Association between cutaneous melanoma incidence rates among white US residents and county-level estimates of solar ultraviolet exposure

The risk of ultraviolet exposure for melanoma in Fitzpatrick skin types I-IV: A 20-year systematic review with meta-analysis for sunburns

Within the last two decades, no studies have comprehensively reviewed the risk of varying types of ultraviolet (UV) exposure on melanoma in fairer skinned individuals. Our research objective was to determine whether or not there was a change in the risk of UV exposure with development of melanoma in Fitzpatrick skin types I-IV based on more recent data over the past 20 years. We performed a systematic review from January 2002 to December 2021 analysing UV exposure and melanoma risk in Fitzpatrick type I-IV individuals. Out of 19,852 studies, 26 met inclusion criteria. Data spanned subjects from national and multinational cohorts (USA, Europe, Australia, Asia and South America). Twenty studies (77%, 20/26) identified a significant association between UV exposure and melanoma incidence. Sunburn was the most commonly assessed risk factor. Sunburn studies encompassed 3417 melanoma and found positive significant odds ratios (OR [95% CI]) in 11 out of 13 studies, ranging from 1.23 [1.01-1.49] to 8.48 [4.35-16.54]. Pooled analysis of the risk of melanoma with sunburn history found an unadjusted odds ratio of 1.66 [1.40-1.97] and adjusted odds ratio of 1.23 [1.04-1.46]. Cumulative sun exposure, measured as number of hours of sun exposure or calculated UV flux, was the second most common risk factor, encompassing 913 melanomas with positive significant ORs ranging from 1.1 [1.0-1.2] to 5.2 [2.1-12.5]. For other forms of UV exposure, a majority of studies showed an association with UV index (6/9), outdoor leisure activity (3/3) and left-sided laterality (1/1). Overall, UV exposure should continue to be considered a modifiable risk factor for melanoma in individuals of fairer skin.

Frequency and features of malignant tumors clinically mimicking cutaneous cysts: A retrospective chart review

BACKGROUND

Many cutaneous lesions are clinically suspected as "cyst"; however, following histopathological examination, are found to be more significant lesions. Here, we examine the frequency and features of malignancies with cutaneous cysts in the clinical differential.

METHODS

A retrospective study of surgical pathology specimens at the James A. Haley Veterans' Hospital from January 2018 to December 2022 was conducted. Cutaneous specimens containing the clinical diagnosis of "cyst" were included. The clinicopathological features were summarized.

RESULTS

Premalignant or malignant neoplasms accounted for 4.5% of all specimens submitted with cysts in the clinical differential. Most cyst-mimicking cancers were basal cell carcinoma (BCC) or squamous cell carcinoma (SCC); however, cancers with poorer prognoses, such as Merkel cell carcinoma and melanoma, also clinically masqueraded as cysts. The BCCs were predominately nodular, and the SCCs were largely well-differentiated and invasive. Many exhibited clinical signs and symptoms compatible with benign cysts, such as central punctum, pain, and rapid growth. Identified risk factors included history of prior non-melanoma skin cancer diagnosis, previous excision, and immunosuppression.

CONCLUSIONS

Many lesions clinically concerning cutaneous cysts were found to be malignancies following histopathological review. Accordingly, following biopsy all cyst-like lesions should be examined microscopically, especially in certain clinical contexts in which the incidence of skin cancer is increased.

Pediatric Melanoma: Geographic Trends in Incidence, Stage, and Mortality in the United States

INTRODUCTION

Pediatric melanoma is the most commonly diagnosed skin cancer in children, with the annual incidence recently increasing by an average of 2% each year. Ultraviolet (UV) radiation from excessive sun exposure is an important carcinogenic risk factor, with penetration varying greatly throughout the country. Consequently, an individual's geographic location may play a role in how much exposure to high UV index rays they receive throughout their lifetime. The objective of this study was to use the surveillance, epidemiology, and end results SEER database to study geographic trends in incidence, staging, and mortality of pediatric melanoma between 2009 and 2019 and determine their relation to UV index in the United States.

MATERIALS AND METHODS

A retrospective analysis of pediatric patients from 0 to 19 years in the surveillance, epidemiology, and end results 22 registries incidence database (17 states) and 17 registries incidence-based mortality database (12 states) was conducted from 2009 to 2019 based on a diagnosis of melanoma of the skin using the International Classification of Childhood Cancer codes for malignant melanoma. Data regarding patient demographics and incidence, staging, and mortality per state were extracted. Incidence data were geographically mapped and mean UV index distribution from www.epa.gov was superimposed.

