- Email: [email protected]
The Struggle for Primary Prevention of Skin Cancer
Editorials and Commentary
The Struggle for Primary Prevention of Skin Cancer Martin A. Weinstock, MD, PhD
S
kin cancer is more common than all other cancers combined in the United States, and several times more common in Australia. This is despite its being among the most preventable types of cancer, with a well-known carcinogen, ultraviolet radiation (UVR), responsible for most cases. What should we do? First we document that UVR is indeed responsible, as has been done over the last several decades.1 Then we publicize this conclusion, conduct public health campaigns to disseminate this information, and encourage practices and policies that will result in reduced incidence. The most comprehensive and sustained campaign of this sort has been conducted in Victoria, Australia, over the past quarter century. The results have been systematically assessed, and key findings are reported in this issue of the American Journal of Preventive Medicine by Dobbinson et al.2 They report that after initial impressive gains in the first decade of assessments, there now appears to be regression or at best no further progress on major indices such as sunburn, sunscreen use, body exposure, and attitudes. The good news is that most of those initial gains have been sustained over these 15 years of assessments; the bad news is that this may not be good enough. The goal is to reduce skin cancer morbidity and mortality. Given the long lag time after UVR exposure that has been associated with most melanomas, and presumably basal cell carcinomas, we do not yet know the ultimate effect of sun-protection campaigns on those actual cancer rates. However, it does appear that squamous cell carcinoma of the skin has a shorter lag period. The epidemiologic evidence for this conclusion is supported by a randomized trial of 4.5 years of consistent sunscreen use that reported a 40% decline in incidence of squamous cell carcinoma of the skin in the intervention group.3,4 Hence the observation that squamous cell carcinoma incidence rates appear to be increasing in the U.S., Europe, and Australia suggests that our prevention efforts may indeed be inadequate.5,6
From the Dermatoepidemiology Unit, Veterans Affairs Medical Center Providence; Department of Dermatology, Rhode Island Hospital; and Departments of Dermatology and Community Health, Brown University, Providence, Rhode Island Address correspondence and reprint requests to: Martin A. Weinstock, MD, PhD, Dermatoepidemiology Unit, VA Medical Center– 111D, 830 Chalkstone Avenue, Providence RI 02908. E-mail: [email protected].
Furthermore, the skin cancer prevention efforts in U.S. populations are not as comprehensive as those in Victoria. We do see evidence of decreased sunburn prevalence in younger teenagers in the U.S.7 However, recent data suggest increases in sunburn prevalence among older teens and adults since the late 1990s.7,8 Here we are, after a quarter century of prevention campaigns; we have not yet reduced our incidence rates of melanoma or keratinocyte carcinomas. We have learned much regarding the factors that distinguish successful from unsuccessful campaigns. Reports of efforts that do not result in better UVR protection continue to appear.9,10 Efforts that succeed in changing behavior are also being documented, such as the recent effort to improve (or, more precisely, to halt the deterioration) of the practices of adolescents with respect to UVR.11 This campaign was notable for its comprehensive, multichannel approach sustained over 2 years. Dobbinson and her co-authors suggest the power of television advertisements as an important component of these multifaceted sustained campaigns. With respect to protection from UVR to reduce skin cancer risk, these studies suggest that effective prevention campaigns don’t come cheap, although these efforts may ultimately be cost effective.12 Beyond the cost, there are challenges to effective skin cancer prevention campaigns in our complex multiple risk factor environment. First, sun-protection campaigns often include advice to avoid the sun or limit time in the sun, which may conflict with other health promotion messages. There are major efforts underway to increase physical activity to combat overweight and obesity, as well as cardiovascular disease and diabetes, among other major health hazards. But moderate or intense physical activity often occurs outdoors during the daytime, with consequent exposure to solar UVR. Coups et al.13 report in this issue that skin cancer risk behavior is indeed associated with higher levels of physical activity in the general U.S. population, but also with overweight and obesity, hence this population would benefit from a further increase in physical activity. The potential conflict between preventing skin cancer and maintaining healthy weight may be reduced or eliminated with focus on the “Slip! Slop! Slap!”—slip on a shirt, slop on the sunscreen, slap on a hat—message that emphasizes sun protection while outdoors instead of an “Avoid. Cover. Screen” message that may conflict with active lifestyle goals. It is
