[Don't] Let the Sun Shine In:
Avoiding Excessive Exposure Reduces Risk

Martin Weinstock, M.D., Ph.D., is a professor of dermatology and director of the pigmented lesions unit at Brown University. Dr. Weinstock is also the chief of dermatology at the VA Medical Center in Providence, R.I., and chair of the American Cancer Society's skin cancer advisory group.

Q. Even with decades of research to debunk the myth of the "healthy tan," many people are still chasing this goal. What is the reality of tanning, and why do you think the myth persists?

A. Tanning has an interesting history in this country. A hundred years ago, it was a very unfashionable thing. It signified that you were the type of person who had to work for a living, usually out in the field under the sun. People who owned farms and big plantations could spend the day inside, sipping mint juleps in the shade. That changed rather drastically with the industrial revolution, when working people moved indoors and wealthy people became able to travel to tropical locations and lie on the beach. So tans became fashionable as a sign of wealth. Now people are beginning to understand that exposure to ultraviolet radiation is potentially quite harmful. It can harm your health; it can harm your appearance and it's just generally not a good idea. So people are starting to use more sun protection. However, this is a long and slow process of cultural change. It has been the social norm to go out and seek a tan, and now that is starting to reverse.

Q. Despite a unified call from the medical community for the public to avoid sun exposure, research by you and others has shown that few protect themselves. What needs to be done to change this?

A. It's really a process of education and behavior change and changing cultural norms. The federal government is involved; the Centers for Disease Control and Prevention is particularly involved in promoting sun protection in schools. They just published a series of guidelines and they will be engaging in more efforts. (6) They have also promoted the UV index, which is now used by many TV news programs to forecast the intensity of ultraviolet radiation during the day. State and local governments also are important in, for example, supporting school-based efforts to educate youth about sun protection. Then there is the voluntary sector, organizations such as the American Cancer Society, the American Academy of Dermatology and others that are promoting the message that too much sun can lead to skin cancer. Many different types of efforts are needed to deliver this message successfully.

Q. What perceptions or attitudes persist among teenagers to motivate them to sunbathe or go to tanning salons?

A. There is the old view, which is no longer much adhered to, that a tan is healthy. In the young set, it's not so much a regard for health, but for fashion. As long as it is perceived as cool, then it's going to be very difficult to change. So what needs to change is the perception that tanning itself is cool. And I think that is changing. But as I say, it is a slow process.

Q. What happens when someone gets a tan?

A. Ultraviolet radiation that hits the skin causes a reaction in the melanocytes, pigment-producing skin cells, to produce a browner color in the skin. It is not the brown color that causes the problem. What causes the problem is the ultraviolet radiation that triggers this response, because that same ultraviolet radiation causes damage in the DNA of skin cells as well as other types of damage to the skin, and that is what has been related to risk of skin cancer. If people get tan skin or have tan skin without exposing themselves to ultraviolet light, there's no problem with that, it doesn't increase their risk of skin cancer. It's not the tan that's the problem; it's the ultraviolet radiation used to get a tan.

If you use some of those artificial self-tanners, tan in a bottle, they will give you a tan that is safe in the sense that we do not know of any adverse health consequences associated with those tans. They don't protect against sun exposure, they don't protect against ultraviolet light, but they're not damaging in and of themselves.

Q. What role do parents need to take in ensuring that their children are protected from sun exposure?

A. The first thing they can do is protect their children from intense sunlight when they're particularly young, getting them in the habit. That's when parents have complete control. We have slogan at the American Cancer Society, "Slip, Slop, Slap." Slip on a shirt, slop on sunscreen, slap on a hat. And that's a good way to avoid ultraviolet damage.

Q. Some epidemiological studies have suggested an association between sunscreen use and skin cancer. How do you interpret this?