RESULTS

Incidence of pediatric melanoma was stratified regionally, with a total of 1665 new cases from 2009 to 2019. The Northeast had 393 new cases, with 244 (62.1%) localized cases, 55 (14.0%) lymph node-invasive and metastatic (advanced) cases, and 6/146 (4.1%) cases of mortality. The Midwest had 209 new cases, with 123 (58.9%) localized cases, 29 (13.9%) advanced cases, and 1/57 (1.8%) case of mortality. The South had 487 new cases, with 224 (46.0%) localized cases, 104 (21.4%) advanced cases, and 8/232 (3.4%) cases of mortality. The West had 576 new cases, with 364 (63.2%) localized cases, 82 (14.2%) advanced cases, and 23/551 (4.2%) cases of mortality. Mean UV index was 4.4 in the Northeast, 4.8 in the Midwest, 7.3 in the South, and 5.5 in the West from 2006 to 2020. The regional difference in incidence was not statistically significant. There was a statistically significant increased number of advanced cases in the South as compared to the Northeast (P = 0.005), West (P = 0.002), and Midwest (P = 0.02), with a significant correlation coefficient of 0.7204 between advanced cases and mean UV index in the South.

CONCLUSIONS

There is a statistically significant increased incidence of lymph node-invasive and metastatic pediatric melanoma cases in the South as compared to the West, Northeast, and Midwest regions of the United States. There is also a significant correlation between the incidence of lymph node-invasive and metastatic pediatric melanoma cases and UV index. In the pediatric population, there is no statistically significant association between total incidence and mortality of melanoma and geographic region. There is an increased prevalence of pediatric melanoma seen in White and female patients. This suggests that an individual's geographic location in the United States during childhood may play a role in their likelihood of malignant melanoma development, advanced-stage melanoma development, and mortality.

Skin Cancer Management: Current Scenario And Future Perspectives

Skin cancer is a life-threatening disease and has caused significant loss to human health across the globe. Its prevalence has been increasing every year and is one of the common malignancies in the case of organ transplant recipients, of which 95% constitute basal cell and squamous cell carcinomas. The prime factor causing skin cancer is UV radiation. Around the 20th century, sunlight was the primary cause of skin cancer. A novel hypothesis by US scientists stated that cutaneous melanoma was mainly due to recurrent exposure to the sun, whereas keratinocyte cancer occurred due to progressive accumulation of sun exposure. Management of skin cancer is done via various approaches, including cryotherapy, radiotherapy, and photodynamic therapy. Post-discovery of X-rays, radiotherapy has proven to treat skin cancers to some extent, but the indications are uncertain since it depends upon the type of tumour and surgical treatment required for the patient. Due to various limitations of skin cancer treatment and increased severity, there is a requirement for cost-effective, novel, and efficient treatment. Various nanocarriers such as SLNs, magnetic nanoparticles, gold nanoparticles, carbon nanotubes, etc., are the potential carriers in the management and prognosis of both non-melanoma and melanoma skin cancer. Various research and review databases and patent reports have been studied, and information compiled to extract the results. The review also discusses the role of various nanocarriers in treating and diagnosing skin cancer.

Metastatic Acral lentiginous melanoma: A case report and review

Of the four subtypes of cutaneous melanoma, acral lentiginous melanoma (ALM) is atypical in its presentation. ALM is a rare melanoma subtype that presents on the volar surfaces of the hand and foot. The difficulty of making an early diagnosis of ALM is highlighted by the case seen in our institution. The dire prognosis associated with ALM is postulated to be not only related to its destructive nature, but also due to a lack of patient awareness and vigilance, inadequate physician awareness, and disparity in healthcare access. We present this as a unique account of an ALM lesion in a 76 year old African-American male presenting originally in the left foot that went misdiagnosed for several years. The original lesion was considered to be an ulcerating left great toe lesion with signs typical of osteomyelitis. These clinical findings were corroborated by radiological x-ray evidence. Upon amputation and biopsy for suspected worsening osteomyelitis five years later, the pathological diagnosis of melanoma was finally made.

Developing indices to identify hotspots of skin cancer vulnerability among the Non-Hispanic White population in the United States

PURPOSE

Skin cancer is the most common, yet oftentimes preventable, cancer type in the United States. Exposure to ultraviolet radiation from sunlight is the most prominent environmental risk factor for skin cancer. Besides environmental exposure, demographic characteristics such as race, age, and socioeconomic status may make some groups more vulnerable. An exploratory spatial clustering method is described for identifying clusters of vulnerability to skin cancer incidence and mortality based on composite indices, which combine data from environmental and demographic risk factors.

METHODS

Based on county-level ultraviolet data and demographic risk factors, two vulnerability indices for skin cancer were generated using an additive percentile rank approach. With these indices, univariate local Moran's I spatial autocorrelation identified significant clusters, or hotspots, of neighboring counties with high overall vulnerability indices. Clusters were identified separately for skin cancer incidence and mortality.