Am J Prev Med 2008;34(2) © 2008 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/08/$–see front matter doi:10.1016/j.amepre.2007.11.002
171
important to evaluate the many potential effects of our activities on overall health promotion. Second, there is an increasing interest in the health benefits of vitamin D, which can be synthesized in human skin exposed to ultraviolet B radiation. The amount of vitamin D that can be obtained from UVR exposure depends on many factors, including the person’s age and skin color, and the weather, time of day, season of year, altitude, and latitude. Hence the sun is a rather unreliable source of this vitamin, as has been documented in multiple contexts.14,15 The more dependable source, and the one generally used in the trials that demonstrate beneficial effects of vitamin D, is the oral vitamin supplement.16 Third, in their analysis of the U.S. National Health Interview Survey (NHIS) data, Coups and his colleagues13 report on the association of multiple skin cancer risk behaviors with other risk behaviors such as smoking and risky drinking, which may facilitate our understanding and interventions. Finally, the $5 billion tanning industry derives much of its profits from the sale of carcinogenic UVR and seeks to increase sales.17 This is not the only industry based on selling carcinogens, and its product is not nearly as toxic as tobacco smoke. Its product has, however, been associated with risk of squamous cell carcinoma18 and melanoma,19 and hence with considerable morbidity and mortality. There is accumulating evidence that UVR exposure in tanning parlors can be addictive. This evidence includes responses among frequent tanners to CAGE (Cut down, Annoyed, Guilty and Eye opener, an alcoholuse disorders screening test) questionnaires indicative of a substance-related disorder20 and withdrawal symptoms after naltrexone administration in a substantial proportion of these individuals.21 With these challenges, the future of successful primary prevention of skin cancer through protection from UVR exposure, whether from the sun or artificial sources, is uncertain. The author has served as a consultant for Schering-Plough, a manufacturer of suncare products.
References 1. International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans: solar and ultraviolet radiation. Vol 55. Lyon, France: IARC, 1992.
172
2. Dobbinson SJ, Wakefield MA, Jamsen K, et al. Weekend sun protection and sunburn in Australia: trends (1997–2002) and association with SunSmart television advertising. Am J Prev Med 2008;34:94 –101. 3. van der Pols JC, Williams GM, Pandeya N, Logan V, Green AC. Prolonged prevention of squamous cell carcinoma of the skin by regular sunscreen use. Cancer Epidemiol Biomarkers Prev 2006;15:2546 – 8. 4. Green A, Williams G, Neale R, et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamouscell carcinomas of the skin: a randomised controlled trial. Lancet 1999; 354:723–9. 5. Staples MP, Elwood M, Burton RC, Williams JL, Marks R, Giles GG. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985. Med J Aust 2006;184:6 –10. 6. Karagas MR, Weinstock MA, Nelson H. Keratinocyte carcinomas (basal cell and squamous cell carcinomas of the skin). In: Schottenfeld D, Fraumeni JF, eds. Cancer epidemiology and prevention. 3d edn. San Francisco: Oxford University Press, 2006:1230 –50. 7. Cokkinides V, Weinstock M, Glanz K, Albano J, Ward E, Thun M. Trends in sunburns, sun protection practices, and attitudes toward sun exposure protection and tanning among U.S. adolescents, 1998 –2004. Pediatrics 2006;118:853– 64. 8. Saraiya M, Balluz L, Wen DK, Joseph DA. Sunburn prevalence among adults: United States, 1999, 2003, and 2004. MMWR Morb Mortal Wkly Rep 2007;56:524 – 8. 9. Dixon HG, Hill DJ, Karoly DJ, Jolley DJ, Aden SM. Solar UV forecasts: a randomized trial assessing their impact on adults’ sun-protection behavior. Health Educ Behav 2007;34:486 –502. 