Does intermittent sun exposure cause basal cell carcinoma? a case-control study in Western Australia

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 1: Epidemiology, Genetics and Diagnosis

Basal cell carcinoma is the most common malignant tumor among fair-skinned individuals, and its incidence has been rising steadily in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 1 highlights new developments in genetics in particular as well as aspects regarding epidemiology, diagnosis, and histology.

Nonmelanoma skin cancer in women

Men continue to develop nonmelanoma skin cancer (NMSC) at higher rates than women, but the epidemiologic pattern of NMSC development is evolving. We present a selective, narrative review of the literature showing that there is a trend toward a development of basal cell carcinomas in women at younger ages, and highlight potential causes of this trend. We review evidence that indoor tanning is associated with the development of NMSC and show that young women use indoor tanning more than any other age-sex group. We discuss societal factors that relate to the tanning behavior of young women. Finally, we argue that facial NMSCs may have more of a negative impact on quality of life in women than in men.

MelaNostrum: a consensus questionnaire of standardized epidemiologic and clinical variables for melanoma risk assessment by the melanostrum consortium

BACKGROUND

Many melanoma observational studies have been carried out across different countries and geographic areas using heterogeneous assessments of epidemiologic risk factors and clinical variables.

AIM

To develop a consensus questionnaire to standardize epidemiologic and clinical data collection for melanoma risk assessment.

METHODS

We used a stepwise strategy that included: compilation of variables from case-control datasets collected at various centres of the MelaNostrum Consortium; integration of variables from published case-control studies; consensus discussion of the collected items by MelaNostrum members; revision by independent experts; addition of online tools and image-based charts; questionnaire testing across centres and generation of a final draft.

RESULTS

We developed a core consensus questionnaire (MelanoQ) that includes four separate sections: A. general and demographic data; B. phenotypic and ultraviolet radiation exposure risk factors and lifestyle habits; C. clinical examination, medical and family history; and D. diagnostic data on melanoma (cases only). Accompanying online tools, informative tables, and image-based charts aid standardization. Different subsections of the questionnaire are designed for self-administration, patient interviews performed by a physician or study nurse, and data collection from medical records.

CONCLUSIONS

The MelanoQ questionnaire is a useful tool for the collection and standardization of epidemiologic and clinical data across different studies, centres, cultures and languages. This will expedite ongoing efforts to compile high-quality data for pooled analyses or meta-analyses and offer a solid base for the design of clinical, epidemiologic and translational studies on melanoma.

Towards improving diagnosis of skin diseases by combining deep neural network and human knowledge

BACKGROUND

The emergence of the deep convolutional neural network (CNN) greatly improves the quality of computer-aided supporting systems. However, due to the challenges of generating reliable and timely results, clinical adoption of computer-aided diagnosis systems is still limited. Recent informatics research indicates that machine learning algorithms need to be combined with sufficient clinical expertise in order to achieve an optimal result.

METHODS

In this research, we used deep learning algorithms to help diagnose four common cutaneous diseases based on dermoscopic images. In order to facilitate decision-making and improve the accuracy of our algorithm, we summarized classification/diagnosis scenarios based on domain expert knowledge and semantically represented them in a hierarchical structure.

RESULTS

Our algorithm achieved an accuracy of 87.25 ± 2.24% in our test dataset with 1067 images. The semantic summarization of diagnosis scenarios can help further improve the algorithm to facilitate future computer-aided decision support.

CONCLUSIONS

In this paper, we applied deep neural network algorithm to classify dermoscopic images of four common skin diseases and archived promising results. Based on the results, we further summarized the diagnosis/classification scenarios, which reflect the importance of combining the efforts of both human expertise and computer algorithms in dermatologic diagnoses.

Do all infants need vitamin D supplementation?