RESULTS

Counties with high vulnerabilities were spatially distributed across the United States in a pattern that generally increased to the South and West. Clusters of counties with high skin cancer incidence vulnerability were mostly observed in Utah and Colorado, even with highly conservative levels of significance. Meanwhile, clusters for skin cancer mortality vulnerability were observed in southern Alabama and west Florida as well as across north Alabama, north Georgia and up through the Tennessee-North Carolina area.

CONCLUSIONS

Future skin cancer research and screening initiatives may use these innovative composite vulnerability indices and identified clusters to better target resources based on anticipated risk from underlying demographic and environmental factors.

Sex disparity in skin carcinogenesis and potential influence of sex hormones

Background

Sex or gender disparity in skin cancer has been documented for a long time at the population level. UV radiation (UVR) is a common environmental risk for all three major types of skin cancer: cutaneous melanoma (CM), basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). The underlying mechanism for sex disparity has been largely attributed to sex‐differentiated behaviour patterns related to UVR. Non‐UVR factors such as intrinsic physiological differences have been suggested but remain understudied.

Aims, Materials and Methods

This review summarizes and compares the known sex differences in three skin cancer types with regard to body site distribution and age influence.

Results

We found a similar age‐dependent sex difference pattern in CM and BCC. Specifically, CM and BCC tend to show higher incidence in young women and old men, with a switching age around menopause. The switching age suggests involvement of sex hormones, which has shown controversial influence on skin cancers at epidemiological level. Literatures regarding sex hormone receptors for oestrogen, androgen and progesterone are summarized for potential explanations at molecular level.

Discussion

Overall, more and more evidence suggests non‐UVR factors such as sex hormones play critical roles in skin cancer (especially CM and BCC), yet solid population and molecular evidence are required. Incidences of skin cancer are increasing which suggests limited effect for the current UVR‐avoidance prevention methods.

Conclusion

Fully understanding the causes of sex disparities in incidence is necessary for developing a comprehensive prevention strategy.

Examination of Laws Allowing Sunscreen Use in Schools in the Context of UV Levels by State

PURPOSE

Sunscreen use provides ultraviolet radiation (UV) protection but is often limited in school settings because sunscreen is classified as an over-the-counter drug product. Some US states have laws allowing students to carry and self-apply sunscreen. We examined these laws in the context of state UV levels.

METHODS

We obtained legislative information through April 2020 from the American Society for Dermatologic Surgery Association website and UV data for years 2005-2015 from Centers for Disease Control and Prevention's National Environmental Public Health Tracking website.

RESULTS

Twenty-three states and District of Columbia have sunscreen laws, including 11 states with UV levels above the median UV level across states. There was no significant association between state UV levels and sunscreen laws.

CONCLUSIONS

The presence of state sunscreen legislation has increased but is not associated with UV levels. Future research could examine the implementation and public health effects of these laws.

Cumulative solar ultraviolet radiation exposure and basal cell carcinoma of the skin in a nationwide US cohort using satellite and ground-based measures

BACKGROUND

Basal cell carcinoma of the skin (BCC) is the most common cancer in populations of European ancestry. Although consistently linked with basal cell carcinoma of the skin in case-control studies, few prospective cohort studies have evaluated the shape of the exposure-response of basal cell carcinoma associated with cumulative radiant solar ultraviolet exposure (UVR).

METHODS

We followed 63,912 white cancer-free US radiologic technologists from entry (1983-1998) to exit (2003-2005) with known ultraviolet irradiance at up to 5 residential locations. Using generalized-additive and relative risk models we analyzed the exposure-response of basal cell carcinomas associated with ambient cumulative ultraviolet radiant exposure using ground-based National Solar Radiation database Average Daily Total Global data and satellite-based National Aeronautics and Space Administration Total Ozone Mapping Spectrometer data.

RESULTS

There were 2151 technologists with an incident primary basal cell carcinoma. Risk of basal cell carcinoma rose with increasing cumulative ultraviolet radiation exposure using both measures, such that 1 MJ cm^- 2 increased basal cell carcinoma risk by 8.48 (95% CI 5.22, 11.09, p < 0.001) and by 10.15 (95% CI 6.67, 13.10, p < 0.001) per 10,000 persons per year using the Average Daily Total Global and Total Ozone Mapping Spectrometer ultraviolet data, respectively; relative risk was likewise elevated. There was some evidence of upward curvature in the cumulative ultraviolet exposure response using both exposure measures with a greater increase in risk of basal cell carcinoma at higher levels of ultraviolet radiation exposure, but less evidence for curvature in relative risk. There are indications of substantial variation of relative risk with time after exposure and age at exposure, so that risk is highest for the period 10-14 years after ultraviolet radiation exposure and for those exposed under the age of 25.

CONCLUSIONS

We observed increases in risk of basal cell carcinoma and a similar exposure-response for ground-based and satellite ultraviolet radiation measures. Our observations suggest that interventions should concentrate on persons with higher levels of ultraviolet radiation exposure.

