13. Cancers attributable to solar (ultraviolet) radiation exposure in the UK in 2010

Organic UV filters: Occurrence, risks and (anti-)progestogenic activities in samples from the Czech aquatic environment and their bioaccumulation in fish

The occurrence, environmental risks and contribution of organic UV filters to detected (anti-)progestogenic activities were examined in samples of wastewater treatment plant influents and effluents, various surface waters and fish from the Czech Republic. Of the 20 targeted UV filters, 15 were detected in the WWTP influent samples, 11 in the effluents, and 13 in the surface water samples. Benzophenone-3, benzophenone-4, and phenyl benzimidazole sulfonic acid (PBSA) were found in all water samples. Octocrylene, UV-327 and 4-methylbenzylidene camphor exceeded the risk quotient of 1 at some sites. In the anti-progestogenic CALUX assay, 10 out of the 20 targeted UV filters were active. Anti-progestogenic activities reaching up to 7.7 ng/L, 3.8 ng/L, and 4.5 ng/L mifepristone equivalents were detected in influents, effluents, and surface waters, respectively. UV filters were responsible for up to 37 % of anti-progestogenic activities in influents. Anti-progestogenic activities were also measured in fish tissues from the control pond and Podroužek (pond with the highest number of detected UV filters) and ranged from 2.2 to 9.5 and 1.9 to 8.6 ng/g dw mifepristone equivalents, respectively. However, only benzophenone was found in fish, but it does not display anti-progestogenic activity and thus could not explain the observed activities.

Initiation of Cancer: The Journey From Mutations in Somatic Cells to Epigenetic Changes in Tissue-resident VSELs

Multiple theories exist to explain cancer initiation, although a consensus on this is crucial for developing effective therapies. 'Somatic mutation theory' suggests that mutations in somatic cells during DNA repair initiates cancer but this concept has several attached paradoxes. Research efforts to identify quiescent cancer stem cells (CSCs) that survive therapy and result in metastasis and recurrence have remained futile. In solid cancers, CSCs are suggested to appear during epithelial-mesenchymal transition by the dedifferentiation and reprogramming of epithelial cells. Pluripotent and quiescent very small embryonic-like stem cells (VSELs) exist in multiple tissues but remain elusive owing to their small size and scarce nature. VSELs are developmentally connected to primordial germ cells, undergo rare, asymmetrical cell divisions and are responsible for the regular turnover of cells to maintain tissue homeostasis throughout life. VSELs are directly vulnerable to extrinsic endocrine insults because they express gonadal and gonadotropin hormone receptors. VSELs undergo epigenetic changes due to endocrine insults and transform into CSCs. CSCs exhibit genomic instability and develop mutations due to errors during DNA replication while undergoing excessive proliferation and clonal expansion to form spheroids. Thus tissue-resident VSELs offer a connection between extrinsic insults and variations in cancer incidence reported in various body tissues. To conclude, cancer is indeed a stem cell disease with mutations occurring as a consequence. In addition to immunotherapy, targeting mutations, and Lgr5 + organoids for developing new therapeutics, targeting CSCs (epigenetically altered VSELs) by improving their niche and epigenetic status could serve as a promising strategy to treat cancer.

Enhancing skin lesion classification with advanced deep learning ensemble models: a path towards accurate medical diagnostics

Skin cancer, including the highly lethal malignant melanoma, poses a significant global health challenge with a rising incidence rate. Early detection plays a pivotal role in improving survival rates. This study aims to develop an advanced deep learning-based approach for accurate skin lesion classification, addressing challenges such as limited data availability, class imbalance, and noise. Modern deep neural network designs, such as ResNeXt101, SeResNeXt101, ResNet152V2, DenseNet201, GoogLeNet, and Xception, which are used in the study and ze optimised using the SGD technique. The dataset comprises diverse skin lesion images from the HAM10000 and ISIC datasets. Noise and artifacts are tackled using image inpainting, and data augmentation techniques enhance training sample diversity. The ensemble technique is utilized, creating both average and weighted average ensemble models. Grid search optimizes model weight distribution. The individual models exhibit varying performance, with metrics including recall, precision, F1 score, and MCC. The "Average ensemble model" achieves harmonious balance, emphasizing precision, F1 score, and recall, yielding high performance. The "Weighted ensemble model" capitalizes on individual models' strengths, showcasing heightened precision and MCC, yielding outstanding performance. The ensemble models consistently outperform individual models, with the average ensemble model attaining a macro-average ROC-AUC score of 96 % and the weighted ensemble model achieving a macro-average ROC-AUC score of 97 %. This research demonstrates the efficacy of ensemble techniques in significantly improving skin lesion classification accuracy. By harnessing the strengths of individual models and addressing their limitations, the ensemble models exhibit robust and reliable performance across various metrics. The findings underscore the potential of ensemble techniques in enhancing medical diagnostics and contributing to improved patient outcomes in skin lesion diagnosis.

The role of community pharmacists in primary and secondary prevention of skin cancer: an evaluation of a Flemish skin cancer prevention campaign

BACKGROUND

Skin cancer is a leading form of cancer in Belgium. Prevention of skin cancer by community pharmacists can play a role in increasing awareness and promoting sun protection. However, which persons could be reached by community pharmacists for skin cancer awareness in Belgium and whether this increased awareness is associated with increased sun protection and early detection remains unclear.

METHODS

Demographics of approached persons in Flemish community pharmacies during the months of May-June 2022 and the content of the skin cancer counseling were retrieved from the pharmacy database. Sunscreen purchases and dermatologist visits were evaluated up to 180 days after the skin cancer counseling.

RESULTS

Community pharmacists provided skin cancer counseling to a broad population of visitors (n = 822, 69% females, median age of 59 years Q1-Q3: 44-71 years). During the campaign, 822 visitors received a leaflet with skin cancer prevalence and sunscreen importance. On top of that, 335 visitors (41%) received additional counseling: skin type sensitivity was checked for 198 visitors (24%), typical characteristics of melanoma were discussed with 100 visitors (12%) and 37 visitors (5%) were referred to a physician for further information or concerns regarding a skin spot. Overall, one out of three visitors purchased sunscreen on the day of the counseling (33%, increasing up to 38% after 180 days). Among people under 20 years, this was even higher (51%). Additional counseling increased the likelihood of a dermatologist visit within 180 days (OR = 1.80; 95%CI: 1.12-2.88).

CONCLUSIONS

By providing skin cancer counseling in Belgian community pharmacies, a broad range of citizens was reached and triggered to purchase sunscreen, often on the same day as the counseling. Notably, young people were likely to purchase sunscreen. Citizens receiving additional counseling were more likely to visit a dermatologist within 180 days.

Sun-protective behaviors and sunburn among US adults

Individuals can reduce the risk of developing skin cancer by minimizing ultraviolet sunlight exposure, though recent trends in sun-protective behaviors remain to be investigated. To evaluate sun-protective behaviors and sunburn among US adults. We analyzed data from the 2010, 2015, and 2020 National Health Interview Survey (NHIS), an annual, cross-sectional survey conducted by the US Census Bureau. Multivariable regression models were stratified by demographic variables and constructed to evaluate sun-protective behaviors and sunburn avoidance across time. From 2010 through 2020, US adults had significantly increased prevalence of seeking shade (p value, 0.003), wearing wide-brimmed hats (< 0.001), wearing long-sleeved shirts (< 0.001), using sunscreen (< 0.001), and avoiding sunburns (< 0.001) and significantly decreased prevalence of sun avoidance (< 0.001). Disparities in sun-protective behaviors also exist among different sexes, ages, education levels, and those reporting higher sun sensitivity. This cross-sectional study found that by 2020, US adults had an increased prevalence of wearing sun-protective clothing and sunscreen use, though decreased prevalence of sun avoidance. Although certain sun-protective behaviors have become more prevalent, the incidence of skin cancer continues to rise. Efforts to understand drivers of sun-protective behaviors and targeted intervention efforts are needed.