A high prevalence of vitamin D deficiency (VDD) in children has been observed worldwide, but there are few studies on the nutritional status of vitamin D (VD) in healthy infants. The main cause of deficiency in healthy children is breastfeeding without supplementation and lack or insufficiency of sun exposure. The aims of this study were to determine serum concentrations of 25(OH)D and verify its association with parathyroid hormone (PTH) concentrations and use of VD supplementation in healthy infants aged ≥ 6 to ≤ 24 months attended at two Primary Health Care Units in Ribeirão Preto city, São Paulo, Brazil. A cross-sectional, observational and analytical study was performed in which serum concentrations of 25(OH)D, PTH, alkaline phosphatase (AP), calcium (Ca), phosphorus (P) and albumin were determined in 155 healthy infants. Information on sun exposure, sociodemographic aspects of mothers and clinical and nutritional characteristics of infants were obtained through interviews with responsible infants’s legal representatives. Ten infants (6%) presented deficient 25(OH)D serum concentration (≤20ng/ml) and 46 (30%), insufficient (21 to 29ng/ml). No changes in serum P, Ca and albumin concentrations were detected. Only one infant had an increase in PTH serum concentrations. 35% (55/155) of infants had high AP e 40% (22/55) presented insufficient serum concentrations of 25(OH)D but none presented deficient ones. There was a weak association between serum concentrations of 25(OH)D and PTH and an association between serum concentrations of 25(OH)D and P when adjusted for sex, age and BMI. There were no associations between inadequate serum concentrations of 25(OH)D (deficient ou insufficient), sun exposure and VD supplementation. This study found a low prevalence of deficient 25(OH)D serum concentration and high prevalence of insufficient ones which was not associated with changes in serum PTH, AP, P, Ca and albumin concentrations, VD supplementation and the formula volume intake.

Small Molecule Inhibitors of the Hedgehog Pathway in the Treatment of Basal Cell Carcinoma of the Skin

Basal cell carcinoma (BCC) is the most common type of skin cancer, with rising incidence rates primarily attributed to an aging population and ultraviolet radiation exposure. While the majority of BCCs are localized and respond to standard therapies, a very small minority of these tumors become locally destructive or metastasize. These advanced BCCs may not be amenable to localized treatment with surgery and/or radiation therapy. Most BCCs result from mutations in key receptors in the Hedgehog (HH) signaling pathway. As a result, identification of drugs that inhibit the receptor Smoothened (SMO) in the HH pathway has resulted in novel therapeutic approaches to treating patients with advanced BCC. These HH-pathway inhibiting medications have shown efficacy in clinical trials, and two medications, vismodegib and sonidegib, have received FDA approval. However, several limitations of these drugs have been identified, including treatment-limiting adverse events, drug resistance, and the formation of additional malignancies. This paper aims to summarize the clinical trials leading to the approval of SMO inhibitors, as well as reviewing potential mechanisms driving tumor resistance and the formation of cutaneous squamous cell carcinomas. Strategies to overcome some of these challenges, including the development of drugs that inhibit other downstream targets in the HH pathway, are the subject of ongoing clinical trials.

Trends in basal cell carcinoma incidence rates: a 16-year retrospective study of a population in central Poland

Introduction

Basal cell carcinoma (BCC) is the most commonly occurring cancer worldwide, and the overall incidence is still rising. Unfortunately, the cancer registry in Poland does not record BCC individually. Thus, the incidence of BCC in a defined population is unknown.

Aim

Analysis of incidence rates of primary BCC in central Poland during 16 years considering sex, site distribution and age to determine trends.

Material and methods

We retrospectively included all cases of BCC which were diagnosed and treated in the Department of Dermatology and Venereology, Medical University of Lodz, during the 16-year period from 1999 to 2015.

Results

We recorded 945 BCCs occurring in 890 patients (504 females - 57%, 386 males - 43%). Patient's age was between 21 and 94. A distinct increase in BCC was observed after 1999, while after 2010 during the next 2-year period a slight decrease was noted. A statistically significant correlation was observed between histopathological types of BCC and the location of the lesions. The superficial type predominates on photoprotected areas, especially on the trunk, while the nodular type occurs mainly in facial areas. No statistically significant correlation was observed between histopathological types of BCC and sex. We found a significant increase in incidence for superficial BCC among middle-age patients, while the nodular type was observed more frequently among elderly subjects.

