Community-wide Interventions to Prevent Skin Cancer: Two Community Guide Systematic Reviews

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma. Part 1: Diagnostics and prevention-Update 2023

Invasive cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in white populations, accounting for 20% of all cutaneous malignancies. Overall, cSCC mostly has very good prognosis after treatment, with 5-year cure rates greater than 90%. Despite the overall favourable prognosis and the proportionally rare deaths, cSCC is associated with a high total number of deaths due to its high incidence. A collaboration of multidisciplinary experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV) and the European Organization of Research and Treatment of Cancer (EORTC), was formed to update recommendations on cSCC, based on current literature and expert consensus. Part 1 of the guidelines addresses the updates on classification, epidemiology, diagnosis, risk stratification, staging and prevention in immunocompetent as well as immunosuppressed patients.

Current practice and beliefs of parents toward sunscreen use for their children: A cross-sectional study

Parents are generally influencing the sun protection behaviors of their children, including sunscreen use. In Saudi Arabia, sunscreen use was estimated in adults but not children. The objective was to estimate the prevalence and predictors of sunscreen use among parents and their children. An observational cross-sectional study was conducted in April 2022. Parents who were visiting outpatient clinics at a university hospital in Al-Kharj city, Saudi Arabia, were invited to complete an online questionnaire. A total of 266 participants were included in the final analysis. The mean age of parents was 39.0 ± 8.9 years, and the mean age of children was 8.2 ± 3.2 years. The prevalence of sunscreen use was 38.7% in parents and 24.1% in their children. Females had higher sunscreen use than males in both parents (49.7% versus 7.2%, p < 0.001) and in children (31.9% versus 18.3%, p = 0.011). The most frequent sunburn protection measures practiced by children were wearing long-sleeved clothes (77.0%), sitting in the shade (70.6%), and wearing hats (39.2%). In multivariable analysis, predictors of sunscreen use in parents included female sex, history of sunburn, and sunscreen use by children. Independent predictors of sunscreen use in children included a history of sunburn, wearing hats, and practicing other sunburn protection measures on risky occasions, and sunscreen use in parents. Sunscreen use in parents and children in Saudi Arabia is still inadequate or limited. This calls for community/school intervention programs using educational activities and multimedia promotion. Further studies are needed.

Use of phosphodiesterase-5 inhibitors and the incidence of melanoma

INTRODUCTION

Recent evidence of a causal link between Phosphodiesterase-5-inhibitor (PDE-5i) use and melanoma has caused concern in PDE-5i use and was even addressed in the 2018 American Urological Association guideline on erectile dysfunction (ED). Given that several studies have affirmed this low probability but statistically significant association, one might expect a shift in melanoma diagnoses since PDE-5is were introduced in 1998. We sought to determine if the introduction of PDE-5i drugs for ED treatment increased incidence of melanoma.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to compare the incidence of melanoma diagnosis in American men between 1973 and 2015, providing over a decade of data before and after PDE-5i introduction in 1998. Interrupted time-series and logistic regression were used to assess this relationship.

RESULTS

Over 43 years, the SEER database has reported 292,166 cases of Melanoma, with males accounting for 53.7% of cases (Standard deviation [SD] 3%, Range 47.5-58.3%). After the introduction of PDE-5i, there was no proportional increase in melanoma diagnoses, in fact demonstrating a 2% lower incidence from prediction models (p < 0.05).

CONCLUSION

Our analysis of the SEER database demonstrates that the trend in incidence of melanoma has fallen in the era of PDE-5i use for ED. These findings may be of value in counseling patients anxious about the potential association between PDE-5i use and skin cancer; however, continued research analyzing individual-level risk are needed.

Invasive cutaneous squamous cell carcinoma resulting in arm amputation. Case discussion and literature review

Skin cancer is one of the most common cancers in the world. Specifically incidence of non-melanoma malignancy in the UK has increased by 56% in the last decade. Cutaneous squamous cell carcinoma (cSCC) is a type of non-melanoma skin cancer that if caught early can be successfully treated. Conservative excision surgery is the most common treatment modality with high cure rates even if tumours are advanced. Radical surgery is rarely required, and amputations, especially when the distal part of the upper extremity is involved, are very uncommon. Here, we describe a case of an invasive cutaneous squamous cell carcinoma of the elbow that required trans-humeral arm amputation.

Generating political priority for skin cancer primary prevention: A case study from Aotearoa New Zealand

ISSUES ADDRESSED

Skin cancer is highly prevalent but preventable, yet little research has been done on the challenges in generating political priority for skin cancer prevention. This qualitative study aimed to identify the political challenges to, facilitators of, and strategies to strengthen skin cancer prevention. The focus was on the case of Aotearoa New Zealand (NZ): a country with high skin cancer rates, but limited investment in primary prevention.