Skin Cancer-Related Health Behavior Interventions in the Context of the Health Belief Model

The incidence of skin cancer is increasing around the world every year. Although there are many reasons for the occurrence of skin cancer, UV radiation caused by sunlight is seen as the most important factor. Therefore, reducing exposure to UV radiation should be a top priority for skin cancer prevention. In addition, different demographic features also affect the amount of UV exposure. These include age, gender and professional groups. On the other hand, people can be exposed to UV radiation voluntarily. Sunbathing or using tanning devices can be shown as examples for this. For these reasons, interventions to reduce exposure to UV radiation should focus on demographic features and the desire to tan. At the same time, it is emphasized in the literature that theory-based and systematic interventions are more effective than others. In this context, we think that the Health Belief Model, which is an effective psychosocial model for health behaviors, will be useful in developing sun protection behaviors. In this review, interventions based on the Health Belief Model in the context of tanning behavior, age, gender, and outdoor activities for the prevention of skin cancer and the improvement of sun protection behaviors have been discussed.

Objectively-Assessed Ultraviolet Radiation Exposure and Sunburn Occurrence

Ultraviolet radiation (UVR) exposure is the primary modifiable risk factor for melanoma. Wearable UVR sensors provide a means of quantifying UVR exposure objectively and with a lower burden than self-report measures used in most research. The purpose of this study was to evaluate the relationship between detected UVR exposure and reported sunburn occurrence. In this study, a UVR monitoring device was worn by 97 parent-child dyads during waking hours for 14 days to measure instantaneous and accumulated UVR exposure. The results showed that the participants' total UVR exposure was associated with reported sunburn after adjusting for Fitzpatrick skin type and geographic location. It was observed that one standard erythemal dose (SED) increase in the participants' daily total UVR exposure was associated with reported sunburn (an odds ratio (OR) of 1.26 with a 95% CI of 1.13 and 1.41, and p < 0.001 for parents and an OR of 1.28 with a 95% CI of 1.12 and 1.47, and p < 0.001 for children). A one-SED increase in the participants' UVR exposure from 10 am to 4 pm was also associated with reported sunburn (an OR of 1.31 with a 95% CI of 1.15 and 1.49, and p < 0.001 for parents and an OR of 1.33 with a 95% CI of 1.12 and 1.59, and p = 0.001 for children). We found that elevated UVR exposure recordings measured by the UVR sensor were associated with reported sunburn occurrence. Future directions for wearable UVR sensors may include their use as an intervention tool to support in-the-moment sunburn prevention.

Imaging Mass Spectrometry for the Classification of Melanoma Based on BRAF/NRAS Mutational Status

Mutations of the oncogenes v-raf murine sarcoma viral oncogene homolog B1 (BRAF) and neuroblastoma RAS viral oncogene homolog (NRAS) are the most frequent genetic alterations in melanoma and are mutually exclusive. BRAF V600 mutations are predictive for response to the two BRAF inhibitors vemurafenib and dabrafenib and the mitogen-activated protein kinase kinase (MEK) inhibitor trametinib. However, inter- and intra-tumoral heterogeneity and the development of acquired resistance to BRAF inhibitors have important clinical implications. Here, we investigated and compared the molecular profile of BRAF and NRAS mutated and wildtype melanoma patients' tissue samples using imaging mass spectrometry-based proteomic technology, to identify specific molecular signatures associated with the respective tumors. SCiLSLab and R-statistical software were used to classify peptide profiles using linear discriminant analysis and support vector machine models optimized with two internal cross-validation methods (leave-one-out, k-fold). Classification models showed molecular differences between BRAF and NRAS mutated melanoma, and identification of both was possible with an accuracy of 87-89% and 76-79%, depending on the respective classification method applied. In addition, differential expression of some predictive proteins, such as histones or glyceraldehyde-3-phosphate-dehydrogenase, correlated with BRAF or NRAS mutation status. Overall, these findings provide a new molecular method to classify melanoma patients carrying BRAF and NRAS mutations and help provide a broader view of the molecular characteristics of these patients that may help understand the signaling pathways and interactions involving the altered genes.

A novel hybrid meta-heuristic contrast stretching technique for improved skin lesion segmentation

The high precedence of epidemiological examination of skin lesions necessitated the well-performing efficient classification and segmentation models. In the past two decades, various algorithms, especially machine/deep learning-based methods, replicated the classical visual examination to accomplish the above-mentioned tasks. These automated streams of models demand evident lesions with less background and noise affecting the region of interest. However, even after the proposal of these advanced techniques, there are gaps in achieving the efficacy of matter. Recently, many preprocessors proposed to enhance the contrast of lesions, which further aided the skin lesion segmentation and classification tasks. Metaheuristics are the methods used to support the search space optimisation problems. We propose a novel Hybrid Metaheuristic Differential Evolution-Bat Algorithm (DE-BA), which estimates parameters used in the brightness preserving contrast stretching transformation function. For extensive experimentation we tested our proposed algorithm on various publicly available databases like ISIC 2016, 2017, 2018 and PH², and validated the proposed model with some state-of-the-art already existing segmentation models. The tabular and visual comparison of the results concluded that DE-BA as a preprocessor positively enhances the segmentation results.

A Hybrid Preprocessor DE-ABC for Efficient Skin-Lesion Segmentation with Improved Contrast

Rapid advancements and the escalating necessity of autonomous algorithms in medical imaging require efficient models to accomplish tasks such as segmentation and classification. However, there exists a significant dependency on the image quality of datasets when using these models. Appreciable improvements to enhance datasets for efficient image analysis have been noted in the past. In addition, deep learning and machine learning are vastly employed in this field. However, even after the advent of these advanced techniques, a significant space exists for new research. Recent research works indicate the vast applicability of preprocessing techniques in segmentation tasks. Contrast stretching is one of the preprocessing techniques used to enhance a region of interest. We propose a novel hybrid meta-heuristic preprocessor (DE-ABC), which optimises the decision variables used in the contrast-enhancement transformation function. We validated the efficiency of the preprocessor against some state-of-the-art segmentation algorithms. Publicly available skin-lesion datasets such as PH2, ISIC-2016, ISIC-2017, and ISIC-2018 were employed. We used Jaccard and the dice coefficient as performance matrices; at the maximum, the proposed model improved the dice coefficient from 93.56% to 94.09%. Cross-comparisons of segmentation results with the original datasets versus the contrast-stretched datasets validate that DE-ABC enhances the efficiency of segmentation algorithms.