10. Naldi L, Chatenoud L, Bertuccio P, et al. Improving sun-protection behavior among children: results of a cluster-randomized trial in Italian elementary schools. The “SoleSi SoleNo-GISED” Project. J Invest Dermatol 2007;127:1871–7. 11. Olson AL, Gaffney C, Starr P, Gibson JJ, Cole BF, Dietrich AJ. SunSafe in the middle school years: a community-wide intervention to change earlyadolescent sun protection. Pediatrics 2007;119:e247–56. 12. Carter R, Marks R, Hill D. Could a national skin cancer primary prevention campaign in Australia be worthwhile?: An economic perspective. Health Promot Int 1999;14:73– 82. 13. Coups EJ, Manne SL, Heckman CJ. Multiple skin cancer risk behaviors in the U.S. population. Am J Prev Med 2008;34:87–93. 14. Binkley N, Novotny R, Krueger D, et al. Low vitamin D status despite abundant sun exposure. J Clin Endocrinol Metab 2007;92:2130 –5. 15. Gonzalez G, Alvarado JN, Rojas A, Navarrete C, Velasquez CG, Arteaga E. High prevalence of vitamin D deficiency in Chilean healthy postmenopausal women with normal sun exposure: additional evidence for a worldwide concern. Menopause 2007;14(3 Pt 1):455– 61. 16. Lim HW, Gilchrest BA, Cooper KD, et al. Sunlight, tanning booths, and vitamin D. J Am Acad Dermatol 2005;52:868 –76. 17. Levine JA, Sorace M, Spencer J, Siegel DM. The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol 2005;53:1038 – 44. 18. Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst 2002;94:224 – 6. 19. International Agency for Research on Cancer Working Group on artificial ultraviolet light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer 2007;120:1116 –22. 20. Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol 2007;56: 375–9. 21. Kaur M, Liguori A, Lang W, Rapp SR, Fleischer AB Jr., Feldman SR. Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. J Am Acad Dermatol 2006;54:709 –11.
American Journal of Preventive Medicine, Volume 34, Number 2
www.ajpm-online.net
The Struggle for Primary Prevention of Skin Cancer Martin A. Weinstock, MD, PhD
S
kin cancer is more common than all other cancers combined in the United States, and several times more common in Australia. This is despite its being among the most preventable types of cancer, with a well-known carcinogen, ultraviolet radiation (UVR), responsible for most cases. What should we do? First we document that UVR is indeed responsible, as has been done over the last several decades.1 Then we publicize this conclusion, conduct public health campaigns to disseminate this information, and encourage practices and policies that will result in reduced incidence. The most comprehensive and sustained campaign of this sort has been conducted in Victoria, Australia, over the past quarter century. The results have been systematically assessed, and key findings are reported in this issue of the American Journal of Preventive Medicine by Dobbinson et al.2 They report that after initial impressive gains in the first decade of assessments, there now appears to be regression or at best no further progress on major indices such as sunburn, sunscreen use, body exposure, and attitudes. The good news is that most of those initial gains have been sustained over these 15 years of assessments; the bad news is that this may not be good enough. The goal is to reduce skin cancer morbidity and mortality. Given the long lag time after UVR exposure that has been associated with most melanomas, and presumably basal cell carcinomas, we do not yet know the ultimate effect of sun-protection campaigns on those actual cancer rates. However, it does appear that squamous cell carcinoma of the skin has a shorter lag period. The epidemiologic evidence for this conclusion is supported by a randomized trial of 4.5 years of consistent sunscreen use that reported a 40% decline in incidence of squamous cell carcinoma of the skin in the intervention group.3,4 Hence the observation that squamous cell carcinoma incidence rates appear to be increasing in the U.S., Europe, and Australia suggests that our prevention efforts may indeed be inadequate.5,6
From the Dermatoepidemiology Unit, Veterans Affairs Medical Center Providence; Department of Dermatology, Rhode Island Hospital; and Departments of Dermatology and Community Health, Brown University, Providence, Rhode Island Address correspondence and reprint requests to: Martin A. Weinstock, MD, PhD, Dermatoepidemiology Unit, VA Medical Center– 111D, 830 Chalkstone Avenue, Providence RI 02908. E-mail: [email protected].