METHODS

Data sources included 18 national key informant interviews and documentary analysis. Data were analysed inductively for emerging themes and framed using a conceptual framework of political priority.

RESULTS

Challenges to advocates for skin cancer primary prevention include limited resources and competing priorities. Political-level challenges include a lack of quick results compared with other initiatives vying for political attention, lack of negative externalities and, in NZ, misalignment with health system priorities. Challenges in the evidence base include the perceived conflict of sun protection with Vitamin D and physical activity, the lack of data on the financial burden of skin cancer and relatively low temperatures in NZ. Facilitators include strong policy community cohesion and issue framing, and weak opposition. Promising strategies to strengthen skin cancer prevention in NZ could include network building, using framing that resonates with policy makers and addressing key knowledge gaps in NZ, such as the financial burden of skin cancer.

CONCLUSION

Advocacy for skin cancer prevention faces challenges due to advocates' limited resources, political challenges such as lack of quick results and gaps in evidence. Nonetheless, the initiative encounters little opposition and can be framed in ways that resonate with policy makers. SO WHAT?: Skin cancer is highly preventable, but advocates for prevention initiatives have struggled to gain political traction. This study identifies several strategies that could help raise the political profile for skin cancer prevention.

Supporting health literacy in adolescent populations: distinguishing pedagogies for sun safety education in schools

Purpose

The aim of this paper is to distinguish pedagogies supporting critical health literacy development in adolescent populations. Specifically, for sun safety education in schools.

Design/methodology/approach

The paper draws on an exploratory intrinsic case study design to qualitatively examine the learning conditions that Pre-Service Teachers' (PsTs) mobilise to advance Health Literary (HL) in learning activities.

Findings

This paper presents data that shows the different ways thirty Pre-Service Teachers (PsTs) in Western Australia conceptualise HL in sun safety education for Year 7 students (12–13 years old). Examination of three consecutive lesson plans categorised learning activities (n = 444) according to HL competencies. Data shows that the PsTs pedagogically advance HL but are constrained when conceptualising learning to support critical HL. Further examination of the lesson plans of the 11 PsTs who pedagogically advanced learning to support a critical level of health literacy, distinguished the learning conditions and pedagogies supporting critically health literate adolescents.

Originality/value

By distinguishing pedagogies to situate individual and social health within broader societal goals, the paper identifies teacher education institutions as key players enabling young people to socially advocate healthier living, particularly, regarding melanoma and non-melanoma incidence.

Identification of Relevant Sociocognitive Determinants Explaining Multiple Parental Sun Protection Behaviors

Background

Adequate sun safety during childhood is crucial for decreasing skin cancer risk in later life. Although parents are an essential target group in applying sun protection measures for their children, insight into the determinants associated with their sun protection behaviors is limited.

Aims

This study aims to identify the most relevant determinants in predicting multiple parental sun protection intentions and behaviors in different sun exposure situations.

Method

A longitudinal survey study with two measurements was conducted among Dutch parents (N = 670) of children (4–12 years old). Twenty-seven sociocognitive determinants were examined in terms of relevance regarding four parental sun protection behaviors in different sun exposure situations. The Confidence Interval-Based Estimation of Relevance approach was used to visualize room for improvement (sample means) on all determinants and their association strengths (correlations) with sun protection intentions and behaviors.

Results

Behavior-specific rather than generic determinants were most relevant in explaining all sun protection behaviors. Of these determinants, attitude, self-efficacy and action planning, and especially parental feelings of difficulty in performing sun protection behaviors, were most relevant. Altogether, the explained variance of all sociocognitive determinants was highest for shade-seeking behavior (R² = .41 and .43) and lowest for supportive behavior (R² = .19 and .29) in both planned and incidental sun exposure situations, respectively.

Discussion

This study provides detailed insight into relevant sociocognitive determinants of parental sun protection behaviors in various sun exposure situations and directions for composing parental skin cancer prevention interventions.

Conclusions

Future composition of sun safety interventions should emphasize on enhancing parental feelings of self-efficacy, especially for shade-seeking and clothing behaviors.

Sunburn, Sun Safety and Indoor Tanning Among Schoolchildren in Ireland

Objectives: We present patterns of sunburn, sun safety behaviors and indoor tanning bed use in a nationally representative sample of schoolchildren aged 10–17. These behaviors were explored across gender, age, and social class groups.

Methods: Within the Health Behaviour in School-aged Children (HBSC) Ireland study, 10,271 young people (aged 13.54 ± 1.92, percentage girls 53.3%) reported frequency of sun safety behaviors, sunburn, and frequency and circumstances of indoor tanning bed use.