Skin cancer diagnosis based on deep transfer learning and sparrow search algorithm

Skin cancer affects the lives of millions of people every year, as it is considered the most popular form of cancer. In the USA alone, approximately three and a half million people are diagnosed with skin cancer annually. The survival rate diminishes steeply as the skin cancer progresses. Despite this, it is an expensive and difficult procedure to discover this cancer type in the early stages. In this study, a threshold-based automatic approach for skin cancer detection, classification, and segmentation utilizing a meta-heuristic optimizer named sparrow search algorithm (SpaSA) is proposed. Five U-Net models (i.e., U-Net, U-Net++, Attention U-Net, V-net, and Swin U-Net) with different configurations are utilized to perform the segmentation process. Besides this, the meta-heuristic SpaSA optimizer is used to perform the optimization of the hyperparameters using eight pre-trained CNN models (i.e., VGG16, VGG19, MobileNet, MobileNetV2, MobileNetV3Large, MobileNetV3Small, NASNetMobile, and NASNetLarge). The dataset is gathered from five public sources in which two types of datasets are generated (i.e., 2-classes and 10-classes). For the segmentation, concerning the “skin cancer segmentation and classification” dataset, the best reported scores by U-Net++ with DenseNet201 as a backbone architecture are 0.104, $$94.16\%$$ 94.16 % , $$91.39\%$$ 91.39 % , $$99.03\%$$ 99.03 % , $$96.08\%$$ 96.08 % , $$96.41\%$$ 96.41 % , $$77.19\%$$ 77.19 % , $$75.47\%$$ 75.47 % in terms of loss, accuracy, F1-score, AUC, IoU, dice, hinge, and squared hinge, respectively, while for the “PH2” dataset, the best reported scores by the Attention U-Net with DenseNet201 as backbone architecture are 0.137, $$94.75\%$$ 94.75 % , $$92.65\%$$ 92.65 % , $$92.56\%$$ 92.56 % , $$92.74\%$$ 92.74 % , $$96.20\%$$ 96.20 % , $$86.30\%$$ 86.30 % , $$92.65\%$$ 92.65 % , $$69.28\%$$ 69.28 % , and $$68.04\%$$ 68.04 % in terms of loss, accuracy, F1-score, precision, sensitivity, specificity, IoU, dice, hinge, and squared hinge, respectively. For the “ISIC 2019 and 2020 Melanoma” dataset, the best reported overall accuracy from the applied CNN experiments is $$98.27\%$$ 98.27 % by the MobileNet pre-trained model. Similarly, for the “Melanoma Classification (HAM10K)” dataset, the best reported overall accuracy from the applied CNN experiments is $$98.83\%$$ 98.83 % by the MobileNet pre-trained model. For the “skin diseases image” dataset, the best reported overall accuracy from the applied CNN experiments is $$85.87\%$$ 85.87 % by the MobileNetV2 pre-trained model. After computing the results, the suggested approach is compared with 13 related studies.

Defining novel causal SNPs and linked phenotypes at melanoma-associated loci

A number of genomic regions have been associated with melanoma risk through genome-wide association studies; however, the causal variants underlying the majority of these associations remain unknown. Here, we sequenced either the full locus or the functional regions including exons of 19 melanoma-associated loci in 1959 British melanoma cases and 737 controls. Variant filtering followed by Fisher's exact test analyses identified 66 variants associated with melanoma risk. Sequential conditional logistic regression identified the distinct haplotypes on which variants reside, and massively parallel reporter assays provided biological insights into how these variants influence gene function. We performed further analyses to link variants to melanoma risk phenotypes and assessed their association with melanoma-specific survival. Our analyses replicate previously known associations in the melanocortin 1 receptor (MC1R) and tyrosinase (TYR) loci, while identifying novel potentially causal variants at the MTAP/CDKN2A and CASP8 loci. These results improve our understanding of the architecture of melanoma risk and outcome.

An Overview of Ultraviolet-Protective Clothing

Protection from harmful ultraviolet radiation (UVR) can be achieved in a multitude of ways: sunscreen, chemical laundering additives, regular clothing, and photoprotective clothing. While sunscreen remains a popular sun-protective method, research has shown that its long-term use can lead to serious neurological, endocrine, and developmental consequences. Chemical laundering additives have been marketed as a means to absorb or reflect UVR, but data on its efficacy tests are not currently available, and skin contact with these chemicals may prove to be harmful. All clothing, regular or sun-protective, confers sun protection through dyes, weave patterns, and textile materials. However, photoprotective clothing is generally rated as more protective on the ultraviolent protection factor (UPF) scale and garment protection factor (GPF) scale. A combination of photoprotective clothing and sunscreen use over non-covered body areas is likely to be the optimal way for sun protection with minimal risk. However, further research on the topic is needed to gain deeper insights into it.

Loss of 'Epidermal Melanin Unit' Integrity in Human Skin During Melanoma-Genesis

Cutaneous melanoma can be a most challenging neoplasm of high lethality, in part due to its extreme heterogeneity and characteristic aggressive and invasive nature. Indeed, its moniker 'the great masquerader' reflects that not all melanomas are created equal in terms of their originating cellular contexts, but also that melanoma cells in the malignant tumor can adopt a wide range of different cell states and variable organotropism. In this review, we focus on the early phases of melanomagenesis by discussing how the originating pigment cell of the melanocyte lineage can be influenced to embark on a wide range of tumor fates with distinctive microanatomical pathways. In particular, we assess how cells of the melanocyte lineage can differ by maturation status (stem cell; melanoblast; transiently amplifying cell; differentiated; post-mitotic; terminally-differentiated) as well as by micro-environmental niche (in the stratum basale of the epidermis; within skin appendages like hair follicle, eccrine gland, etc). We discuss how the above variable contexts may influence the susceptibility of the epidermal-melanin unit (EMU) to become unstable, which may presage cutaneous melanoma development. We also assess how unique features of follicular-melanin unit(s) (FMUs) can, by contrast, protect melanocytes from melanomagenesis. Lastly, we postulate how variable melanocyte fates in vitiligo, albinism, psoriasis, and alopecia areata may provide new insights into immune-/non immune-mediated outcomes for melanocytes in cutaneous melanin units.

Sunproofed study protocol: A mixed-methods scoping study of sun safety policies in primary schools in Wales

BACKGROUND

Skin cancer, including melanoma and non-melanoma (keratinocyte), is increasing in incidence in the UK. Accounting for half of all cancers in England and Wales, the disease significantly impacts overstretched dermatology services. Research suggests that 86% of melanoma is preventable with modified sun exposure. Educating children about sun safety in schools can help prevent skin cancer and is recommended by major health organisations. In England, teaching sun safety in primary schools is compulsory, while in Wales this is left to school discretion.

AIMS

Understand how primary schools in Wales are responding to growing skin cancer rates and explore the effectiveness of sun safety policies in schools on knowledge and behaviour.

METHODS

Sunproofed is a mixed-methods scoping study comprising 5 work packages (WP) using survey and routine electronic health record (EHR) data supplemented by qualitative case studies. Objective(s) are to: WP1: Discover if primary schools in Wales have sun safety policies; policy characteristics; determine factors that may influence their presence and identify areas where schools need support. WP2: Determine what EHR data is available regarding the incidence of sunburn in primary school children and the feasibility of using this data to evaluate the impact of sun safety policies. WP3: Understand the impact of sun safety policies on sun-safe knowledge and behaviour amongst children, parents, teachers, and school management; identify barriers and facilitators to schools implementing sun safety policies. WP4: Co-produce guidance regarding sun safety policies and best methods for implementation in schools. WP5: Disseminate guidance and findings widely to ensure impact and uptake.