A. I don't believe you can conclude from the epidemiological studies that sunscreen causes skin cancer. Quite the opposite; I think that sunscreens prevent skin cancer, if used properly. There are many subtleties to those epidemiological studies and you have to be sort of careful about how you read and interpret them. (11)

Q.Can people rely solely on sunscreen, if applied properly and frequently, or are other measures required?

A. The sun is out there, and you've got to protect yourself from intense exposures. You can do that by scheduling activities so they're not during the middle of the day when the sun is its most intense, or by using sun-protective clothing or sunscreen or some combination of those methods. A combination of strategies is generally recommended. Unfortunately, a lot of people simply do not use sunscreen correctly. One of the findings in a survey we did was that a lot of people, when they got the worst sunburn of the summer, they were using a sunscreen with SPF 15 or greater. (12) That would seem to be the opposite of what you would expect, until you look at how people use sunscreen. If someone goes to the beach, plays a couple of games of volleyball, and then says "My skin is turning red, I'd better put on some sunscreen," well, obviously that is too late. Most of the damage has already been done. The other problem is that people may use too little sunscreen. Or it can wash off, if it's not waterproof or water-resistant.

Q. What is the current thinking on sunscreen rating? Is higher better?

A. I recommend a 30 or greater. If you go from a 30 to a 45, the difference in protection is not that great. But if you go from a 5 to a 30, that is a big difference. As you get to higher numbers, the differences become less important.

Risk Factors for Melanoma and Non-Melanoma Skin Cancers

A Mountain out of a Mole:
Key Components and Benefits of Early Detection

Allan C. Halpern, M.D., is the chief of dermatology services at Memorial-Sloan Kettering Cancer Center in New York City. He is also the co-chair of the National Council for Skin Cancer Prevention and a vice president of the Skin Cancer Foundation.

Q. What are the benefits of early detection of skin cancer?

A. As is true of cancer in general, the earlier skin cancer is detected, the more readily it is cured. Almost all skin cancers are amenable to early detection and cure. In the case of melanoma, there is a direct correlation between the stage at which it is diagnosed and survival. In the case of all skin cancers, the earlier they are recognized, the more readily they can be removed in a simple, non-disfiguring way, with less potential for scarring and functional deficits. It is important to recognize that skin cancer is very common, with more than 1 million new cases each year. The majority of skin cancers are of the non-melanoma type, meaning they are either basal cell skin cancer or squamous cell skin cancer. For basal cell-type skin cancer, the key to early detection has to do primarily with cosmetic implications. Because these often occur on the face and are locally destructive they can be quite disfiguring, but if identified early they can typically be treated with relatively minimal scarring. With squamous cell cancer, early detection has very significant cosmetic implications as well. At the same time, early detection has significant implications for life saving, since a small percentage of these, if allowed to grow to a larger size, will risk metastasis and death. In the case of melanoma skin cancer, which is less common than non-melanoma skin cancer but unfortunately way too common, early detection is critical because melanoma, when not detected in its early stages, has a high likelihood of metastasis and death.

Q. Who should be responsible for skin cancer screening? Dermatologists, primary care physicians or the patients themselves?

A. Skin cancer is a little different from other cancers since it occurs right on the surface of the skin and is therefore amenable to self-detection. This is a good example of patient education playing an enormous role in early detection. If people understand the earliest warning signs of skin cancer, they have a better chance of picking up on them than even their physician does. That's because in the case of nonmelanoma skin cancer, the earliest warning sign is often the way a lesion behaves, even more so than the way it appears.

A suspicious behavior would be a pink spot on the skin that either persists or goes away, only to reoccur in the exact same place. These lesions are also easily irritated by everyday things like towel drying. Paying attention to these warning signs, the patient can often recognize very small skin cancers.

In the case of melanoma, the important warning signs are changes in the color, shape or size of a pigmented lesion on the surface of the skin. Patients play a disproportionately important role in skin cancer compared with other cancers in terms of early detection.