Results: Children frequently experienced sunburn (90% lifetime, 74% last year), and 3% reported never using any sun protection. Applying sunscreen and wearing sunglasses were the most commonly used sun safety measures; other ways of sun protection were less popular. Indoor tanning bed use was reported by around 5%, and a large proportion of users were not advised of any indoor tanning safety measures. Sun safety behaviors varied by age and gender, with some socio-economic differences in tanning bed use. An association was found between frequency of family holidays abroad and sunburn.

Conclusion: Targeted interventions are needed to increase sun safety behaviors and eliminate tanning bed use among children in Ireland.

School-based interventions to improve sun-safe knowledge, attitudes and behaviors in childhood and adolescence: A systematic review

Ultraviolet radiation exposure is the leading cause of skin cancer, and childhood and adolescence is a particularly susceptible life period for exposure. This systematic review assessed whether interventions in elementary and secondary school settings reduced sun exposure, sunburns, and development of melanocytic nevi, and improved sun-safe knowledge, attitudes and sun protection behaviors in childhood and adolescence. A systematic search up to June 2020 of MEDLINE, Embase, CINAHL, Cochrane and ProQuest databases was undertaken, for studies conducted among students in an elementary or secondary school setting that compared an intervention group with a pre-intervention or separate control group. Data were summarized using qualitative synthesis. Pooled effects from meta-analysis with random effects were also reported where appropriate. Sixty-five studies were included (22 randomized, 43 non-randomized). Most studies assessed measures of sun-safe behaviors, knowledge and attitudes (57, 48 and 33 studies, respectively), and observed improved sun protection behaviors and sun-safe knowledge, whereas few studies reduced time in the sun. About half improved participants' attitudes towards tanning desirability. Sunburns and nevus counts were less frequently assessed, but about half of these studies observed a reduction. There was substantial heterogeneity for outcomes except attitudes towards the desirability of tanning (pooled odds ratio from 6 studies: 0.81, 95% confidence interval 0.70-0.94). Key positive intervention features included: elementary school settings, interactive features or multiple components, and incorporating social norm influences. Most studies were classified at high risk of bias. In conclusion, school-based sun-related interventions had positive impacts on behaviors and attitudes among elementary and secondary school children.

Solar Ultraviolet Exposure in Individuals Who Perform Outdoor Sport Activities

BACKGROUND

Skin cancer is the most common cancer in the USA. Therefore, it is important to review the contribution of ultraviolet radiation (UVR) exposure to skin cancer in individuals with the highest risk. Documenting the relationship between outdoor sports solar ultraviolet exposure and their risk of skin cancer along with appropriate risk mitigation strategies can help inform clinicians of practical information for counseling sun protective behaviors in this population.

METHODS

We conducted a review of the current evidence using PubMed to answer the following research questions: (1) How is ultraviolet radiation measured? (2) What is the modern utility of the ultraviolet index in modifying recreational sun protection behaviors? (3) What is the risk of developing skin cancer for outdoor sport participants? (4) What is the prevalence of skin cancer in sport participants? and (5) Is the number of nevi and solar lentigines elevated in outdoor sport participants?

RESULTS

Based on the literature, individuals who practice outdoor sport-related activities receive high ultraviolet radiation exposure, have a high risk for skin cancer, have a high prevalence for pigmented lesions, and may benefit from electronic sun protection educational interventions.

CONCLUSIONS

Individuals who practice outdoor sports experience substantially higher ultraviolet radiation exposure, routinely exceed the recommended exposure limits, and are at a higher risk of developing skin cancer. Therefore, those who are frequently engaged in outdoor leisure activities should be coached about efficient sun protective practices and relevant mobile technologies that may facilitate adherence.

Sun protection habits and behaviors of a group of outdoor workers and students from the agricultural and construction sectors in north-Italy

Background:

Despite the relevant frequency of ultraviolet induced adverse health effects in workers, solar ultraviolet radiation (UVR) exposure is an occupational risk not adequately minimized in Italy.

Objective:

To assess the characteristics and prevalence of sun exposure habits and behaviors in a group of students and outdoor workers (OW) from the agricultural and construction sectors of a north-Italian region.

Methods:

Based on a previously developed standardized questionnaire, we collected full information on individual sun exposure habits at work and during leisure activities.

Results:

In 2018, 380 high school students and OW from the agricultural and construction sectors participated in a sun-safety campaign. More than a third (39.0%) of OW reported never using sunglasses, 52.8% never applied sunscreens at work, and a quarter never wear a UV protective hat. Considering leisure-time, students reported more frequent sunburns compared to OW: 25.0% vs. 13.8%; half (51.6%) of students and a third (36.4%) of OW reported never wearing a UV protective hat. A third (30.1%) of students and 37.2% of OW never or only seldom applied sunscreens on holidays.