DISCUSSION

Skin cancer rates are increasing in the UK, straining limited resources. Sunproofed has the potential to inform the development of future prevention activities, both in Wales and beyond. This could reduce the number of skin cancer cases in the future and keep people healthier for longer.

Sunburns and Sun Protection Behaviors among Male Hispanic Outdoor Day Laborers

Individuals who work outside are at increased risk for skin cancer due to excessive exposure to ultraviolet (UV) radiation. Little is known about UV exposures and sun safety practices of outdoor day laborers, who are disproportionately Hispanic. This study identified the correlates of sunburn and sun protection behaviors in a sample of male, Hispanic day laborers (n = 175). More than half of the participants (54.9%) experienced one or more sunburns when working during the past summer, and 62.9% reported having one or more symptoms of heat illness. The frequency of engaging in sun protection behaviors was suboptimal, including sunglasses use (M = 2.68, SD = 1.71), staying in the shade (M = 2.30, SD = 0.94), wearing sunscreen (M = 2.10, SD = 1.39), and wearing a wide-brimmed hat (M = 1.75, SD = 1.32), based on a 5-point scale (1 = never; 5 = always). Lower education level, higher levels of skin sensitivity to the sun, any symptom of heat illness, fewer barriers to wearing a wide-brimmed hat, and not wearing a wide-brimmed hat were associated with a greater number of sunburns. Factors associated with each sun protection behavior varied. Implications and directions for future research are discussed.

Let's talk about sex: a biological variable in immune response against melanoma

As science culture gravitates toward a more holistic inclusion of both males and females in research design, the outlining of sex differences and their respective intersections with disease physiology and pathophysiology should see reciprocal expansion. Melanoma skin cancer, for example, has observed a female advantage in incidence, mortality, and overall survival since the early 1970s. The exact biological mechanism of this trend, however, is unclear and further complicated by a layering of clinical variables such as skin phototype, age, and body mass index. In this perspective, we highlight epidemiological evidence of sex differences in melanoma and summarize the landscape of their potential origin. Among several biological hallmarks, we make a note of sex‐specific immune profiles—along with divergent hormonal regulation, social practices, DNA damage and oxidative stress responses, body composition, genetic variants, and X‐chromosome expression—as probable drivers of disparity in melanoma initiation and progression. This review further focuses the conversation of sex as an influencing factor in melanoma development and its potential implication for disease management and treatment strategies.

Circadian effects on UV-induced damage and mutations

Skin cancer is the most diagnosed type of cancer in the United States, and while most of these malignancies are highly treatable, treatment costs still exceed $8 billion annually. Over the last 50 years, the annual incidence of skin cancer has steadily grown; therefore, understanding the environmental factors driving these types of cancer is a prominent research-focus. A causality between ultraviolet radiation (UVR) exposure and skin cancer is well-established, but exposure to UVR alone is not necessarily sufficient to induce carcinogenesis. The emerging field of circadian biology intersects strongly with the physiological systems of the mammalian body and introduces a unique opportunity for analyzing mechanisms of homeostatic disruption. The circadian clock refers to the approximate 24-hour cycle, in which protein levels of specific clock-controlled genes (CCGs) fluctuate based on the time of day. Though these CCGs are tissue specific, the skin has been observed to have a robust circadian clock that plays a role in its response to UVR exposure. This in-depth review will detail the mechanisms of the circadian clock and its role in cellular homeostasis. Next, the skin's response to UVR exposure and its induction of DNA damage and mutations will be covered - with an additional focus placed on how the circadian clock influences this response through nucleotide excision repair. Lastly, this review will discuss current models for studying UVR-induced skin lesions and perturbations of the circadian clock, as well as the impact of these factors on human health.

A review on association of fungi with the development and progression of carcinogenesis in the human body

The role and impact of commensal and pathogenic fungi in different parts of the human body are being increasingly appreciated, unveiling the importance of such microorganisms in human health. A key function is the involvement of the mycobiota in cross-kingdom interactions within the microbiome. Any disturbance in the functionality of the microbiota could alter metabolic reactions, have a negative impact on homeostasis or induce diseases. The association of fungi with cancer development is the focus of this review. Several studies have reported direct or indirect involvement of fungal pathogens and mycobiome dysbiosis in induction of carcinogenesis. Most studies focused on cancers of the gastrointestinal tract. However, researchers are now investigating other organs, such as the skin, where the significant results obtained confirm the involvement of fungal pathogens and administration of antifungal drugs in development of cancer. This review gives an overview of the different organs affected and describes the mechanisms used by these eukaryotes or antifungals to induce oncogenesis.

Cutaneous melanoma attributable to UVR exposure in Denmark and Germany

BACKGROUND

Increasing incidence rates of cutaneous melanoma (CM) observed during the last five decades in white populations are largely attributed to increased exposure to solar ultraviolet radiation (UVR), often expressed as population attributable fraction (PAF). Thus, many CMs could be prevented by reducing UVR exposure. The aim of this study was to estimate the PAF of CM attributable to UVR exposure and demographic changes in Denmark and Saarland/Germany for the period 1943 to 2036.

MATERIAL AND METHODS

CM incidence data (ICD-10, C43) for Denmark (1943-2016) and the German Federal State of Saarland (1972-2016) were retrieved from the NORDCAN database and from the Saarland Cancer Registry. The number of CMs attributable to UVR exposure was calculated by comparing contemporary or predicted CM incidence rates with CM rates in Denmark during the years 1943-1946.

RESULTS

In Denmark, the proportion of CM cases attributable to UVR exposure increased from around 20% in 1947-1951 to 96% in 2012-2016; in the Federal State of Saarland, it increased from 50% in 1972-1976 to 90% in 2012-2016. Until 2032-2036, the PAF is expected to rise in Denmark to 97% and in the Saarland to 92%. The demographic influence, on the other hand, is rather small.

CONCLUSIONS

More than 90% of all CM in Germany and Denmark are attributable to UVR exposure, and in principle, preventable. These findings underline the need for primary prevention strategies, aiming to increase the awareness of melanoma and its risk factors and to promote behavioural changes that decrease sun exposure.

National and subnational burden of disease attributable to occupational exposure to solar ultraviolet radiation (SUVR) in Iran, 2005-2019

Overexposure to solar ultraviolet radiation (SUVR) can cause skin and eye adverse effects for outdoor workers. In this study, the burden of disease induced by occupational exposure to SUVR and its spatiotemporal trend at national and sub-national levels in Iran, 2005-2019 were assessed. The attributable burden of disease was assessed using the following five datasets: (1) distribution of occupational exposure to SUVR, (2) total incidences and deaths of health outcomes of SUVR exposure, (3) population attributable fractions of the health outcomes of SUVR exposure, (4) age-gender distribution of outdoor workers, and (5) disability-adjusted life year (DALY) calculation constants. During 2005-2019, the attributable DALYs increased from 2442 to 2907 and the attributable DALY rate (per 100,000 workers) slightly decreased from 11.94 to 11.91. The share of YLL in the attributable burden of disease was in the range of 43%-46%. Out of nine causes, about 90% of the attributable burden of disease in 2019 was related to cataracts (29.9%), malignant skin melanoma (27.4%), squamous-cell carcinoma (18.6%), and sunburn (17.2%). During the study period, the attributable DALY rate in women increased by 60.95% (from 5.04 to 8.11) and in men decreased by 2.06% (from 13.03 to 12.76). The total attributable DALYs and DALY rate rose by age during 2005-2019. The contributions of population growth, risk-deleted DALY rates, exposure risk, and population age structure in temporal changes of the attributable burden of disease were 19.27%, 9.13%, -1.35%, and -14.8%, respectively. The three highest attributable DALY rates in 2019 were observed in South Khorasan (21.28), Chahar Mahal and Bakhtiari (17.42), and Kordestan (17.26), respectively. The preventive interventions against SUVR overexposure, regular screenings, and early treatments with an emphasis on occupations with continuous sun exposure and provinces with increasing attributable DALY rates should be considered in the occupational health action plan in the country.