Conclusions

Basal cell carcinoma is quite common in Poland and predominantly develops in the facial area. In middle-age patients the most common is superficial BCC, while in elderly people the nodular type is most common. Based on our results we assume that there is a strong need to educate general physicians to enable them to diagnose BCC in the early stages.

Patterns of Ultraviolet Radiation Exposure and Skin Cancer Risk: the E3N-SunExp Study

BACKGROUND

While ultraviolet (UV) radiation exposure is a recognized risk factor for skin cancer, associations are complex and few studies have allowed a direct comparison of exposure profiles associated with cutaneous melanoma, basal-cell carcinoma (BCC), and squamous-cell carcinoma (SCC) within a single population.

METHODS

We examined associations between UV exposures and skin cancer risk in a nested case-control study within E3N, a prospective cohort of 98,995 French women born in 1925-1950. In 2008, a lifetime UV exposure questionnaire was sent to all reported skin cancer cases and three controls per case, which were matched on age, county of birth, and education. Analyses were performed using conditional logistic regression and included 366 melanoma cases, 1,027 BCC cases, 165 SCC cases, and 3,647 controls.

RESULTS

A history of severe sunburns <25 years was associated with increased risks of all skin cancers (melanoma: OR 2.7; BCC: OR 1.7; SCC: OR 2.0 for ≥6 sunburns vs. none), while sunburns ≥25 years were associated with BCC and SCC only. While high-sun protection factor sunscreen use before age 25 was associated with lower BCC risk (Ptrend = 0.02), use since age 25 and reapplication of sunscreen were associated with higher risks of all three types of skin cancer. There were positive linear associations between total UV score and risks of BCC (Ptrend = 0.01) and SCC (Ptrend = 0.09), but not melanoma. While recreational UV score was strongly associated with BCC, total and residential UV scores were more strongly associated with SCC.

CONCLUSIONS

Melanoma, BCC, and SCC are associated with different sun exposure profiles in women.

Emerging concepts and recent advances in basal cell carcinoma

Basal cell carcinoma (BCC) is the most common malignancy worldwide, arising from non-keratinizing cells within the basal layer of the epidermis. The incidence of BCC continues to rise annually, increasing the burden of management of these carcinomas and the morbidity associated with their treatment. While surgical interventions such as Mohs micrographic surgery and surgical excision are the standard of care and yield the highest cure rates, the number of non-surgical interventions approved for the treatment of BCC continues to expand. We review various surgical and non-surgical approaches to the treatment of BCC, focusing on targeted molecular therapies that are approved for locally advanced or recurrent disease.

Epidemiology of skin cancer in the mature patient

Epidermal cancers include keratinocyte cancer, melanocyte cancer, and Merkel cell carcinoma. These cancers account for the vast majority of new cancers diagnosed in Australia, North America, and Europe. Keratinocyte cancer is the most common epidermal cancer and accounts for 7 out of 8 new cancers diagnosed in Australia. Melanoma and Merkel cell carcinoma are less common than keratinocyte carcinoma but are more important causes of mortality in Australia. Keratinocyte cancer has also been demonstrated to be a marker of cancer-prone phenotype. Risk factors for epidermal cancer include intrinsic and environmental factors, in particular exposure to ultraviolet radiation and advanced age. Actinic keratosis has an approximate prevalence of 79% of men and 68% of women between 60 and 69 years of age, and has a low risk of malignant transformation into squamous cell carcinoma. Basal cell carcinoma is the most common malignancy in Caucasians worldwide, with the incidence increasing by 2% per year in Australia. Squamous cell carcinoma is the second most common epidermal cancer, with an incidence of approximately 1035 or 472 per 100,000 person-years in men and women, respectively. Primary risk factors for both basal cell carcinoma and squamous cell carcinoma include light skin color, UV radiation exposure, and chronic immunosuppression. Although the rate of melanoma is increasing, the mortality in Australia is reducing and is currently 9%. The overall incidence of melanoma in Australia is approximately 50 cases per 100,000 persons (62 for men and 40 for women). Keratinocyte carcinoma and melanoma are risk factors for developing further skin cancer and primary malignancy. This contribution reviews the incidence, prevalence, and risk factors associated with the development of epidermal cancer and premalignant epidermal neoplasia.

