 2004 and 2008, a 'care in the sun' module was included in the Northern Ireland (NI) Omnibus survey. Randomly selected subjects were asked to complete a sun-related questionnaire and proportions of respondents analysed by demographic and socio-economic factors, with differences tested using z-tests and the chi-squared test.

RESULTS

Around 3623 persons responded. Skin cancer knowledge was high (97%). Sun avoidance decreased with time and was lowest among younger age groups and males. Sunscreen use was high (70%), unchanged over 8 years, and more likely among younger age groups, females, those in paid employment, and those with tertiary level education. Use of sunscreen with minimum Sun Protection Factor (SPF) 15 (a campaign message) increased from 45% to 70% (P < 0.01). Skin self-examination was infrequent (8%), less common among those aged ≥65 years, males and those with only primary or secondary level education.

CONCLUSIONS

Messages on sunscreen use have penetrated the population well, but lower use among the unemployed suggests cost as an issue. Lack of sun avoidance in young people, especially men, poses a risk for further skin cancer increases. Low levels of reported skin self-examination in older people, men and those with lower educational attainment identify areas for further action.

Melanoma: epidemiology, diagnosis, treatment, and outcomes

Melanoma is a skin cancer that arises from the malignant transformation of melanocytes. Although it is typically considered a pigmented lesion, the clinical presentation of melanoma can vary greatly. With increased efforts in screening and detection of early-stage melanoma, researchers and clinicians hope to improve clinical outcomes for patients with melanoma. Novel immunotherapies directed at specific molecular targets in the pathogenesis of melanoma usher in a new era of treatment of advanced melanoma.

Increases in invasive melanoma in England, 1979-2006, by anatomical site

BACKGROUND

National melanoma incidence trends with details of anatomical site have not been previously described for England.

OBJECTIVES

To describe site-specific trends in cutaneous melanoma for England as a whole during the last three decades.

METHODS

Anonymized data, 1979-2006, were obtained from national cancer registrations of all patients in England up to age 89years with incident primary invasive cutaneous melanomas (n=124055). Sex-specific age-standardized incidence rates and average annual percentage change in rates were calculated for each broad anatomical site.

RESULTS

Overall incidence rates of cutaneous melanoma in England, 1979-2006, were 81 and 100 per million, in males and females, respectively. Site-specific rates were consistently highest on the lower limbs in females followed by the trunk in males. Greatest annual increases occurred on the trunk in both sexes over 45years (males 9·9%, females 6·8%), then upper limbs (males 8·7%, females 6·8%). Incidence trends in males relative to females varied little across sites apart from a more rapid rise in head/neck melanomas in males than in females after the 1980s.

CONCLUSIONS

Invasive melanoma rates continue to rise in England, particularly on the trunk and arms, and in males on the head/neck. The steeper increases in melanoma rates among males are consistent with their greater sun exposure and poorer compliance with sun protection measures than females.

UV wavelength-dependent DNA damage and human non-melanoma and melanoma skin cancer

Ultraviolet (UV) irradiation from the sun has been epidemiologically and mechanistically linked to skin cancer, a spectrum of diseases of rising incidence in many human populations. Both non-melanoma and melanoma skin cancers are associated with sunlight exposure. In this review, we discuss the UV wavelength-dependent formation of the major UV-induced DNA damage products, their repair and mutagenicity and their potential involvement in sunlight-associated skin cancers. We emphasize the major role played by the cyclobutane pyrimidine dimers (CPDs) in skin cancer mutations relative to that of (6-4) photoproducts and oxidative DNA damage. Collectively, the data implicate the CPD as the DNA lesion most strongly involved in human cancers induced by sunlight.