Multilevel analysis in rural cancer control: A conceptual framework and methodological implications

Rural populations experience a myriad of cancer disparities ranging from lower screening rates to higher cancer mortality rates. These disparities are due in part to individual-level characteristics like age and insurance status, but the physical and social context of rural residence also plays a role. Our objective was two-fold: 1) to develop a multilevel conceptual framework describing how rural residence and relevant micro, macro, and supra-macro factors can be considered in evaluating disparities across the cancer control continuum and 2) to outline the unique considerations of multilevel statistical modeling in rural cancer research. We drew upon several formative frameworks that address the cancer control continuum, population-level disparities, access to health care services, and social inequities. Micro-level factors comprised individual-level characteristics that either predispose or enable individuals to utilize health care services or that may affect their cancer risk. Macro-level factors included social context (e.g. domains of social inequity) and physical context (e.g. access to care). Rural-urban status was considered a macro-level construct spanning both social and physical context, as "rural" is often characterized by sociodemographic characteristics and distance to health care services. Supra-macro-level factors included policies and systems (e.g. public health policies) that may affect cancer disparities. Our conceptual framework can guide researchers in conceptualizing multilevel statistical models to evaluate the independent contributions of rural-urban status on cancer while accounting for important micro, macro, and supra-macro factors. Statistically, potential collinearity of multilevel model predictive variables, model structure, and spatial dependence should also be considered.

Compilation and spatio-temporal analysis of publicly available total solar and UV irradiance data in the contiguous United States

Skin cancer is the most common type of cancer in the United States, the majority of which is caused by overexposure to ultraviolet (UV) irradiance, which is one component of sunlight. National Environmental Public Health Tracking Program at CDC has collaborated with partners to develop and disseminate county-level daily UV irradiance (2005-2015) and total solar irradiance (1991-2012) data for the contiguous United States. UV irradiance dataset was derived from the Ozone Monitoring Instrument (OMI), and solar irradiance was extracted from National Solar Radiation Data Base (NSRDB) and SolarAnywhere data. Firstly, we produced daily population-weighted UV and solar irradiance datasets at the county level. Then the spatial distributions and long-term trends of UV irradiance, solar irradiance and the ratio of UV irradiance to solar irradiance were analyzed. The national average values across all years are 4300 Wh/m2, 2700 J/m2 and 130 mW/m2 for global horizontal irradiance (GHI), erythemally weighted daily dose of UV irradiance (EDD) and erythemally weighted UV irradiance at local solar noon time (EDR), respectively. Solar, UV irradiances and the ratio of UV to solar irradiance all increased toward the South and in some areas with high altitude, suggesting that using solar irradiance as indicator of UV irradiance in studies covering large geographic regions may bias the true pattern of UV exposure. National annual average daily solar and UV irradiances increased significantly over the years by about 0.3% and 0.5% per year, respectively. Both datasets are available to the public through CDC's Tracking network. The UV irradiance dataset is currently the only publicly-available, spatially-resolved, and long-term UV irradiance dataset covering the contiguous United States. These datasets help us understand the spatial distributions and temporal trends of solar and UV irradiances, and allow for improved characterization of UV and sunlight exposure in future studies.

Melanoma Among Non-Hispanic Black Americans

INTRODUCTION

Few studies have examined melanoma incidence and survival rates among non-Hispanic black populations because melanoma risk is lower among this group than among non-Hispanic white populations. However, non-Hispanic black people are often diagnosed with melanoma at later stages, and the predominant histologic types of melanomas that occur in non-Hispanic black people have poorer survival rates than the most common types among non-Hispanic white people.

METHODS

We used the US Cancer Statistics 2001-2015 Public Use Research Database to examine melanoma incidence and 5-year survival among non-Hispanic black US populations.

RESULTS

From 2011 through 2015, the overall incidence of melanoma among non-Hispanic black people was 1.0 per 100,000, and incidence increased with age. Although 63.8% of melanomas in non-Hispanic black people were of unspecified histology, the most commonly diagnosed defined histologic type was acral lentiginous melanoma (16.7%). From 2001 through 2014, the relative 5-year melanoma survival rate among non-Hispanic black people was 66.2%.

CONCLUSION

Although incidence of melanoma is relatively rare among non-Hispanic black populations, survival rates lag behind rates for non-Hispanic white populations. Improved public education is needed about incidence of acral lentiginous melanoma among non-Hispanic black people along with increased awareness among health care providers.

Association Between Sun Protection Behaviors and Sunburn Among U.S. Older Adults

BACKGROUND AND OBJECTIVES

Skin cancer incidence rates are highest among U.S. older adults. However, little is known about sun protection behaviors and sunburn among adults aged 65 years and older.