Discussion:

The majority of OW in our study reported poor protective solar exposure habits. Young students of the construction and agricultural sectors indicated even worse sun-protective behaviors, both during apprenticeship and leisure activities. Our study highlights the low health literacy related to solar UVR in OW and apprentices. Further educational initiatives are required in Italy to improve the adoption of protective behaviors during outdoor activities.

European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 1. epidemiology, diagnostics and prevention

Invasive cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in the white populations, accounting for 20% of all cutaneous malignancies. Factors implicated in cSCC etiopathogenesis include ultraviolet radiation exposure and chronic photoaging, age, male sex, immunosuppression, smoking and genetic factors. A collaboration of multidisciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organisation of Research and Treatment of Cancer (EORTC) was formed to update recommendations on cSCC classification, diagnosis, risk stratification, staging and prevention, based on current literature, staging systems and expert consensus. Common cSCCs are typically indolent tumors, and most have a good prognosis with 5-year cure rates of greater than 90%, and a low rate of metastases (<4%). Further risk stratification into low-risk or high-risk common primary cSCC is recommended based on proposed high-risk factors. Advanced cSCC is classified as locally advanced (lacSCC), and metastatic (mcSCC) including locoregional metastatic or distant metastatic cSCC. Current systems used for staging include the American Joint Committee on Cancer (AJCC) 8th edition, the Union for International Cancer Control (UICC) 8th edition, and Brigham and Women's Hospital (BWH) system. Physical examination for all cSCCs should include total body skin examination and clinical palpation of lymph nodes, especially of the draining basins. Radiologic imaging such as ultrasound of the regional lymph nodes, magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography-computed tomography (PET-CT) scans are recommended for staging of high-risk cSCC. Sentinel lymph node biopsy is currently not recommended. Nicotinamide, oral retinoids, and topical 5-FU have been used for the chemoprevention of subsequent cSCCs in high-risk patients but are not routinely recommended. Education about sun protection measures including reducing sun exposure, use of protective clothing, regular use of sunscreens and avoidance of artificial tanning, is recommended.

Testing General Versus Specific Behavioral Focus in Messaging for the Promotion of Sun Protection Behaviors

BACKGROUND

Recommendations for skin cancer prevention include behaviors such as using sunscreen, seeking shade, and wearing a shirt with sleeves, but the best way to persuasively communicate this information to the public is not clear.

PURPOSE

To test whether a messaging strategy using videos that focus on one specific behavior at a time versus a more general or multibehavior sun protection message is effective at changing attitudinal beliefs and intention with regard to sun protection behaviors.

METHODS

Online experiment among non-Hispanic white 18-49 year old adults in the USA. Participants were randomly assigned to one of four conditions, each one with health messages on a different sun protection prevention behavior: "using sunscreen" (Condition 1, n = 259), "seeking shade" (Condition 2, n = 245), or "covering up" (Condition 3, n = 289). Condition 4 (the control, n = 251) is a multibehavior message that equally promotes sunscreen, seeking shade, and covering up and features a general message on sun safety.

RESULTS

ANOVA and path analysis results suggest that messages which emphasize a single sun protection behavior compared with general sun safety messaging could potentially be a promising approach. The effectiveness of the videos in influencing attitudinal beliefs varied by behavior, with some gender and age moderation. There was an indirect effect on intention to use sunscreen.

CONCLUSIONS

This study advances our understanding of strategies for skin cancer prevention campaigns. Specifically, it suggests that focusing on a single sun protection behavior with targeted beliefs may be valuable as a first step in encouraging sun safety.

Sun Exposure and Protection Index (SEPI) and Self-Estimated Sun Sensitivity

The incidence of skin cancer is increasing worldwide, mostly because of increasing exposure to ultraviolet (UV) radiation from the sun. The Sun Exposure and Protection Index (SEPI) questionnaire, developed in Linköping and validated in Sweden and Australia, is used to map sun habits, sun protection behaviour, and readiness to increase sun protection. We sought to examine differences in sun habits or sun protection behaviour and propensity to increase sun protection, based on SEPI as related to self-estimated skin UV sensitivity according to the Fitzpatrick classification. The study population comprised students at Linköping University, who were asked to complete the SEPI questionnaire. We examined differences in sun habits and sun protection behaviour according to skin type and gender. Individuals with lower UV sensitivity had significantly riskier sun habits and sun protection behaviour and were significantly less likely to increase sun protection. Women spent significantly more time tanning than men, more time in the midday sun, used sunscreen more frequently, and were more likely to seek the shade for sun protection. Individuals with higher UV sensitivity were significantly more likely to increase sun protection; individuals with low UV sensitivity tended to have a riskier attitude to sunbathing. In conclusion, self-estimated skin type and gender are important factors influencing sun exposure habits and sun protection behaviour.