The Mutagenic Impact of Environmental Exposures in Human Cells and Cancer: Imprints Through Time

During life, the DNA of our cells is continuously exposed to external damaging processes. Despite the activity of various repair mechanisms, DNA damage eventually results in the accumulation of mutations in the genomes of our cells. Oncogenic mutations are at the root of carcinogenesis, and carcinogenic agents are often highly mutagenic. Over the past decade, whole genome sequencing data of healthy and tumor tissues have revealed how cells in our body gradually accumulate mutations because of exposure to various mutagenic processes. Dissection of mutation profiles based on the type and context specificities of the altered bases has revealed a variety of signatures that reflect past exposure to environmental mutagens, ranging from chemotherapeutic drugs to genotoxic gut bacteria. In this review, we discuss the latest knowledge on somatic mutation accumulation in human cells, and how environmental mutagenic factors further shape the mutation landscapes of tissues. In addition, not all carcinogenic agents induce mutations, which may point to alternative tumor-promoting mechanisms, such as altered clonal selection dynamics. In short, we provide an overview of how environmental factors induce mutations in the DNA of our healthy cells and how this contributes to carcinogenesis. A better understanding of how environmental mutagens shape the genomes of our cells can help to identify potential preventable causes of cancer.

Difference in Sun Exposure Habits Between Individuals with High and Low Risk of Skin Cancer

Background

Skin cancer incidence is rapidly increasing. The main risk factor, sun exposure, can be modified. Informational campaigns can be effective in raising skin cancer awareness and target the high-risk population. Still, sun exposure habits in people at high risk of skin cancer are not well-known.

Objective

To investigate if and how sun exposure habits differ between low-risk and high-risk individuals.

Methods

During the Swedish Euromelanoma campaign of 2018, questionnaires were collected containing information regarding sun exposure habits and risk factors for skin cancer. Data on 4,141 participants was used to investigate the association between risk factors and sun exposure habits.

Results

A fair skin type and a previous history of skin cancer were significantly associated with enhanced sun protective behavior. Family history of skin cancer, childhood sunburns and the presence of large/atypical nevi had no effect on sun exposure habits. Going on sunny holidays were particularly unaffected by being at high risk of skin cancer.

Conclusion

Individuals at high risk of developing skin cancer showed suboptimal sun exposure habits and harmful traveling behaviors. We suggest that future skin cancer campaigns inform on accurate sun protection behavior during sunny holidays and associated risk factors. Risk factors such as childhood sunburns, numerous common and large/atypical nevi, as well as family history of skin cancer seem to be less recognized by the population.

Changing epidemiology and age-specific incidence of cutaneous malignant melanoma in England: An analysis of the national cancer registration data by age, gender and anatomical site, 1981-2018

Background

The incidence of cutaneous malignant melanoma, which is mostly attributable (86%) to UV radiation exposure, has been steadily increasing over the past four decades in predominantly fair-skinned populations. Although public health campaigns are increasing sun-protective behaviour in England, their effect on melanoma incidence is largely unknown. We conducted a retrospective population-based cohort study to examine whether there have been changes in the epidemiology of melanoma in England during the past four decades.

Methods

Individual level data for patients diagnosed with melanoma in England during 1981–2018 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by three age categories (0–34, 35–64, 65+ years), gender and anatomical site during the seven five-year time periods (1981–85 to 2011–15) and the recent three-year period (2016–18). The percentage change in incidence was calculated as change in the average incidence rate from the first (1981–85) to the last time period (2016–18). The Average Annual Percentage Change (AAPC) was estimated using the slope of the linear trend line fitted to the incidence rates by year of diagnosis.

Findings

During the 38-year period (1981–2018), a total of 265,302 cases of melanoma (45.7% males, 54.3% females) were registered in England. The average annual number of cases increased from 837/year in 1981–85 to 6963/year in 2016–18 in males (+732%), and from 1609/year in 1981–85 to 6952/year in 2016–18 in females (+332%). In the young age-group (0–34 years), the average annual incidence rates initially increased from 1981–85 to 2001–05 and then stabilised during the recent period (2006–18). In the middle age group (35–64 years), the rates increased by +332% (AAPC, 10.4%) in males (from 5.6/100,000 in 1981–85 to 24.2/100,000 in 2016–18) and +185% (AAPC, 5.7%) in females (from 10.2/100,000 in 1981–85 to 29.1/100,000 in 2016–18); and in the old age-group (65+ years) the rates increased by +842% (AAPC, 25.7%) in males (from 9.6/100,000 in 1981–85 to 90.4/100,000 in 2016–18) and +381% (AAPC, 11.2%) in females (from 12.5/100,000 in 1981–85 to 60.1/100,000 in 2016–18). The largest increase in incidence in both males and females was observed for melanoma of the trunk (+817%, AAPC, 24.8% in males and +613%, AAPC, 18.3% in females), followed by melanoma of upper limb (+750%, AAPC, 22.9% in males and 518%, AAPC, 15.5% in females).

Interpretation

It appears that the incidence of melanoma among young people in England has stabilised (or levelled off) in recent decades, whereas it continues to increase substantially in older population. These findings suggest that public health campaigns targeted at children/adolescents/parents may be favourably influencing melanoma incidence. The steeper increase in incidence in males is consistent with their relatively greater sun exposure and poor sun-protective behaviour. All the available evidence suggests that the enormous increase in the melanoma of the trunk and upper limb, since the 1980s, is most likely due to increasing trend in intermittent high intensity recreational UV radiation exposure (e.g. sunbathing, holidaying in places with strong sunlight, indoor tanning).

Funding

This work was supported by Brighton and Sussex Medical School (BSMS).

Circadian clock protein BMAL1 regulates melanogenesis through MITF in melanoma cells

Solar ultraviolet B radiation (UVB) is one of the leading causes of various skin conditions, including photoaging, sunburn erythema, and melanoma. As a protective response, the skin has inbuilt defense mechanisms, including DNA repair, cell cycle, apoptosis, and melanin synthesis. Though DNA repair, cell cycle, and apoptosis are clock controlled, the circadian mechanisms associated with melanin synthesis are not well understood. Using human melanocytes and melanoma cells under synchronized clock conditions, we observed that the microphthalmia-associated transcription factor (MITF), a rate-limiting protein in melanin synthesis, is expressed rhythmically with 24-hr periodicity in the presence of circadian clock protein, BMAL1. Furthermore, we demonstrated that BMAL1 binds to the promoter region of MITF and transcriptionally regulates its expression, which positively influences melanin synthesis. Finally, we report that an increase in melanin levels due to BMAL1 overexpression protects human melanoma cells from UVB. In conclusion, our studies provide novel insights into the mechanistic role of the circadian clock in melanin synthesis and protection against UVB-mediated DNA damage and genomic instability.