RESEARCH DESIGN AND METHODS

We used data from the 2015 National Health Interview Survey to examine the association between sun protection behaviors (sun avoidance, wearing protective clothing, and sunscreen use) and likelihood of having experienced sunburn in the past year.

RESULTS

Just over one in ten older adults (13.2%) had experienced sunburn in the past year; sunburn prevalence was nearly twice as high (20.4%) among sun-sensitive older adults. Men, ages 65-69 years, non-Hispanic whites, and those with skin that burns or freckles after repeated sun exposure were more likely to have been sunburned in the past year compared with the respective comparison groups. The only sun protection behavior significantly associated with sunburn was sunscreen use. None of the sun protection behaviors were significantly associated with a decreased risk of sunburn.

DISCUSSION AND IMPLICATIONS

The prevalence of sunburn among older adults suggests opportunities to reduce skin cancer risk within this demographic group by preventing overexposure to the sun. The lack of reduced sunburn risk among those who regularly used sun protection may be related to inadequate or inconsistent use of sun protection or the way the sun protection behaviors were measured. Multi-sector approaches to facilitate sun-safety among older adults are warranted and could include targeted efforts focused on those most likely to get sunburned, including men and those with sun-sensitive skin.

Risk of Kaposi sarcoma after solid organ transplantation in the United States

Due to treatment with immunosuppressive medications, solid organ transplant recipients have elevated risk for Kaposi sarcoma (KS), which is caused by human herpesvirus 8 (HHV8). Other risk factors for KS are poorly understood. We linked the United States solid organ transplant registry with 17 population-based cancer registries to ascertain KS incidence among 244,964 transplant recipients from 1987-2014. To compare incidence rates of KS according to patient and transplant characteristics, we calculated incidence rate ratios (IRRs) using Poisson regression. To compare associations of KS with other skin cancers occurring before or within 12 months of KS diagnosis, we computed odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression. All statistical tests were two-sided. We identified 163 KS cases during follow-up. Among transplant recipients, we found significantly increased risk of KS associated with male sex (IRR = 1.87; 95%CI:1.32,2.71), nonwhite race (IRR = 2.67; 95%CI:1.92,3.72), non-US citizenship (IRR = 2.10; 95%CI:1.19,3.47), lung transplant (IRR = 2.22; 95%CI:1.03,4.24, vs. kidney), and older age at transplant. KS risk decreased significantly with time since transplant and recent calendar year, however, no specific induction or maintenance medication was associated with KS. KS incidence was not significantly associated with ambient ultraviolet radiation (IRR = 1.32 95%CI:0.87,2.02, tertile 3 vs. 1). KS incidence has decreased in recent calendar years. In a cross-sectional sample, we found cutaneous squamous cell carcinoma was associated with KS (OR = 4.83; 95%CI:1.30,14.69). KS risk factors included those potentially associated with HHV8 infection and increased immunosuppression. Our findings suggest that transplant recipients with a non-KS skin cancer may also be at high KS risk.

Improving Assessment of Lifetime Solar Ultraviolet Radiation Exposure in Epidemiologic Studies: Comparison of Ultraviolet Exposure Assessment Methods in a Nationwide U.S. Occupational Cohort

Solar ultraviolet radiation is the primary risk factor for skin cancers and sun-related eye disorders. Estimates of individual ambient ultraviolet irradiance derived from ground-based solar measurements and from satellite measurements have rarely been compared. Using self-reported residential history from 67 189 persons in a nationwide occupational US radiologic technologists' cohort, we estimated ambient solar irradiance using data from ground-based meters and noontime satellite measurements. The mean distance moved from city of longest residence in childhood increased from 137.6 km at ages 13-19 to 870.3 km at ages ≥65, with corresponding increases in absolute latitude difference moved. At ages 20/40/60/80, the Pearson/Spearman correlation coefficients of ground-based and satellite-derived potential solar ultraviolet exposure, using irradiance and cumulative radiant exposure metrics, were high (=0.87-0.92). There was also moderate correlation (Pearson/Spearman correlation coefficients = 0.51-0.60) between irradiance at birth and at last-known address, for ground-based and satellite data. Satellite-based lifetime estimates of ultraviolet radiation were generally 14-15% lower than ground-based estimates, albeit with substantial uncertainties, possibly because ground-based estimates incorporate fluctuations in cloud and ozone, which are incompletely incorporated in the single noontime satellite-overpass ultraviolet value. If confirmed elsewhere, the findings suggest that ground-based estimates may improve exposure assessment accuracy and potentially provide new insights into ultraviolet radiation-disease relationships in epidemiologic studies.