Sustainable effect of individualised sun protection advice on sun protection behaviour: a 10-year follow-up of a randomised controlled study in primary care

Background

In the light of increasing skin cancer incidences worldwide, preventive measures to promote sun protection in individuals with risky sun habits have continued relevance and importance.

Aim

To report the long-term effect of individualised sun protection advice given in primary health care (PHC), on sun habits and sun protection behaviour.

Design & setting

In 2005, 309 PHC patients were enrolled in a randomised controlled study performed in a Swedish PHC setting.

Method

At baseline, the study participants completed a Likert scale-based questionnaire, mapping sun habits, propensity to increase sun protection, and attitudes towards sun exposure, followed by randomisation into three intervention groups, all receiving individualised sun protection advice: in Group 1 (n = 116) by means of a letter, and in Group 2 (n = 97) and 3 (n = 96) communicated personally by a GP. In Group 3, participants also underwent a skin ultraviolet-sensitivity phototest, with adjusted sun protection advice based on the result. A repeated questionnaire was administered after 3 and 10 years.

Results

Statistically significant declines were observed in all groups for sun exposure mean scores over time. When using a cumulative score, according to the Sun Exposure and Protection Index (SEPI), significantly greater decrease in SEPI mean score was observed in Groups 2 and 3 (GP), compared to Group 1 (letter); P<0.01. The addition of a phototest did not enhance the effect of the intervention.

Conclusion

Individualised sun protection advice mediated verbally by the GP can lead to sustained improvement of sun protective behaviour.

Walking and Sun Protective Behaviors: Cross-Sectional Associations of Beneficial Health Factors

Sun protective behaviors and physical activity have the potential to reduce cancer risk. Walking is the most common type of physical activity in the United States, but it is unclear whether sun protective behaviors differ by categories of walking, such as leisure versus transportation walking. We examined whether sun protective behaviors varied by category or duration of walking in the 2015 National Health Interview Survey (N = 26,632), age ≥ 18 years. We used logistic regression to estimate sunscreen use, sun avoidance, and sun protective clothing use by four categories of walking (no reported walking, transportation only, leisure only, or walking for both) and separately for walking duration for the general population and sun-sensitive individuals. Prevalence of sunscreen use varied across walking categories and the odds of use were higher with longer walking duration for transportation and leisure compared to those who reported no walking. Sun avoidance varied across walking categories and the odds of avoidance were lower with longer duration leisure but not transportation walking. Sun protective clothing varied across walking categories and the odds of use were higher for longer duration transportation, but not leisure walking. Data on the concurrence of walking and sun protection is needed to further understand the relationship between these health behaviors. By examining leisure and transportation walking, we found variations in sun protective behaviors that may provide important insight into strategies to increase sun protection while promoting physical activity.

Regular Sunscreen Use and Risk of Mortality: Long-Term Follow-up of a Skin Cancer Prevention Trial

INTRODUCTION

Sunscreen is widely used to protect the skin from harmful effects of sun exposure. However, there are concerns that sunscreens may negatively affect overall health. Evidence of the general safety of long-term regular sunscreen use is therefore needed.

METHODS

The effect of long-term sunscreen use on mortality was assessed over a 21-year period (1993-2014) among 1,621 Australian adults who had participated in a randomized skin cancer prevention trial of regular versus discretionary sunscreen use (1992-1996). In 2018, an intention-to-treat analysis was conducted using Cox proportional hazards regression to compare death rates in people who were randomized to apply sunscreen daily for 4.5years, versus randomized to use sunscreen at their usual, discretionary level. All-cause mortality and deaths resulting from cardiovascular disease, cancer, and other causes were considered.

RESULTS

In total, 160 deaths occurred in the daily sunscreen group compared with 170 deaths in the discretionary sunscreen group (hazard ratio=0.94, 95% CI=0.76, 1.17); 59vs 76 cardiovascular disease deaths (hazard ratio=0.77, 95% CI=0.55, 1.08), 63vs 58 cancer deaths (hazard ratio=1.09, 95% CI=0.76, 1.57), and 45vs 44 deaths resulting from other causes (hazard ratio=1.02, 95% CI=0.67, 1.54) occurred respectively.

CONCLUSIONS

Regular use of a sun protection factor 16 sunscreen on head, neck, arms, and hands for 4.5years did not increase mortality.