Early Life UV and Risk of Basal and Squamous Cell Carcinoma in New South Wales, Australia

Sun exposure is the main cause of squamous (SCC) and basal cell carcinoma (BCC) although pattern and amount differ by cancer type, and sun sensitivity is the major host risk factor. Our study investigated risk factors and residential ambient UV in a population-based sample of Australian 45 and Up Study participants: 916 BCC cases, 433 SCC cases, 1224 controls. Unconditional logistic regression models adjusting for key covariates demonstrated 60% increased BCC risk and two-fold increased SCC risk with sun sensitivity, and three- and four-fold increased risk, respectively, with solar keratoses. BCC but not SCC risk increased with higher early-life residential UV in all participants (odds ratio (OR) = 1.54; 95% CI 1.22-1.96 for intermediate; OR = 1.31; 95% CI 1.03-1.68 for high UV at birthplace) and similarly in Australian-born participants (P-values < 0.05). Risk of SCC but not BCC increased with long-term cumulative sun exposure assessed by self-reported outdoor work (OR 1.74, 95% CI 1.21-2.49). In conclusion, sun sensitivity is important for both cancers, early-life UV but not cumulative UV appears to increase BCC risk, the former an apparently novel finding, and SCC risk appears only to be related to long-term cumulative sun exposure.

Vitamin D3 Produced by Skin Exposure to UVR Inhibits Murine Basal Cell Carcinoma Carcinogenesis

The effect of UVR on human basal cell carcinoma (BCC) epidemiology is complex-the incidence rises until approximately 30,000 hours of lifetime sunlight exposure and then plateaus. We hypothesize that UVR has opposing effects on BCC carcinogenesis-stimulatory via mutagenesis and inhibitory via production of hedgehog-inhibiting vitamin D₃ (D₃). We find that UVR exposure of ionizing radiation-treated Ptch1^+/- mice accelerates BCC carcinogenesis in male mice, in which UVR does not produce D₃. By contrast, in female mice, in which UVR does produce D₃, UVR fails to accelerate BCC carcinogenesis, thus mirroring the plateauing in humans. However, if D₃ production is attenuated in female mice by deletion of keratinocyte lathosterol 5-desaturase, then UVR accelerates ionizing radiation-induced BCC carcinogenesis. Congruently, chronic topical application of D₃ inhibits ionizing radiation-induced BCC tumorigenesis. These findings confirm that UVR-induced production of D₃ in keratinocytes significantly restrains murine BCC tumorigenesis and demonstrate the counterintuitive conclusion that UVR has anti-BCC carcinogenic effects that can explain, at least in part, the complex relationship between exposure to UVR and BCC incidence.

Sun exposure and skin cancer, and the puzzle of cutaneous melanoma: A perspective on Fears et al. Mathematical models of age and ultraviolet effects on the incidence of skin cancer among whites in the United States. American Journal of Epidemiology 1977; 105: 420-427