Research Techniques Made Simple: An Introduction to Use and Analysis of Big Data in Dermatology

Big data is a term used for any collection of datasets whose size and complexity exceeds the capabilities of traditional data processing applications. Big data repositories, including those for molecular, clinical, and epidemiology data, offer unprecedented research opportunities to help guide scientific advancement. Advantages of big data can include ease and low cost of collection, ability to approach prospectively and retrospectively, utility for hypothesis generation in addition to hypothesis testing, and the promise of precision medicine. Limitations include cost and difficulty of storing and processing data; need for advanced techniques for formatting and analysis; and concerns about accuracy, reliability, and security. We discuss sources of big data and tools for its analysis to help inform the treatment and management of dermatologic diseases.

Geographic Clusters of Basal Cell Carcinoma in a Northern California Health Plan Population

Importance

Rates of skin cancer, including basal cell carcinoma (BCC), the most common cancer, have been increasing over the past 3 decades. A better understanding of geographic clustering of BCCs can help target screening and prevention efforts.

Objective

Present a methodology to identify spatial clusters of BCC and identify such clusters in a northern California population.

Design, Setting, and Participants

This retrospective study used a BCC registry to determine rates of BCC by census block group, and used spatial scan statistics to identify statistically significant geographic clusters of BCCs, adjusting for age, sex, and socioeconomic status. The study population consisted of white, non-Hispanic members of Kaiser Permanente Northern California during years 2011 and 2012.

Main Outcomes and Measures

Statistically significant geographic clusters of BCC as determined by spatial scan statistics.

Results

Spatial analysis of 28 408 individuals who received a diagnosis of at least 1 BCC in 2011 or 2012 revealed distinct geographic areas with elevated BCC rates. Among the 14 counties studied, BCC incidence ranged from 661 to 1598 per 100 000 person-years. After adjustment for age, sex, and neighborhood socioeconomic status, a pattern of 5 discrete geographic clusters emerged, with a relative risk ranging from 1.12 (95% CI, 1.03-1.21; P = .006) for a cluster in eastern Sonoma and northern Napa Counties to 1.40 (95% CI, 1.15-1.71; P < .001) for a cluster in east Contra Costa and west San Joaquin Counties, compared with persons residing outside that cluster.

Conclusions and Relevance

In this study of a northern California population, we identified several geographic clusters with modestly elevated incidence of BCC. Knowledge of geographic clusters can help inform future research on the underlying etiology of the clustering including factors related to the environment, health care access, or other characteristics of the resident population, and can help target screening efforts to areas of highest yield.

Ultraviolet Radiation and Kaposi Sarcoma Incidence in a Nationwide US Cohort of HIV-Infected Men

Background

Although ultraviolet radiation (UVR) is established as both an inducer of herpes simplex virus reactivation and as the primary risk factor for many common skin cancers, its relationship with human herpes virus 8 (HHV8) infection or risk of Kaposi sarcoma (KS) is unknown.

Methods

Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for the association between ambient UVR, history of nonmelanoma skin cancer (NMSC; as a biomarker of personal cumulative UVR dose), and incidence of first primary KS in a nationwide US cohort of white and African American male veterans infected with HIV between 1986 and 1996 (prior to the widespread availability of treatment) using Cox regression. All statistical tests were two-sided.

Results

Based on discharge records, there were 422 newly diagnosed KS cases among 17 597 HIV-infected veterans. Cohort members with prior NMSC had a statistically significantly increased risk of KS (HR = 8.64, 95% CI = 6.23 to 11.96) in the total population. Risk of KS was higher for quartile 4 vs 1 among the total population (HR = 1.49, 95% CI = 1.02 to 2.16, P_trend UVR quartile [coded 1 to 4] = .02) and among whites (HR = 1.75, 95% CI = 1.11 to 2.78, P_trend = .009), but not among African Americans (HR = 1.23, 95% CI = 0.71 to 2.15, P_trend = .23).

Conclusions

KS risk was elevated among HIV-infected men with NMSC diagnosis and in those living in locations with high ambient UVR at time of HIV diagnosis. Our novel findings suggesting that UVR exposure may increase KS risk warrant further investigation.

Ultraviolet Radiation Exposure and Its Impact on Skin Cancer Risk

OBJECTIVES

To review research and evidence-based resources on skin cancer prevention and early detection and their importance for oncology nurses.

DATA SOURCES

Journal articles, federal reports, cancer surveillance data, behavioral surveillance data.

CONCLUSION

Most cases of skin cancer are preventable. Survivors of many types of cancer are at increased risk of skin cancers.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses can play an important role in protecting their patients from future skin cancer morbidity and mortality.

DCAF4, a novel gene associated with leucocyte telomere length

BACKGROUND

Leucocyte telomere length (LTL), which is fashioned by multiple genes, has been linked to a host of human diseases, including sporadic melanoma. A number of genes associated with LTL have already been identified through genome-wide association studies. The main aim of this study was to establish whether DCAF4 (DDB1 and CUL4-associated factor 4) is associated with LTL. In addition, using ingenuity pathway analysis (IPA), we examined whether LTL-associated genes in the general population might partially explain the inherently longer LTL in patients with sporadic melanoma, the risk for which is increased with ultraviolet radiation (UVR).