Content analysis of Twitter chatter about indoor tanning

Twitter may be useful for learning about indoor tanning behavior and attitudes. The objective of this study was to analyze the content of tweets about indoor tanning to determine the extent to which tweets are posted by people who tan, and to characterize the topics of tweets. We extracted 4,691 unique tweets from Twitter using the terms "tanning bed" or "tanning salon" over 7 days in March 2016. We content analyzed a random selection of 1,000 tweets, double-coding 20% of tweets (κ = 0.74, 81% agreement). Most tweets (71%) were by tanners (n = 699 individuals) and included tweets expressing positive sentiment about tanning (57%), and reports of a negative tanning experience (17%), burning (15%), or sleeping in a tanning bed (9%). Four percent of tweets were by tanning salon employees. Tweets posted by people unlikely to be tanners (15%) included tweets mocking tanners (71%) and health warnings (29%). The term "tanning bed" had higher precision for identifying individuals who engage in indoor tanning than "tanning salon"; 77% versus 45% of tweets captured by these search terms were by individuals who engaged in indoor tanning, respectively. Extrapolating to the full data set of 4,691 tweets, findings suggest that an average of 468 individuals who engage in indoor tanning can be identified by their tweets per day. The majority of tweets were from tanners and included reports of especially risky habits (e.g., burning, falling asleep). Twitter provides opportunity to identify indoor tanners and examine conversations about indoor tanning.

Human health in relation to exposure to solar ultraviolet radiation under changing stratospheric ozone and climate

The Montreal Protocol has limited increases in the UV-B (280-315 nm) radiation reaching the Earth's surface as a result of depletion of stratospheric ozone. Nevertheless, the incidence of skin cancers continues to increase in most light-skinned populations, probably due mainly to risky sun exposure behaviour. In locations with strong sun protection programs of long duration, incidence is now reducing in younger age groups. Changes in the epidemiology of UV-induced eye diseases are less clear, due to a lack of data. Exposure to UV radiation plays a role in the development of cataracts, pterygium and possibly age-related macular degeneration; these are major causes of visual impairment world-wide. Photodermatoses and phototoxic reactions to drugs are not uncommon; management of the latter includes recognition of the risks by the prescribing physician. Exposure to UV radiation has benefits for health through the production of vitamin D in the skin and modulation of immune function. The latter has benefits for skin diseases such as psoriasis and possibly for systemic autoimmune diseases such as multiple sclerosis. The health risks of sun exposure can be mitigated through appropriate sun protection, such as clothing with both good UV-blocking characteristics and adequate skin coverage, sunglasses, shade, and sunscreen. New sunscreen preparations provide protection against a broader spectrum of solar radiation, but it is not clear that this has benefits for health. Gaps in knowledge make it difficult to derive evidence-based sun protection advice that balances the risks and benefits of sun exposure.

Sun exposure among teenage and young adult cancer survivors in the United Kingdom

Skin cancers are a common form of second malignant neoplasm among teenage and young adult cancer survivors (TYACS). The Children's Oncology Group specifies that TYACS should adhere to safe sun practices and be screened for skin cancer annually. Cross-sectional self-report data collected by our group indicate over a third of TYACS (n = 229; mean age: 19.8 years) intentionally sunbathe, with many reporting sunburn. TYACS sunbathing, sunburn, and sunbed use are similar to the general population (P > 0.05). These data suggest TYACS require intervention to limit sun exposure and improve their sun safety habits.

Development in sunburn 2007-2015 and skin cancer projections 2007-2040 of campaign results in the Danish population

Exposure to ultraviolet radiation is the main risk factor for skin cancer. Denmark has one of the highest incidences of skin cancer in the world. In 2007, a long-term sun safety campaign was launched in Denmark. We have evaluated the effects on prevalence of sunburn and modeled the effects on future melanoma incidence.Sunburn was evaluated by annual cross-sectional surveys representative for the Danish population on age, gender, and region. During 2007-2015, survey data were collected for 33.315 Danes. Cutaneous Melanoma incidences were modeled in the Prevent program, using population projections, historic incidence, sunburn exposure, and relative risk of sunburn on melanoma.The prevalence of sunburn in Denmark was reduced with 1% annually during 2007 to 2015. The campaign is estimated to have reduced the number of skin cancer cases with 664 annually in 2040 and 14.326 totally during 2007 to 2040. If the campaign was terminated in 2015 and sunburn rates return to precampaign level there would be no annual reduction in 2040 while in total the reduction would be 4.024 cases for 2007 to 2040. A continuous campaign until 2040 would yield annual reductions of 2.121 cases by 2040 and a total of 29.729 cases for the entire period.We have showed the value of prevention and the value of long-term planning in prevention campaigning. Sunburn use was reduced significantly during 2007-2015 and further reductions are possible. Consequently, we predict significant fewer skin cancer cases as anticipated.

Frequent Indoor Tanners' Beliefs About Indoor Tanning and Cessation

PURPOSE

Indoor tanning is associated with an increased risk of developing skin cancer. In the United States, nearly 1 in 5 white women aged 18 to 25 are indoor tanners. This study elicited beliefs about tanning indoors and quitting/cutting back on indoor tanning.