Randomized controlled trial of the mySmartSkin web-based intervention to promote skin self-examination and sun protection among individuals diagnosed with melanoma

Adherence to regular, thorough skin self-examination (SSE) and consistent sun protection behaviors among melanoma survivors is relatively low. This study reports on the impact of an online intervention, called mySmartSkin (MSS), on engagement in SSE and sun protection behaviors among melanoma survivors, as well as the mediators of the intervention effects. The intervention was compared with usual care (UC), and primary outcomes were assessed at 24 and 48 weeks. Short-term outcomes were also evaluated at 8 weeks postbaseline. Results demonstrate a significant effect on SSE and sun protection. At all three follow-up assessments, the proportion of participants reporting conducting a thorough SSE in the time since the previous assessment was significantly greater in MSS than in UC. In addition, both multivariate and univariate analyses indicated that engagement in sun protection behaviors was significantly higher in MSS than UC at 24 weeks, but the effect on sun protection at 48 weeks was significant only in multivariate analyses. Beneficial effects of MSS were significantly mediated by knowledge about melanoma and characteristics of suspicious lesions, as well as self-efficacy. Participant engagement in MSS was satisfactory, with approximately two-thirds of participants completing at least two of the three core components. Content was rated as highly trusted, easy to understand, easy to navigate, and helpful. In conclusion, MSS illustrated significant and durable effects on SSE and mixed results on sun protection. Future studies should consider ways to further enhance treatment effects and engagement in MSS.

Sun Protection Outreach Teaching by Students (SPOTS)-Evaluating the Efficacy of Skin Cancer Prevention Education for Adolescents

BACKGROUND

The Sun Protection Outreach Teaching by Students (SPOTS) program addresses an unmet need by training medical students to teach adolescents about skin cancer prevention and early detection.

OBJECTIVE

To measure (1) changes in adolescents' knowledge, attitudes, and behaviors regarding sun protection and (2) the impact on medical students' confidence in skin cancer preventive counseling.

METHODS

Pre-SPOTS and 1-month post-SPOTS program surveys were completed by adolescent participants and medical student instructors.

RESULTS

Amongst adolescent students, analysis of 1,142 pre-program surveys and 618 post-program surveys revealed statistically significant improvements in knowledge, attitudes, and behaviors. Among the favorable results, 26%, 41%, and 20% improvements over baseline were observed in SPF knowledge, preference for natural untanned skin, and intent to wear sunscreen, respectively (p < .001). One-third of adolescents reported having tried to increase sunscreen use. Amongst medical students, analysis of 78 pre-teaching and 74 post-teaching surveys revealed an increase in feeling "very confident" in counseling patients, from 23% pre-teaching to 82% post-teaching (p < .001).

CONCLUSION

SPOTS demonstrated a dual benefit to adolescents and medical students. The program is available for dermatologists to implement in their communities.

Ultraviolet radiation and risk of cutaneous melanoma and squamous cell carcinoma in males and females in the Norwegian Offshore Petroleum Workers cohort

BACKGROUND

Increased risk of cutaneous melanoma and squamous cell carcinoma (SCC) has been reported among petroleum workers, but few studies include females, exposure data on ultraviolet radiation (UVR), and potential confounding factors. We aimed to examine UVR exposure in relation to risk of melanoma and SCC among male and female offshore petroleum workers. We also examined the association between UVR exposure and melanoma (Breslow) thickness.

METHODS

The Norwegian Offshore Petroleum Workers (NOPW) cohort (n = 27,917) holds information on sunbathing, indoor tanning, sunburns, sunscreen use, and other lifestyle factors recorded in 1998. Linkage to the Cancer Registry of Norway gave information on cancer diagnosis through 2017. We used Cox and logistic regression to estimate hazard ratios (HRs) of skin cancer and odds ratios (OR) of thick (≥1 mm) melanomas, respectively, with 95% confidence intervals (CIs).

RESULTS

Melanoma risk increased with increasing frequency of sunbathing after age 20 (ptrend  = 0.031), sunburn average intensity (ptrend  = 0.028), and sunscreen use (HR = 2.16; 95% CI: 1.42 -3.27 for almost always vs. never/rarely). The risk of thick melanoma was inversely associated with sunbathing frequency after age 20 (OR = 0.38; 95% CI: 0.16 - 0.90 for ≥4 weeks/year vs. 1 week/year). SCC risk increased with increasing frequency of indoor tanning after age 20 (HR = 2.72; 95% CI: 1.22 - 6.05 for ≥3 times/months vs. never), sunburn average intensity (ptrend  < 0.001), and sunscreen use (ptrend  < 0.001).

CONCLUSIONS

Our results support associations between UVR exposure and skin cancer risk in male and female offshore petroleum workers. This occupational group may be especially relevant for targeted sun protection advice.

Correlates of sun protection behaviors among melanoma survivors

BACKGROUND

The study objective was to assess potential correlates of sun protection behaviors among melanoma survivors.

METHODS

Participants were 441 melanoma survivors recruited from three health centers and a state cancer registry in the United States. Sun protection behaviors (sunscreen, shade, protective shirts, and hats) were assessed through an online survey, as were potential correlates (demographic, melanoma risk, knowledge and beliefs, psychological and social influence factors). Hierarchical multiple regression analyses were conducted.

RESULTS

Correlates of sun protection behaviors included education, skin cancer risk factors, melanoma knowledge and beliefs, melanoma worry and distress, physician recommendation for sun protection, injunctive norms, and pro-protection beliefs (e.g., perceived barriers, self-efficacy).

CONCLUSIONS

Future efforts to improve sun safety among melanoma survivors may benefit from targeting individuals with lower education levels, and addressing sun protection social influence, barriers, and self-efficacy.

Epidemiology and Prevention of Cutaneous Cancer

Cutaneous malignancy is becoming an increasing public health burden in terms of morbidity and cost, associated with changing environmental exposures and increased longevity of the general and the immunosuppressed population. Yet the understanding of the scope of this problem is hindered by lack of robust registries for nonmelanoma skin cancer. The risk factor responsible for most of these cancers, exposure to ultraviolet radiation, can be mitigated. However, greater consensus is necessary to enact effective prevention and screening programs. New developments, including identification of biomarkers and use of artificial intelligence, show promise for targeting screening efforts.

Sun Protective Clothing and Sun Avoidance: The Most Critical Components of Photoprotection in Patients With Melanoma

BACKGROUND

Ultraviolet radiation is the main modifiable risk factor for melanoma which can be reduced by avoiding excess sun exposure.

OBJECTIVE

We sought to explore (1) sun protective practices, (2) effectiveness of these sun protective practices, and (3) vitamin D supplementation in patients with melanoma.

METHODS

Using the National Health Interview Survey, the authors conducted a cross-sectional analysis to investigate sun protective behaviors and sunburns among adults with melanoma compared with those without skin cancer. We calculated adjusted odds ratio (aOR), 95% confidence interval (95% CI), and p-values using logistic regression.

RESULTS

Patients with melanoma reported increased use of sun avoidance, shade, sunscreen, long sleeves, and hats, but had similar sunburn rates compared with those without skin cancer. Only sun avoidance and long sleeves were associated with decreased odds of sunburn. Patients with melanoma also reported decreased vitamin D supplementation.