RESULTS

Genome-wide association (GWA) meta-analysis and de novo genotyping of 20 022 individuals revealed a novel association (p=6.4×10(-10)) between LTL and rs2535913, which lies within DCAF4. Notably, eQTL analysis showed that rs2535913 is associated with decline in DCAF4 expressions in both lymphoblastoid cells and sun-exposed skin (p=4.1×10(-3) and 2×10(-3), respectively). Moreover, IPA revealed that LTL-associated genes, derived from GWA meta-analysis (N=9190), are over-represented among genes engaged in melanoma pathways. Meeting increasingly stringent p value thresholds (p<0.05, <0.01, <0.005, <0.001) in the LTL-GWA meta-analysis, these genes were jointly over-represented for melanoma at p values ranging from 1.97×10(-169) to 3.42×10(-24).

CONCLUSIONS

We uncovered a new locus associated with LTL in the general population. We also provided preliminary findings that suggest a link of LTL through genetic mechanisms with UVR and melanoma in the general population.

In vivo skin fluorescence imaging in young Caucasian adults with early malignant melanomas

Background

Human cutaneous malignant melanoma (CMM) is an aggressive cancer showing a dramatic worldwide increase in incidence over the past few decades. The most prominent relative epidemiological increase has been disclosed in young women. The aim of the study was to assess the effects of chronic sun exposures in order to rate the extend of melanocytic stimulations in the vicinity of CMM.

Methods

The study was designed to evaluate the melanin distribution and density using ultraviolet light illumination. The present study was performed on surgical excision specimens of thin CMM lesion removed from the upper limbs of 55 Caucasian adults (37 women and 18 men). Two control groups comprised 23 men and 21 women of similar ages who had medium-size congenital melanocytic nevi, also present on the upper limbs. The peritumoral skin was scrutinized using a Visioscan^® VC98 device, revealing the faint mosaic melanoderma (FMM) pattern that grossly indicates early signs of chronic photodamage in epidermal melanin units.

Results

The median extent of relative FMM was significantly higher in the CMM male group. By contrast, the CMM female group showed a reverse bimodal distribution in FMM size. Only 12/37 (32.5%) of the CMM female group had an increased FMM size, whereas 25/37 (67.5%) of females with CMM had a global FMM extent in the normal range, relative to the controls.

Conclusion

Thin CMM supervening in young women appear unrelated to repeat photoexposure. Other mechanisms are possibly involved.

Association of UV index and sunscreen use among White high school students in the United States

BACKGROUND

When used appropriately, sunscreen decreases the amount of ultraviolet (UV) radiation exposure to the skin and is recommended to prevent skin cancer. This study examined the association between annual average UV index and sunscreen use among White, non-Hispanic youth.

METHODS

The 2007 and 2009 national Youth Risk Behavior Survey (YRBS) data were analyzed. The YRBS is a school-based, cross-sectional study that uses a 3-stage cluster sample design to obtain a nationally representative sample of public and private high school students in the United States. Overall response rates were 68% and 72% (N = 14,041 and 16,410, respectively). Logistic regression analyzes, controlling for grade, examined whether annual average (mean) UV index where students attend school, a proxy measure of potential sunlight exposure, was associated with sunscreen use.

RESULTS

Among White male students, as the mean UV index increased, the adjusted odds of never wearing sunscreen increased (adjusted odds ratio, AOR = 1.15 [95% CI = 1.04, 1.27], p < .01) and the adjusted odds of most of the time or always wearing sunscreen decreased (AOR = 0.85 [0.78, 0.94], p < .01). There was no association between sunscreen use and mean UV index among White female students.

CONCLUSION

These findings suggest a need for renewed public health efforts among school, clinical, and public health professionals to promote sunscreen use as part of a comprehensive approach to prevent skin cancer. School and community approaches that passively protect young people from the sun should be considered as a complement to efforts to increase sunscreen use.

Mortality among offspring of women diagnosed with cancer: a population-based cohort study

One in five cancers in women is diagnosed prior to and during a woman's fertile years. Our study evaluates mortality risks in offspring of mothers with history of cancer. From the Swedish Multi-generation Register and the Cancer Register, we identified all 174,893 children whose mother had been diagnosed with cancer between 1958 and 2001. We categorized offspring into those born before (>1 year before), around (within 1 year before and after diagnosis) and after (>1 year after) their mother's cancer diagnosis and compared their risks of death (standardized mortality ratios, SMRs) and causes of death to the background population. Overall, offspring of mothers diagnosed with cancer had no increased mortality risk (SMR, 1.00; 95% confidence interval [CI], 0.97-1.03). Increased mortality risks were found in offspring of mothers with tobacco-related cancers (head and neck, thoracic and cervical) (SMR, 1.23; 95% CI, 1.13-1.33), in children born around their mother's diagnosis (SMR, 1.66; 95% CI, 1.25-2.13) and in children born after their mother's hematopoietic cancer diagnosis (SMR, 2.07; 95% CI, 1.10-3.35). Compared to the background population, children born around their mother's diagnosis were more likely to die of congenital and perinatal conditions. Overall, offspring of women diagnosed with cancer were not at increased risk of death, except for certain subgroups. Timing of pregnancy in relation to diagnosis and cancer site modifies mortality risks in the offspring.