Sunlight has been known as an important cause of skin cancer since around the turn of the 20th Century. A 1977 landmark paper of US scientists Fears, Scotto, and Schneiderman advanced a novel hypothesis whereby cutaneous melanoma was primarily caused by intermittent sun exposure (i.e. periodic, brief episodes of exposure to high-intensity ultraviolet radiation) while the keratinocyte cancers, squamous cell carcinoma and basal cell carcinoma, were primarily caused by progressive accumulation of sun exposure. With respect to cutaneous melanoma, this became known as the intermittent exposure hypothesis. The hypothesis stemmed from analysis of measured ambient ultraviolet radiation and age-specific incidence rates of melanoma and keratinocyte cancers collected as an extension to the US Third National Cancer Survey in several US States. In this perspective paper, we put this novel hypothesis into the context of knowledge at the time, and describe subsequent epidemiological and molecular research into melanoma that elaborated the intermittent exposure hypothesis and ultimately replaced it with a dual pathway hypothesis. Our present understanding is of two distinct biological pathways by which cutaneous melanoma might develop; a nevus prone pathway initiated by early sun exposure and promoted by intermittent sun exposure or possibly host factors; and a chronic sun exposure pathway in sun sensitive people who progressively accumulate sun exposure to the sites of future melanomas.

Effect of an intervention on observed sun protection by vacationers in a randomized controlled trial at North American resorts

During vacations, many individuals receive high-risk sun exposure that is associated with skin cancer. Vacationers in outdoor recreation venues (pretest n=4347; posttest n=3986) at warm-weather destination resorts in North America (n=41) were enrolled in a pair-matched, group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Print, audiovisual, and online messages based on Transportation Theory and Diffusion of Innovation Theory and promoting advanced sun protection (e.g., use of clothing, hats, shade and pre-application/reapplication of sunscreen and reliable cues to high UV) were delivered through resort channels. Vacationers' sun protection practices observed by trained research staff (i.e., body coverage and shade use analyzed individually and in combined scores) did not differ by experimental condition (p>0.05) or intervention implementation (p>0.05). However, recreation venue moderated intervention impact. The intervention improved sun protection at waterside recreation venues (z-score composite: intervention pre=-22.74, post=-15.77; control pre=-27.24, post=-23.24) but not non-waterside venues (z-score composite: intervention pre=20.43, post=20.53; control pre=22.94, post=18.03, p<0.01). An additional analysis showed that resorts with greater program implementation showed more improvements in sun protection by vacationers at waterside (z=score composite: high implementation pre=-25.45, post=-14.05; low implementation pre=-24.70, post=-21.40) compared to non-waterside (z-score composite: high implementation pre=14.51, post=19.98; low implementation pre=24.03, post=18.98, p<0.01) recreation venues. The intervention appeared effective with the vacationers in recreation venues with the highest-risk for sun exposure, waterside venues. However, it was not effective throughout all the resort venues, possibly because of the sun-seeking desires of vacationers, information overload at the resorts, and constraints on clothing styles and sun protection by recreation activity.

Non-melanoma skin cancer treated with high-dose-rate brachytherapy: a review of literature

PURPOSE

The incidence of non-melanoma skin cancer (NMSC) has been increasing over the past 30 years. There are different treatment options and surgical excision is the most frequent treatment due to its low rates of recurrence. Radiotherapy is an effective alternative of surgery, and brachytherapy (BT) might be a better therapeutic option due to high radiation dose concentration to the tumor with rapid dose fall-off resulting in normal tissues sparing. The aim of this review was to evaluate the local control, toxicity, and cosmetic outcomes in NMSC treated with high-dose-rate BT (HDR-BT).

MATERIAL AND METHODS

In May 2016, a systematic search of bibliographic database of PubMed, Web of Science, Scopus, and Cochrane Library with a combination of key words of "skin cancer", "high dose rate brachytherapy", "squamous cell carcinoma", "basal cell carcinoma", and "non melanoma skin cancer" was performed. In this systematic review, we included randomized trials, non-randomized trials, prospective and retrospective studies in patients affected by NMSC treated with HDR-BT.

RESULTS

Our searches generated a total of 85 results, and through a process of screening, 10 publications were selected for the review. Brachytherapy was well tolerated with acceptable toxicity and high local control rates (median: 97%). Cosmetic outcome was reported in seven study and consisted in an excellent and good cosmetic results in 94.8% of cases.