In terms of physicians' role, the reality is that the greatest opportunity for physician detection is in the hands of primary care physicians because of their greater exposure to patients. Dermatologists are obviously best equipped to make the clinical assessment of individual lesions and are the most appropriate to screen patients in especially high-risk categories and to follow high-risk patients on a regular basis for the early detection of skin cancer. (18)

Q. Do patients who find potential signs of skin cancer benefit from direct access to dermatologists?

A. In general, direct access to dermatologists is in the best interest of the patient as well as in the best interest of the primary care physician. If there is already a lesion that a patient has specific concerns about, it typically warrants comprehensive evaluation. That's not to say that the majority of primary care physicians are not adequately trained to see patients with common skin complaints. But my suggestion would be that a patient who has access to a dermatologist and has a specific lesion of concern or significant risk factors for skin cancer would do well to seek the care of a dermatologist.

Q. Given increasing time constraints on primary care physicians, can patients expect skin cancer screening to be a part of their office visit?

A. Obviously it would be optimal if primary care physicians were well trained in the recognition of skin cancer and included a complete skin examination as part of their routine evaluation of patients. Unfortunately, our own work and that of others indicates that skin cancer is not a high priority in the primary care setting and that whole-body screenings are rarely done. (5) Having said that, there are numerous opportunities for primary care physicians to recognize skin cancer without resorting to whole-body formal screening. It's very important that those opportunities are capitalized upon. Every patient encounter is an opportunity to find skin cancer in the skin that is exposed during the examination.

Q. Research has shown that sunburns during the teen years contribute greatly to the risk of skin cancer later. Is this simply a product of timing, or are there other biological mechanisms at work?

A. Sunburns at any point in one's life have implications for skin cancer risk. It is true, however, that childhood sun exposure may play a disproportionate role in the development of skin cancer. This may be because many of us get the majority of our sun exposure during childhood, or it may well relate to childhood being a time of greater susceptibility to the development of skin cancer. As to the specific duration of time between sun exposure and the onset of skin cancer, it likely relates to a sufficient period of time to amass the DNA damage that leads to cancer. This sort of a lag period between exposures and the development of cancer is typical of most cancer types.

This is not to suggest that recent sun exposure in adulthood doesn't play an important role in the development of skin cancer. Adult sun exposure likely contributes to all types of skin cancer and recent sun exposure is especially relevant in the case of squamous cell-type skin cancer.

Q. What exactly is the role of sun exposure in the formation of skin cancer? Do low levels of exposure that don't lead to sunburn still increase the risk of skin cancer?

A. The association between sun exposure and skin cancer in general relates to the ultraviolet portion of the spectrum of sunlight. Ultraviolet light is broken into the categories UVA, UVB and UVC. UVC rays do not typically reach the earth because they are completely blocked by the ozone layer. UVB is partially blocked by the ozone layer and is typically responsible for sunburn. UVA, which is not blocked by ozone, can actually lead to tanning without the burn. It used to be thought that UVB, because it's implicated in sunburn, was the component of the ultraviolet spectrum causing skin cancer. In recent decades we've come to understand that UVA is also an important potential carcinogen for the development of skin cancer. We've also come to recognize that people do not begin to develop a tan until they have been exposed to sufficient ultraviolet radiation to cause DNA damage, and hence skin cancer.

Q. What is the process of skin cancer development?

A. Most skin cancers develop over the course of years or decades. In basal cell skin cancer there is no precursor lesion, so these tend to be cancerous from the time they are recognized on the surface of the skin. Many cases of squamous cell skin cancers arise from a precursor lesion called actinic keratosis. Many regard actinic keratoses as the earliest stage of squamous cell skin cancer. These lesions can be quite numerous and are amenable to topical or non-surgical therapies. Melanoma-type skin cancer can arise from pre-existing moles that have been present for decades, or as new spots on the surface of the skin.