DESIGN

Semi-structured interviews.

PARTICIPANTS AND SETTING

Forty 18- to 25-year-old white females who engaged in frequent indoor tanning participated in either in-person or telephone interviews. Most were college students from southeastern Pennsylvania and Delaware.

METHOD

A semi-structured interview was used to elicit beliefs about indoor tanning and quitting or cutting back. Data analyses using NVivo and multiple coders identified key themes about going and quitting/cutting back on indoor tanning.

RESULTS

Key themes stated as reasons for indoor tanning included improving physical appearance, social acceptance, increased confidence, and happiness. The main themes identified as advantages of quitting/cutting back on indoor tanning were to decrease skin cancer risk and save money. Perceived disadvantages of quitting/cutting back included themes of concerns about being pale and a decline in self-confidence. The prospect of saving money and warm weather were seen as facilitating quitting/cutting back.

CONCLUSION

Findings suggest the necessity of addressing appearance concerns, psychological benefits associated with feeling more attractive, and short-term gains such as saving money. These findings provide a foundation for developing effective anti-indoor tanning communication.

Skin cancer interventions across the cancer control continuum: A review of experimental evidence (1/1/2000-6/30/2015) and future research directions

While the general efficacy of skin cancer interventions have been reviewed, employing the cancer control continuum would be useful to identify research gaps at specific cancer control points. We characterized the intervention evidence base for specific behavioral targets (e.g., tanning, sun protection, screening) and clinically related targets (e.g., sunburn, skin exams, cancers) at each point in the cancer control continuum. The review included articles published from 1/1/2000-6/30/15 that had an experimental design and targeted behavioral intervention in skin cancer (e.g., specific behaviors or clinically related targets). The search yielded 86 articles, including seven dissemination studies. Of the 79 non-dissemination studies, 57 exclusively targeted primary prevention behaviors, five exclusively targeted screening, 10 targeted both detection and prevention, and eight addressed cancer survivorship. Among prevention studies (n=67), 29 (43%) targeted children and 38 (57%) targeted adults. Of the 15 screening studies, nine targeted high-risk groups (e.g., men aged ≥50 years) and six targeted the general population. Although research has focused on skin cancer prevention, empirically validated interventions are still needed for youth engaged in indoor tanning and for behavioral interventions to pursue change in clinically relevant targets. Research must also address detection among those at highest risk for skin cancer, amelioration of emotional distress attendant to diagnosis and treatment, and survivorship concerns. We discuss essential qualities and opportunities for intervention development and translational research to inform the field.

Environmental effects of ozone depletion, UV radiation and interactions with climate change: UNEP Environmental Effects Assessment Panel, update 2017

The Environmental Effects Assessment Panel (EEAP) is one of three Panels of experts that inform the Parties to the Montreal Protocol. The EEAP focuses on the effects of UV radiation on human health, terrestrial and aquatic ecosystems, air quality, and materials, as well as on the interactive effects of UV radiation and global climate change. When considering the effects of climate change, it has become clear that processes resulting in changes in stratospheric ozone are more complex than previously held. Because of the Montreal Protocol, there are now indications of the beginnings of a recovery of stratospheric ozone, although the time required to reach levels like those before the 1960s is still uncertain, particularly as the effects of stratospheric ozone on climate change and vice versa, are not yet fully understood. Some regions will likely receive enhanced levels of UV radiation, while other areas will likely experience a reduction in UV radiation as ozone- and climate-driven changes affect the amounts of UV radiation reaching the Earth's surface. Like the other Panels, the EEAP produces detailed Quadrennial Reports every four years; the most recent was published as a series of seven papers in 2015 (Photochem. Photobiol. Sci., 2015, 14, 1-184). In the years in between, the EEAP produces less detailed and shorter Update Reports of recent and relevant scientific findings. The most recent of these was for 2016 (Photochem. Photobiol. Sci., 2017, 16, 107-145). The present 2017 Update Report assesses some of the highlights and new insights about the interactive nature of the direct and indirect effects of UV radiation, atmospheric processes, and climate change. A full 2018 Quadrennial Assessment, will be made available in 2018/2019.

Assessment of temperature and ultraviolet radiation effects on sunburn incidence at an inland U.S. Beach: A cohort study

BACKGROUND

Increases in outdoor temperature may lead to increases in sunburn, outdoor exposure, and skin cancer in human populations.

OBJECTIVE

This study aimed to quantify sunburn incidence and risk for Ohio beachgoers exposed to varying outdoor conditions.

METHODS

Sunburn incidence data were obtained through a prospective cohort study at East Fork Lake (Cincinnati, Ohio, USA). Recruitment occurred over 26 weekend days. Beach interviews and follow-up telephone interviews obtained exposure and health information. New sunburns were self-reported 8-9 days post-enrollment. Survey data were paired with ultraviolet radiation (UVR) index and temperature data for statistical analysis.