CONCLUSIONS

Based on the review data, we can conclude that the treatment of NMSC with HDR-BT is effective with excellent and good cosmetics results, even in elderly patients. The hypofractionated course appears effective with very good local disease control. More data with large-scale randomized controlled trials are needed to assess the efficacy and safety of brachytherapy.

Engaging Moms on Teen Indoor Tanning Through Social Media: Protocol of a Randomized Controlled Trial

BACKGROUND

Indoor tanning elevates the risk for melanoma, which is now the most common cancer in US women aged 25-29. Public policies restricting access to indoor tanning by minors to reduce melanoma morbidity and mortality in teens are emerging. In the United States, the most common policy restricting indoor tanning in minors involves parents providing either written or in person consent for the minor to purchase a tanning visit. The effectiveness of this policy relies on parents being properly educated about the harms of indoor tanning to their children.

OBJECTIVE

This randomized controlled trial will test the efficacy of a Facebook-delivered health communication intervention targeting mothers of teenage girls. The intervention will use health communication and behavioral modification strategies to reduce mothers' permissiveness regarding their teenage daughters' use of indoor tanning relative to an attention-control condition with the ultimate goal of reducing indoor tanning in both daughters and mothers.

METHODS

The study is a 12-month randomized controlled trial comparing 2 conditions: an attention control Facebook private group where content will be relevant to teen health with 25% focused on prescription drug abuse, a topic unrelated to tanning; and the intervention condition will enter participants into a Facebook private group where 25% of the teen health content will be focused on indoor tanning. A cohort of 2000 mother-teen daughter dyads will be recruited to participate in this study. Only mothers will participate in the Facebook groups. Both mothers and daughters will complete measures at baseline, end of intervention (1-year) and 6 months post-intervention. Primary outcomes include mothers' permissiveness regarding their teenage daughters' use of indoor tanning, teenage daughters' perception of their mothers' permissiveness, and indoor tanning by both mothers and daughters.

RESULTS

The first dyad was enrolled on March 31, 2016, and we anticipate completing this study by October 2019.

CONCLUSIONS

This trial will deliver social media content grounded in theory and will test it in a randomized design with state-of-the-art measures. This will contribute much needed insights on how to employ social media for health behavior change and disease prevention both for indoor tanning and other health risk behaviors and inform future social media efforts by public health and health care organizations.

CLINICALTRIAL

Clinicaltrials.gov NCT02835807; https://clinicaltrials.gov/ct2/show/NCT02835807 (Archived by WebCite at http://www.webcitation.org/6mDMICcCE).

Basal cell carcinoma in two Hermann’s tortoises (Testudo hermanni)

Neoplastic disorders are frequently encountered in the practice of reptile medicine. Herein we report the clinical behavior, antemortem diagnosis, and histopathologic characteristics of a recurrent intraoral keratinizing basal cell carcinoma (BCC) and a metastatic BCC of the carapace in 2 Hermann’s tortoises ( Testudo hermanni). Although squamous cell carcinomas (SCCs) in tortoises show similar predilection sites and gross pathologic features, the BCCs described in our report were characterized by a remarkably fast and highly infiltrative growth in comparison to SCCs. Accordingly, early diagnosis including reliable discrimination from SCC is essential toward the management of this neoplastic entity in tortoises.

Randomized Trial Testing a Worksite Sun Protection Program in an Outdoor Recreation Industry

Health communication campaigns intended to reduce chronic and severe exposure to ultraviolet radiation in sunlight and prevent skin cancer are a national priority. Outdoor workers represent an unaddressed, high-risk population. Go Sun Smart (GSS), a worksite sun safety program largely based on the diffusion-of-innovations theory, was evaluated in a pair-matched, group-randomized, pretest-posttest controlled design enrolling employees at 26 ski areas in Western North America. Employees at the intervention ski areas were more aware of GSS (odds ratio [OR] = 8.27, p < .05) and reported less sunburning (adjusted OR = 1.63, p < .05) at posttest than employees at the control areas. A dose response was evident (OR = 1.46, p < .05) with greater observed program implementation associated with fewer sunburns among employees. Program awareness per se was not predictive ( p > .05) of reduced sunburning in a mediational analysis. Analyses of nonrespondents, including intent-to-treat analyses, further supported the success of GSS.