Q. Cancer in general grows more common as people age. How common is skin cancer in younger people?

A. It's generally true that skin cancer grows more common with age as well. However, there appears to be an ongoing shift in the epidemiology; we are seeing increasing numbers of younger individuals with skin cancer. And melanoma, a disease generally of the relatively young, has an average age of onset of about 50. For these reasons it's important that people even in their 20s and 30s not ignore any of the warning signs of skin cancer. And people in especially high-risk groups, meaning those with dysplastic nevi and family histories of melanoma, should be under dermatological care from a relatively young age, perhaps in their teens.

Q. What techniques are used to detect skin cancer early?

A. The most important is a monthly self-examination, looking at all skin surfaces - including those that are not sun-exposed. People are often misled by the association between sun exposure and skin cancer, and think that skin cancers don't occur in areas normally covered by clothes or otherwise not exposed to sun. Skin cancer can occur anywhere on the surface of the skin, even though it is more common in sun-exposed areas. People need to perform a complete head-to-toe self-examination each month, including the genitalia and between the toes. The most difficult place for people to examine themselves is the scalp, for which they need a partner's help. The back and the back of the legs are common locations for melanoma, requiring the use of a hand-held mirror and a full-length mirror during self-examination or the assistance of a partner.

The second line of defense in skin cancer detection is a physician examination. Patients can, at a minimum, request that their primary care physician examine their skin in the context of the general physical examination. And patients who fall into any high-risk categories should specifically seek dermatological care.

Q. Skin cancer mortality has increased substantially during the past 20 years. However, this increase seems to be almost wholly due to an increase among older men. Is there an explanation for this trend?

A. Melanoma incidence has risen dramatically during this period. However, early detection has also risen dramatically. On average, melanoma is being caught earlier, and among patients diagnosed with melanoma, the likelihood of metastasis or death has actually dropped significantly. But because there are so many more melanoma patients, overall mortality in the population continues to rise.

Men, and older men in particular, continue to be diagnosed with more advanced melanomas and a greater likelihood, therefore, of metastasis and death for two possible reasons. One possibility is that older men are less amenable to the ongoing efforts in early detection. This is quite consistent with what we know about older men's behavior; that is, that they tend not to be as aware of their skin and they are not as likely to seek medical attention for these sorts of things as women are. Having said that, the other possibility is that there's actually a difference in the biological behavior of melanomas in this age group and that they are more rapidly growing.

Cancer Prevention for Kids

What makes an alligator an appropriate health education spokescritter?

"Kids like gators," explains Carol Reed Ash, R.N., Ed.D., the oncology nurse and public educator behind the University of Florida's GatorSHADE program, discussing the choice of the mascot as part of the effort to give away thousands of specially designed hats and free tubes of sunscreen. (19)

The hat-wearing, sunglasses-sporting cartoon alligator is also featured in an educational video explaining how these animals seek shade to avoid excessive sun exposure. Originally meant as a one-time effort to serve as a "wake-up call" to the community, the hat and sunscreen giveaway sparked a flurry of telephone calls to talk to the "hat lady."

"It was very clear that we had struck a chord and people wanted to find out more" about skin cancer and protecting themselves and their children, says Ash. Through more field testing, Ash and colleague Jill W. Varnes, Ed.D., C.H.E.S., refined the program, using different hats and switching to sunscreen that didn't offend the discriminating noses of their target audience of children in the 8-10 age range.

Later, with an internal grant from the university, they were able to shape GatorSHADE into a comprehensive program including printed and video educational materials, as well as educational and experiential games to involve the kids.

Key messages of the program include:

• Excessive sun exposure is dangerous.


• Use a broad-spectrum (UVA.UVB) sunscreen with a sun protective factor (SPF) of 15 or higher. Make sure to use enough sunscreen to ensure adequate protection.


• Wear a hat that covers the head, face, neck and ears.