CONCLUSION

Although it is reassuring that patients with melanoma practice sun protective behaviors, this does not always translate into reduced sunburns. Physicians should emphasize the importance of photoprotection, especially sun avoidance and sun protective clothing, to reduce future melanoma risk.

Protection of the Eye from Ultraviolet Radiation Damage Among Adults in Addis Zemen Town, Northwest Ethiopia

BACKGROUND

Ultraviolet radiation is electromagnetic radiation or light having a wavelength of less than 400 nm but greater than 100 nm. Ultraviolet radiation, majorly from sunlight, can potentially damage any organ that is exposed to any part of its spectrum. Aside from the skin, the organ most susceptible to sunlight-induced damage is the eye. Ultraviolet radiation is reported to be the cause of multiple ocular problems ranging from benign conditions like pterygium and pinguecula to ocular malignancies such as basal cell carcinoma which finally leads to visual impairment and blindness. Protection practice is mandatory to avoid the burden of diseases caused by ultraviolet exposure and maximizing the protection measures implementation is important. To maximize this, it is essential to know the current practice and the associated factors affecting the usage of protective devices in the study area.

METHODS

Community-based cross-sectional study was conducted from April to May 2019 on 453 study participants. The study participants were selected through a systematic random sampling method. Data were collected using a pretested structured questionnaire. The analyzed result was summarized and presented using texts, tables and charts. A Chi-square test was applied to assess the significant association.

RESULTS

A total of 430 study subjects were participated and completed the questionnaire with a response rate of 94.92%. The mean age of the study participants was 35.3 (SD±6.68). Two hundred forty-three (56.5%) study participants were males. About 228 (53%) of participants were married, and 356 (82.8%) were Christian in religion. From the total study participants, 173 (40.23%) had good practice in protecting the eye from ultraviolet radiation damages while the remaining 59.77% had poor practice. A significant association was found between sex and protection practice of the eye from ultraviolet radiation damages.

CONCLUSION

The majority of the study participants had poor protection practice of the eye from ultraviolet radiation damages. Improving awareness and protection practice are vital to reduce the burden of ocular abnormalities due to excessive exposure to ultraviolet radiation.

The current burden of non-melanoma skin cancer attributable to ultraviolet radiation and related risk behaviours in Canada

PURPOSE

Ultraviolet radiation (UVR) is an established cause of non-melanoma skin cancer (NMSC)-basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). The aim of this study was to estimate the current burden of BCC and SCC associated with UVR and modifiable UVR behaviours (sunburn, sunbathing, and indoor tanning) in Canada in 2015.

METHODS

The current burden of BCC and SCC associated with UVR was estimated by comparing 2015 incidence rates with rates of less exposed body sites (trunk and lower limbs) after adjusting for estimated surface areas. The burden associated with modifiable UVR behaviours was estimated by using prevalence estimates among Caucasians from the Second National Sun Survey, and relative risks that are generalizable to Canadians from conducting meta-analyses of relevant studies.

RESULTS

We estimated that 80.5% of BCCs and 83.0% of SCCs were attributable to UVR. Adult sunburn was associated with relative risks of 1.85 (95% CI 1.15-3.00) for BCC and 1.41 (95% CI 0.91-2.18) for SCC, while adult sunbathing was associated with relative risks of 1.82 (95% CI 1.52-2.17) for BCC and 1.14 (95% CI 0.53-2.46) for SCC. We estimated that 18.6% of BCCs and 9.9% of SCCs were attributable to adult sunburn, while 28.1% of BCCs were attributable to adult sunbathing. We estimated that 46.2% of BCCs and 17.3% of SCCs were attributable to modifiable UVR behaviours combined.

CONCLUSION

Our results provide quantifiable estimates of the potentially avoidable burden of NMSCs among Canadians. These estimates can be used to motivate prevention efforts in Canada.

Effects of health beliefs, social support, and self-efficacy on sun protection behaviors among medical students: testing of an extended health belief model

Sun protection behaviors (SPB) are important modifiable risk factors for skin cancer. As the most common malignancies in the world, skin cancers account for significant morbidity, mortality, and economic burden. Physicians play a key role in educating patients about proper SPB. Medical education provides the foundation for physician understanding of SPB and future patient education. The Health Belief Model (HBM) is a theoretical model that offers constructs to help explain health behaviors. This cross-sectional study examined a convenience sample of 186 medical student to assess their engagement in SPB through the lens of the 6 HBM constructs and social support. Overall, we found engagement in SPB among our cohort to be low. About 70.4% report never using wide-brimmed hats and only 44.6% often or always use sunscreen. Hierarchical multiple regressions were performed in three blocks to analyze the relationship between the independent variables (HBM constructs and social support) and dependent variable (SPB) after controlling for the influence of demographic covariates. In our health constructs model, beliefs about susceptibility, benefits minus barriers, and self-efficacy were found to be significant predictors of engaging in SPB. Addition of social support in the final model did not significantly improve prediction of SPB engagement. These findings support use of educational programs based on HBM for the improvement of SPB among medical students.

Sex differences in the association between tumor growth and T cell response in a melanoma mouse model

Epidemiological evidence suggests that females have an advantage over males in cases of melanoma incidence, progression, and survival. However, the biological mechanisms underlying these sex differences remain unclear. With the knowledge that females generally have a more robust immune system than males, we investigated sex differences in melanoma progression in a B16-F10/BL6 syngeneic mouse model. We observed significantly less tumor volume and growth rate over 14 days in female mice compared to male mice. Furthermore, higher populations of CD4⁺ and CD8⁺ T cells, which indicate adaptive immune responses, were found in the circulating blood and tumors of females and corresponded with less tumor growth, and vice versa in males. Our results highlight a mouse model that represents melanoma progression in the human population and displays a higher immune response to melanoma in females compared to males. These findings suggest that the immune system may be one of the mechanisms responsible for sex differences in melanoma.

Actual causes of death in Alaska

We estimated 2011–2015 Alaska mortality from modifiable behavioural risk factors using relative risks, hazard ratios, and population attributable fraction estimates from a comprehensive review of peer-reviewed literature; prevalence estimates from government reports; as well as data from the Alaska Department of Environmental Conservation for 2011–2015. To identify the number of deaths attributable to specified risk factors, we used mortality data from the Alaska Division of Public Health, Health Analytics & Vital Records Section. Data included actual reported deaths of Alaska residents for 2011–2015 that matched relevant underlying International Classification of Diseases and Related Health Problems 10th Revision codes. The actual causes of death in Alaska in 2011–2015 were estimated to be overweight/physical inactivity (20% of all deaths, 26% of Alaska Native deaths), smoking (18%/18%), alcohol consumption (9%/13%), firearms (4%/4%), and drug use (3%/3%). Other actual causes of death included microbial agents (3%/4%), motor vehicles (2%/2%), and environmental pollution (1%/1%). This updated methodology reveals that overweight/physical inactivity was the leading cause of death in Alaska, followed closely by smoking. Just three preventable causes made up almost 60% of all deaths, and almost 70% of deaths among Alaska Native people, both highlighting disparities and underscoring prevention needs.