RESULTS

Among 947 beachgoers, new sunburns were reported in 18% of swimmers. Sunburn incidence was associated with temperature (odds ratio = 1.2; 95% CI: 1.1 - 1.4) and UVR index (odds ratio = 1.6; 95% CI: 1.0 - 2.5) in models adjusted for water exposure, arrival time, and beach visit frequency. Some evidence of a temperature+UVR interaction was observed.

LIMITATIONS

Exposure and sunburn data were self-reported without clinical diagnosis and date of onset. The follow-up period enabled sunburns to be reported from a variety of days rather than only the beach visit day thereby limiting interpretation. Sun protection behaviors were not evaluated.

CONCLUSIONS

Temperature and UVR influence sunburn frequency. Temperature, however was more strongly associated with sunburn in beachgoers than the nearest measured UVR index, suggesting future investigations are needed to better understand how temperature effects sunburn development. Interventions for decreasing sunburn are needed.

Pediatric Predispositional Genetic Risk Communication: Potential Utility for Prevention and Control of Melanoma Risk as an Exemplar

Predispositional genetic testing among minor children is intensely debated due to the potential benefits and harms of providing this type of genetic information to children and their families. Existing guidelines on pediatric genetic testing state that predispositional testing could be appropriate for minors if preventive services exist that mitigate children's risk for or severity of the health condition in question. We use the example of hereditary melanoma to illustrate the rationale for and potential application of genetic risk communication for an adult-onset cancer to a pediatric population where childhood behaviors may reduce risk of disease later in life. We draw from the adult melanoma genetic risk communication and pediatric health behavior change literatures to suggest ways in which genetic test reporting and complementary education could be delivered to children who carry a hereditary risk for melanoma and their families in order to foster children's engagement in melanoma preventive behaviors. Genetic discoveries will continue to yield new opportunities to provide predispositional genetic risk information to unaffected individuals, including children, and could be delivered within programs that provide personalized and translational approaches to cancer prevention.

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.

Novel serum metabolomics-based approach by gas chromatography/triple quadrupole mass spectrometry for detection of human skin cancers: Candidate biomarkers

Skin cancer incidence rates are continuing to rise; however, if detected at an early stage, they can be cured with minimally invasive treatment. Therefore, the identification of novel and robust biomarkers for the early detection of skin cancer is required to improve the quality of life of the patient after treatment. In the present study, we aimed to identify novel biomarkers of skin cancers. We carried out serum metabolomics using gas chromatography/triple quadrupole mass spectrometry for two types of skin cancer: squamous cell carcinoma and melanoma. The changes in the expression of metabolites compared with healthy volunteers were analyzed by principal component analysis. Among all 118 metabolites, 27 in patients with squamous cell carcinoma and 33 in patients with melanoma showed significant changes in comparison with healthy volunteers. Principal component analysis showed that both skin cancer groups could be distinguished from the healthy volunteers group. We further investigated the specific metabolites most useful for these distinctions. In the squamous cell carcinoma group, these metabolites were glycerol, 4-hydroxybenzoic acid, sebacic acid, fucose and suberic acid. In the melanoma group, these metabolites were glutamic acid, sebacic acid, suberic acid, 4-hydroxybenzoic acid and phenylalanine. The present study identified several metabolites that were distinct for certain skin cancer types, which could potentially be used as diagnostic biomarkers leading to novel clinical management strategies.

Unintended Sunburn: A Potential Target for Sun Protection Messages

New Zealand (NZ) has the highest melanoma incidence rate in the world. Primary prevention efforts focus on reducing sunburn incidence and increasing sun protective practices in the population. However, sunburn from excessive ultraviolet radiation (UVR) remains common. To reduce sunburn incidence, it is important to examine those individuals who experience unintended sunburn. This study aims to use data from the NZ Triennial Sun Protection Survey to describe respondents who were not intending to tan but were sunburnt after outdoor UVR exposure. Information on sociodemographics, concurrent weather conditions, sun protection attitudes and knowledge, and outdoor behaviour was also collected. The results showed 13.5% of respondents' experienced unintended sunburn during the survey weekend but had not attempted to obtain a tan that summer. Respondents who reported unintended sunburn were more likely than others to have been near water and in unshaded areas, used sunscreen, had higher SunSmart knowledge scores, had lower positive attitudes towards tanning, and were outdoors for a longer duration with less body coverage. As sunburn was unintended these respondents' outdoor sun protective behaviours may be amenable to change. Future public health initiatives should focus on increasing sun protection (clothing and shade) and reducing potential barriers to sun protection.