• Wear UV-blocking sunglasses, preferably ones that wrap around and protect the especially sensitive skin around the eyes.
• Try to avoid activities during the most sun-intense parts of the day, 10 a.m. to 2 p.m. or when your shadow is shorter than you.
• Seek shade whenever possible.

The program also includes lessons on recognizing the early signs of skin cancer, such as changes in the shape, color or size of moles.

Well-funded, well-designed programs exist, says Ash, and while components of these programs may find their way to the public, they are rarely implemented in a comprehensive way. (6,20)

"Changing behavior at any level is very tough to do," she says, "but if you involve people in the learning process you at least have a leg up on helping them understand what it is they're supposed to do."

Is There Such a Thing as a Safe Tan?

Tanning salons are the new front line for dermatologists and public health advocates trying to inform the public on the dangers of excessive exposure to ultraviolet light. In a recent survey, about 10 percent of teenagers reported using a tanning bed within the past year. (13) An estimated 30 million teens and adults visit tanning salons every year. (14)

While the dangers of excessive exposure to natural sunlight are becoming increasingly clear, there has been little research on the risk of skin cancer from exposure to artificial, high-intensity ultraviolet light generated by tanning booths.

"The party line is that all intentional tanning is to be discouraged, because we have come to understand that a tan doesn't occur until the very exposure associated with skin cancer carcinogenesis has already occurred," says Dr. Allan C. Halpern.

At one time, tanning salon operators suggested that the research showing the harm of natural sunlight was an argument for using booths as a safer alternative. However, most have dropped that tactic in the face of studies showing that tanning booth light produces the same cell changes that are associated with skin cancer. (15)

Now tanning salons are more likely to advertise that their booths produce only UVA radiation, and not the UVB radiation that causes sunburn.

"First of all, it's not true that UVA radiation is innocuous. Second of all, it's not true that tanning booths only give you UVA radiation. They give you some UVB too," says Dr. Martin Weinstock, who notes that most tanning parlors do not have sensitive equipment for measuring the UVB output, which can range from 5 to 10 percent of the total UV mixture.

"They're extremely dangerous and people are lulled into a false sense of security because they think that they go into a booth and they sit under a lamp and its only for a few minutes and it's controlled and there is not harm," says Dr. Carol Reed Ash. "What they don't understand is that what causes skin cancer is cumulative damage to skin cells."

Knowledge of the dangers of tanning salon sessions, such as premature aging of the skin and an increased risk of skin cancer, may not be enough. (16) Perceived benefits such as relaxation and the attractiveness of tans, which the tanning industry relies upon heavily to market their services, remain important motivators. (17)

In what could be interpreted as positive progress, a new UV-free spray-on tanning booth is making inroads in the tanning salon marketplace. And while experts are careful to withhold judgment on this simulated-tanning approach (but do point out potential risks such as allergic reactions), most seem to feel that it has to be safer than intense UV exposure.

But the tanning salon industry is not ready to abandon light-based approaches. Marketing materials for the new machines warn operators not to advertise the spray booths as safer because of the suggestion that the light booths are unsafe. Such an insinuation would be counterproductive to the spray booth movement, which aims to supplement - not compete with - the traditional light booths. (22)

Easy as ABCD: Spotting Suspect Moles

"A" refers to asymmetry. Moles that are melanoma lesions tend to be irregularly shaped.

"B" refers to border irregularity. Normal moles have smooth edges, whereas in the process of invading surrounding skin, melanoma tends to develop irregular edges.

"C" refers to color. A pigmented lesion that is intensely black, possibly with a bluish tint, or one with color that is uneven across the mole, should spark suspicion of possible melanoma.

"D" refers to diameter. A mole that is greater than 6 mm (about the size of a pencil eraser) is considered suspicious.