Furthermore, the skin cancer prevention efforts in U.S. populations are not as comprehensive as those in Victoria. We do see evidence of decreased sunburn prevalence in younger teenagers in the U.S.7 However, recent data suggest increases in sunburn prevalence among older teens and adults since the late 1990s.7,8 Here we are, after a quarter century of prevention campaigns; we have not yet reduced our incidence rates of melanoma or keratinocyte carcinomas. We have learned much regarding the factors that distinguish successful from unsuccessful campaigns. Reports of efforts that do not result in better UVR protection continue to appear.9,10 Efforts that succeed in changing behavior are also being documented, such as the recent effort to improve (or, more precisely, to halt the deterioration) of the practices of adolescents with respect to UVR.11 This campaign was notable for its comprehensive, multichannel approach sustained over 2 years. Dobbinson and her co-authors suggest the power of television advertisements as an important component of these multifaceted sustained campaigns. With respect to protection from UVR to reduce skin cancer risk, these studies suggest that effective prevention campaigns don’t come cheap, although these efforts may ultimately be cost effective.12 Beyond the cost, there are challenges to effective skin cancer prevention campaigns in our complex multiple risk factor environment. First, sun-protection campaigns often include advice to avoid the sun or limit time in the sun, which may conflict with other health promotion messages. There are major efforts underway to increase physical activity to combat overweight and obesity, as well as cardiovascular disease and diabetes, among other major health hazards. But moderate or intense physical activity often occurs outdoors during the daytime, with consequent exposure to solar UVR. Coups et al.13 report in this issue that skin cancer risk behavior is indeed associated with higher levels of physical activity in the general U.S. population, but also with overweight and obesity, hence this population would benefit from a further increase in physical activity. The potential conflict between preventing skin cancer and maintaining healthy weight may be reduced or eliminated with focus on the “Slip! Slop! Slap!”—slip on a shirt, slop on the sunscreen, slap on a hat—message that emphasizes sun protection while outdoors instead of an “Avoid. Cover. Screen” message that may conflict with active lifestyle goals. It is
Am J Prev Med 2008;34(2) © 2008 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/08/$–see front matter doi:10.1016/j.amepre.2007.11.002
171
important to evaluate the many potential effects of our activities on overall health promotion. Second, there is an increasing interest in the health benefits of vitamin D, which can be synthesized in human skin exposed to ultraviolet B radiation. The amount of vitamin D that can be obtained from UVR exposure depends on many factors, including the person’s age and skin color, and the weather, time of day, season of year, altitude, and latitude. Hence the sun is a rather unreliable source of this vitamin, as has been documented in multiple contexts.14,15 The more dependable source, and the one generally used in the trials that demonstrate beneficial effects of vitamin D, is the oral vitamin supplement.16 Third, in their analysis of the U.S. National Health Interview Survey (NHIS) data, Coups and his colleagues13 report on the association of multiple skin cancer risk behaviors with other risk behaviors such as smoking and risky drinking, which may facilitate our understanding and interventions. Finally, the $5 billion tanning industry derives much of its profits from the sale of carcinogenic UVR and seeks to increase sales.17 This is not the only industry based on selling carcinogens, and its product is not nearly as toxic as tobacco smoke. Its product has, however, been associated with risk of squamous cell carcinoma18 and melanoma,19 and hence with considerable morbidity and mortality. There is accumulating evidence that UVR exposure in tanning parlors can be addictive. This evidence includes responses among frequent tanners to CAGE (Cut down, Annoyed, Guilty and Eye opener, an alcoholuse disorders screening test) questionnaires indicative of a substance-related disorder20 and withdrawal symptoms after naltrexone administration in a substantial proportion of these individuals.21 With these challenges, the future of successful primary prevention of skin cancer through protection from UVR exposure, whether from the sun or artificial sources, is uncertain. The author has served as a consultant for Schering-Plough, a manufacturer of suncare products.