Stage-specific incidence trends of melanoma in an English region, 1996-2015: longitudinal analyses of population-based data

The aim of this study was to examine temporal trends in overall and stage-specific incidence of melanoma. Using population-based data on patients diagnosed with melanoma in East Anglia, England, 1996-2015, we estimated age-standardized time trends in annual incidence rates for each stage at diagnosis. Negative binomial regression was used to model trends over time adjusted for sex, age group and deprivation, and to subsequently examine variation in stage-specific trends by sex and age group. The age-standardized incidence increased from 14 to 29 cases/100 000 persons (i.e. 4% annually). Increasing incidence was apparent across all stages but was steepest for stage I [adjusted annual increase: 5%, 95% confidence interval (CI): 5-6%, and more gradual for stage II-IV disease (stage II: 3%, 95% CI: 2-4%; stage III/IV: 2%, 95% CI: 1-3%)]. Stage II-IV increase was apparent in men across age groups and in women aged 50 years or older. Increases in incidence were steeper in those aged 70 years or older, and in men. The findings suggest that both a genuine increase in the incidence of consequential illness and a degree of overdiagnosis may be responsible for the observed increasing incidence trends in melanoma in our population during the study period. They also suggest the potentially lower effectiveness of public health awareness campaigns in men and older people.

In vitro phototherapeutic effects of indolenine-based mono- and dithiosquaraine cyanine dyes against Caco-2 and HepG2 human cancer cell lines

Photodynamic therapy is a noninvasive approach for the treatment of oncological and nononcological diseases which has attempted to address the shortcomings and disadvantages of conventional cancer therapies. Given the scarcity of photosensitizers that exhibit desirable characteristics for its potential application in this therapeutic strategy, the main aims of this work were the study of the photophysical and photochemical properties, and the in vitro photobiological activity of several squaraine cyanine dyes. Thus, herein, the synthesis of indolenine-based N-methyl and N-ethyl mono- and dithiosquaraine dyes, the study of their spectroscopical properties, aggregation behavior, photodegradation and singlet oxygen production ability, and the further application of the previously synthesized dyes in colorectal adenocarninoma and hepatocellular carcinoma cell lines to evaluate their phototherapeutic effects, are described. Thionation significantly favored the ability to singlet oxygen production, and moderate photostability was observed for squaraine and monothionated dyes. Squaraine and monothiosquaraine cyanine dyes showed high promise within the tested concentration range regarding their potential application as cancer photodynamic therapy photosensitizers. Squaraine dyes' monothionation resulted in the preparation of compounds with poor photocytotoxicity, which was an undesirable effect on their phototherapeutic application.

A cross-sectional survey of prevalence and correlates of sunscreen use among a rural Tri-State Appalachian population

Over five million people are diagnosed with skin cancers each year. With the sun's ultraviolet radiation exposure being the major risk factor for all skin cancers, sunscreen use is a vital preventative measure. However, in the US, sunscreen use remains inadequate. Furthermore, research regarding sunscreen use amongst rural populations has been particularly sparse. To identify the prevalence of sunscreen use and identify correlates thereof, a cross-sectional study was conducted on a sample of patients from rural Tri-State Appalachia. A total of 212 patients participated in this study. Findings showed that young individuals, females and those with higher educational attainment were more likely to utilize sunscreen. Furthermore, individuals with skin types prone to burning were four times as likely to utilize sunscreen. Overall, sunscreen use amongst residents in the Tri-State area was low, emphasizing the need for targeted interventions to prevent the incidence of skin cancer amongst this population.

The association between pesticide use and cutaneous melanoma: a systematic review and meta-analysis

BACKGROUND

The incidence of cutaneous melanoma (CM), the deadliest form of skin cancer, has gradually increased in the last decades among populations of European origin. Epidemiological studies suggested that farmers and agricultural workers are at an increased risk of CM because they were exposed to pesticides. However, little is known about the relationship between pesticides and CM.

OBJECTIVES

To investigate the association between exposure to pesticides and CM by systematically reviewing the literature. Secondary aim was to determine the categories of pesticides mainly involved in CM development.

METHODS

A systematic review of the literature was performed up to September 2018 using MEDLINE, Embase and Web of Science. Studies assessing CM risk in licensed pesticide applicators were considered. Strict criteria were established to select independent studies and risk estimates; random effect models, taking into account heterogeneity, were applied. A pooled risk estimate for CM was calculated for the use of each type of pesticide and type of exposure. Between-study and estimate heterogeneity was assessed and publication bias investigated.

RESULTS

A total of nine studies (two case-controls and seven cohorts) comprising 184 389 unique subjects were included. The summary relative risks for the categories 'herbicides - ever exposure', 'insecticides - ever exposure', 'any pesticide - ever exposure' and 'any pesticide - high exposure' resulted 1.85 [95% confidence interval (CI): 1.01, 3.36], 1.57 (95% CI: 0.58, 4.25), 1.31 (95% CI: 0.85, 2.04) and 2.17 (95% CI: 0.45, 10.36), respectively. Herbicides and insecticides had no between-study heterogeneity (I2  = 0%), while a significant heterogeneity (I2  > 50%) was detected for the high exposure to any pesticide. No indication for publication bias was found.

CONCLUSIONS

Individuals exposed to herbicides are at an increased risk of CM. Future properly designed observational studies are required to confirm this finding.

Skin cancer-related knowledge, attitudes, beliefs, and practices among the population in Gulf Cooperation Council countries: a systematic search and literature review

Skin cancers are the most common malignancies diagnosed worldwide. In Gulf Cooperation Council (GCC) countries, skin cancer remains a significant health burden. Multiple studies have attempted to elucidate patient knowledge and attitudes regarding skin cancer risks and behavioral interventions to reduce risks. A systematic literature search of relevant articles was conducted in PubMed, ScienceDirect, and the Saudi Digital Library databases. A narrative analysis of relevant study results was conducted. A total of 12 studies were reviewed across GCC. These studies revealed common themes among GCC populations. Many study participants were aware that excess sun exposure represents a threat to health and increases cancer risk. Several studies reported sun exposure, with a mean of 19.13 h per week. More studies reported patients engaging in lower or no sunscreen use rather than regular sunscreen use. There are discrepancies in the understanding of sun exposure risk and risk mitigation practices among the study populations. Skin cancer poses a significant burden to patients in GCC countries and improved patient education will enhance population health.

A pilot study of a telehealth family-focused melanoma preventive intervention for children with a family history of melanoma

OBJECTIVE

Melanoma preventive interventions for children with familial risk are critically needed because ultraviolet radiation (UVR) exposure and sunburn occurrence early in life are the primary modifiable risk factors for melanoma. The current study examined the feasibility and acceptability of a new, family-focused telehealth intervention for children with familial risk for melanoma and their parents. The study also explored changes in child sun protection and risk behaviors, sunburn occurrence, and objectively measured UVR exposure.

METHODS

This was a prospective study with a single-group design (n = 21 parent-child dyads, children ages 8-17). Dyads were asked to participate in three in-person assessments and three live video teleconference intervention sessions.

RESULTS

The intervention was feasibly delivered, and the intervention content was acceptable to parents and children. The intervention was associated with improvements in child use of certain sun protection strategies over time and declines in child UVR exposure.

CONCLUSIONS

A telehealth-delivered,family-focused melanoma preventive intervention was feasibly delivered and was acceptable to parent-child dyads. Future melanoma preventive interventions for this at-risk population could incorporate eHealth technologies to facilitate improvements in use of sun protection and monitoring of UVR exposure. This trial was registered with Clinicaltrials.gov, number NCT02846714.