Melanoma in situ in a private practice setting 2005 through 2009: location, lesion size, lack of concern

BACKGROUND

Studies have shown that the incidence of melanoma in situ (MIS) is increasing significantly.

OBJECTIVE

This study analyzes selected clinical and demographic characteristics of MIS cases observed in private dermatology practices in the United States.

METHODS

This study collected 257 MIS cases from 4 private dermatology practices in the United States from January 2005 through December 2009, recording age, gender, anatomic location, lesion size, patient-reported change in lesion, and concern about lesion. Case totals for invasive melanoma during the same period were recorded.

RESULTS

The data collected showed a higher incidence of MIS in sun-exposed areas of older patients, especially men. The median age of patients at the time of MIS detection was 69 years. The most common site for MIS was the head-neck region. The number of MIS cases collected exceeded the number of invasive malignant melanoma cases during the study period, with an observed ratio of 1.35:1.

LIMITATIONS

For 136 patients, data were collected retrospectively for lesion size, location, gender, and age. For these patients, patient-reported change in lesion and concern about lesion were not collected. Patients often did not consent to a full body examination, therefore, it is possible that MIS lesions may have been missed in double-clothed areas.

CONCLUSION

Careful attention to pigmented lesions, even lesions less than 4 mm, on sun-exposed areas, including scalp, trunk, and feet, will facilitate earlier diagnosis of MIS. As only 30.4% of male patients and 50% of female patients had concern about these lesions, it still falls to the dermatologist to discover MIS.

Association of cutaneous melanoma incidence with area-based socioeconomic indicators-United States, 2004-2006

BACKGROUND

Socioeconomic status (SES) has been associated with melanoma incidence and outcomes. Examination of the relationship between melanoma and SES at the national level in the United States is limited. Expanding knowledge of this association is needed to improve early detection and eliminate disparities.

OBJECTIVE

We sought to provide a detailed description of cutaneous melanoma incidence and stage of disease in relationship to area-based socioeconomic measures including poverty level, education, income, and unemployment in the United States.

METHODS

Invasive cutaneous melanoma data reported by 44 population-based central cancer registries for 2004 to 2006 were merged with county-level SES estimates from the US Census Bureau. Age-adjusted incidence rates were calculated by gender, race/ethnicity, poverty, education, income, unemployment, and metro/urban/rural status using software. Poisson multilevel mixed models were fitted, and incidence density ratios were calculated by stage for area-based SES measures, controlling for age, gender, and state random effects.

RESULTS

Counties with lower poverty, higher education, higher income, and lower unemployment had higher age-adjusted melanoma incidence rates for both early and late stage. In multivariate models, SES effects persisted for early-stage but not late-stage melanoma incidence.

LIMITATIONS

Individual-level measures of SES were unavailable, and estimates were based on county-level SES measures.

CONCLUSION

Our findings show that melanoma incidence in the United States is associated with aggregate county-level measures of high SES. Analyses using finer-level SES measures, such as individual or census tract level, are needed to provide more precise estimates of these associations.

Melanoma surveillance in the United States: overview of methods

BACKGROUND

Skin cancer is the most common form of cancer in the United States. Melanoma skin cancer is particularly deadly; more than 8000 US residents die from it each year. Although recent reports suggest that melanoma incidence rates have been increasing, these apparent increases could be caused by an increase in reporting and/or screening, and by an actual increase in the occurrence of melanoma.

OBJECTIVE

In this report, we describe methods used in this supplement to assess the current burden of melanoma in the United States using data from two federal cancer surveillance programs: the Centers for Disease Control and Prevention (CDC) National Program of Cancer Registries and the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results program. We also provide basic descriptive epidemiologic data about melanoma in the United States.

METHODS

Cancer incidence data from population-based cancer registries that participate in the CDC National Program of Cancer Registries and/or the NCI Surveillance, Epidemiology, and End Results Program covering 78% of the US population for 2004 to 2006 were used.

RESULTS

Over 45 thousand melanomas were diagnosed annually, with a rate of 19 cases per 100,000 persons.

LIMITATIONS

Melanoma rates may vary because of differences in reporting, diagnosis, and screening.

CONCLUSION

To our knowledge, the articles in this supplement constitute the first comprehensive examination of the overall burden of melanoma in the United States based on data from a majority of the US population.