References 1. International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans: solar and ultraviolet radiation. Vol 55. Lyon, France: IARC, 1992.
172
2. Dobbinson SJ, Wakefield MA, Jamsen K, et al. Weekend sun protection and sunburn in Australia: trends (1997–2002) and association with SunSmart television advertising. Am J Prev Med 2008;34:94 –101. 3. van der Pols JC, Williams GM, Pandeya N, Logan V, Green AC. Prolonged prevention of squamous cell carcinoma of the skin by regular sunscreen use. Cancer Epidemiol Biomarkers Prev 2006;15:2546 – 8. 4. Green A, Williams G, Neale R, et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamouscell carcinomas of the skin: a randomised controlled trial. Lancet 1999; 354:723–9. 5. Staples MP, Elwood M, Burton RC, Williams JL, Marks R, Giles GG. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985. Med J Aust 2006;184:6 –10. 6. Karagas MR, Weinstock MA, Nelson H. Keratinocyte carcinomas (basal cell and squamous cell carcinomas of the skin). In: Schottenfeld D, Fraumeni JF, eds. Cancer epidemiology and prevention. 3d edn. San Francisco: Oxford University Press, 2006:1230 –50. 7. Cokkinides V, Weinstock M, Glanz K, Albano J, Ward E, Thun M. Trends in sunburns, sun protection practices, and attitudes toward sun exposure protection and tanning among U.S. adolescents, 1998 –2004. Pediatrics 2006;118:853– 64. 8. Saraiya M, Balluz L, Wen DK, Joseph DA. Sunburn prevalence among adults: United States, 1999, 2003, and 2004. MMWR Morb Mortal Wkly Rep 2007;56:524 – 8. 9. Dixon HG, Hill DJ, Karoly DJ, Jolley DJ, Aden SM. Solar UV forecasts: a randomized trial assessing their impact on adults’ sun-protection behavior. Health Educ Behav 2007;34:486 –502. 10. Naldi L, Chatenoud L, Bertuccio P, et al. Improving sun-protection behavior among children: results of a cluster-randomized trial in Italian elementary schools. The “SoleSi SoleNo-GISED” Project. J Invest Dermatol 2007;127:1871–7. 11. Olson AL, Gaffney C, Starr P, Gibson JJ, Cole BF, Dietrich AJ. SunSafe in the middle school years: a community-wide intervention to change earlyadolescent sun protection. Pediatrics 2007;119:e247–56. 12. Carter R, Marks R, Hill D. Could a national skin cancer primary prevention campaign in Australia be worthwhile?: An economic perspective. Health Promot Int 1999;14:73– 82. 13. Coups EJ, Manne SL, Heckman CJ. Multiple skin cancer risk behaviors in the U.S. population. Am J Prev Med 2008;34:87–93. 14. Binkley N, Novotny R, Krueger D, et al. Low vitamin D status despite abundant sun exposure. J Clin Endocrinol Metab 2007;92:2130 –5. 15. Gonzalez G, Alvarado JN, Rojas A, Navarrete C, Velasquez CG, Arteaga E. High prevalence of vitamin D deficiency in Chilean healthy postmenopausal women with normal sun exposure: additional evidence for a worldwide concern. Menopause 2007;14(3 Pt 1):455– 61. 16. Lim HW, Gilchrest BA, Cooper KD, et al. Sunlight, tanning booths, and vitamin D. J Am Acad Dermatol 2005;52:868 –76. 17. Levine JA, Sorace M, Spencer J, Siegel DM. The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol 2005;53:1038 – 44. 18. Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst 2002;94:224 – 6. 19. International Agency for Research on Cancer Working Group on artificial ultraviolet light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer 2007;120:1116 –22. 20. Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol 2007;56: 375–9. 21. Kaur M, Liguori A, Lang W, Rapp SR, Fleischer AB Jr., Feldman SR. Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. J Am Acad Dermatol 2006;54:709 –11.
American Journal of Preventive Medicine, Volume 34, Number 2
www.ajpm-online.net