The Research

Bibliography

1. American Cancer Society (2002) Cancer Facts & Figures 2002.
www.cancer.org

2. Armstrong, B.K. & Kricker, A. (1993) How much melanoma is caused by sun exposure? Melanoma Research 3(6), 395-401.

3. American Cancer Society (2002) Cancer Prevention & Early Detection: Facts & Figures
2002.www.cancer.org 4. Ries, L.A.G., Eisner, M.P., Kosary, C.L. et al. (eds). (2002) SEER Cancer Statistics Review, 1973-1999, National Cancer Institute. Bethesda, MD. seer.cancer.gov.

5. Oliveria, S.A., Christos, P.J., Marghoob, A.A. & Halpern, A.C. (2001) Skin cancer screening and prevention in the primary care setting: National Ambulatory Medical Care Survey 1997. Journal of General Internal Medicine 16, 297-301.

6. Center for Disease Control and Prevention. (2002) Guidelines for School Programs to Prevent Skin Cancer. Morbidity and Mortality Weekly Report 51, RR-4.

7. Cokkinides, V.E., Johnston-Davis, K., Weinstock, M. et al. (2001) Sun exposure and sun-protection behaviors and attitudes among U.S. youth, 11 to 18 years of age. Preventive Medicine 33(3), 141-151.

8. Davis, K.J., Weinstock, M.A., O'Connell, M. et al. (1999) Sun exposure and sun protection behaviors among youth ages 11 to 18: A national survey. American Journal of Epidememiology 149, S65.

9. Robinson, J.K., Rigel, D.S. & Amonette, R.A. (2000) Summertime sun protection used by adults for their children. Journal of the American Academy of Dermatology 42(5 Pt 1), 746-53.

10. Robinson, J.K., Rigel, D.S. & Amonette, R.A. (1997) Trends in sun exposure knowledge, attitudes, and behaviors: 1986 to 1996. Journal of the American Academy of Dermatology 37(2 Pt 1), 179-86.

11. Weinstock, M.A. (1999) Do sunscreens increase or decrease melanoma risk: An epidemiologic evaluation. Symposium Proceedings, Journal of Investigative Dermatology 4(1), 97-100.

12. Weinstock, M.A., Rossi, J.S., Redding, C.A. et al. (2000) Sun protection behaviors and stages of change for the primary prevention of skin cancers among beachgoers in southeastern New England. Annals of Behavioral Medicine 22(4), 286-293.

13. Geller A.C., Colditz G., Oliveria S. et al. (2002) Use of sunscreen, sunburning rates, and tanning bed use among more than 10 000 US children and adolescents. Pediatrics 109(6), 1009-1014.

14. The International Smart Tan Network (2002). www.tanningtruth.com

15. Whitmore, S.E., Morison, W.L., Potten, C.S. & Chadwick, C. (2001) Tanning salon exposure and molecular alterations. Journal of the American Academy of Dermatology 44(5), 775-780.

16. Beasley, T.M. & Kittel, B.S. (1997) Factors that influence health risk behaviors among tanning salon patrons. Evaluation & the Health Professions 20(4), 371-388.

17. The International Smart Tan Network (2002).
www.tanningtruth.com

18. Ferrini, R.L., Perlman, M. & Hill, L. (1998). Screening for skin cancer: American College of Preventive Medicine practice policy statement. American Journal of Preventive Medicine 14(1), 80-82.

19. Ash, C.R. (1998). Nursing issues in managing skin cancer in the year 2000. Cancer Control 5(3 Suppl 1), 42-43.

20. Geller, A.C., Cantor, M., Miller et al. (2002). The Environmental Protection Agency's National SunWise School Program: Sun protection education in US schools (1999-2000). Journal of the American Academy of Dermatology 46(5 Pt 1), 683-689.

21. Buller, D.B., Geller, A.C., Cantor, M. et al. (2002). Sun protection policies and environmental features in U.S. elementary schools. Archives of Dermatology 138, 771-774.

22. Barrett, Scott Eric. "Mystic Tan: Spray Booth Offers Universal Appeal." Looking Fit June 2002.
www.lookingfit.com.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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