Is early detection of basal cell carcinoma worthwhile? Systematic review based on the WHO criteria for screening

The incidence of basal cell carcinoma (BCC) has risen three- to fourfold over the last 30 years and is expected to continue to increase with ageing of the population. Although BCC has a good prognosis, it causes significant morbidity and has an important impact on the public health budget due to direct treatment costs. Based on the existing evidence, a systematic evaluation of the World Health Organization criteria was performed to determine whether earlier detection of BCC could reduce morbidity and cost. BCC slowly increases in size, with a median increase in diameter of 0·5 mm over 10 weeks. There is an important delay in diagnosis ranging from 19 to 25 months. In several studies BCC size was the main determinant of treatment cost, surgical complexity, reconstruction technique and the specific surgical procedure performed, such as Mohs micrographic surgery or surgical excision. One study showed that size also seems to affect the cost per treatment for other nonsurgical options. The use of vismodegib, an inhibitor of the hedgehog pathway, is confined to locally advanced or metastatic BCC. Delays in diagnosis and appropriate treatment are the most important underlying causes in the occurrence of giant BCC and/or BCC with metastasis. Although the latter represent only a very small fraction of all BCCs, the majority of them are located in the facial region. The available data point to a slow increase in the size of BCCs over time. Size is one of the major determinants in choice of treatment and the associated cost, especially for facial BCC. Therefore we conclude that current data support early detection and adequate management of BCCs on the face.

Estimation of individual cumulative ultraviolet exposure using a geographically-adjusted, openly-accessible tool

Background

Estimates of an individual’s cumulative ultraviolet (UV) radiation exposure can be useful since ultraviolet radiation exposure increases skin cancer risk, but a comprehensive tool that is practical for use in the clinic does not currently exist.

The objective of this study is to develop a geographically-adjusted tool to systematically estimate an individual’s self-reported cumulative UV radiation exposure, investigate the association of these estimates with skin cancer diagnosis, and assess test reliability.

Methods

A 12-item online questionnaire from validated survey items for UV exposure and skin cancer was administered to online volunteers across the United States and results cross-referenced with UV radiation indices. Cumulative UV exposure scores (CUES) were calculated and correlated with personal history of skin cancer in a case–control design. Reliability was assessed in a separate convenience sample.

Results

1,118 responses were included in the overall sample; the mean age of respondents was 46 (standard deviation 15, range 18 – 81) and 150 (13 %) reported a history of skin cancer. In bivariate analysis of 1:2 age-matched cases (n = 149) and controls (n = 298), skin cancer cases were associated with (1) greater CUES prior to first skin cancer diagnosis than controls without skin cancer history (242,074 vs. 205,379, p = 0.003) and (2) less engagement in UV protective behaviors (p < 0.01). In a multivariate analysis of age-matched data, individuals with CUES in the lowest quartile were less likely to develop skin cancer compared to those in the highest quartile. In reliability testing among 19 volunteers, the 2-week intra-class correlation coefficient for CUES was 0.94. We have provided the programming code for this tool as well as the tool itself via open access.

Conclusions

CUES is a useable and comprehensive tool to better estimate lifetime ultraviolet exposure, so that individuals with higher levels of exposure may be identified for counseling on photo-protective measures.

Electronic supplementary material

The online version of this article (doi:10.1186/s12895-016-0038-1) contains supplementary material, which is available to authorized users.

Non-melanoma skin cancer treated with high-dose-rate brachytherapy and Valencia applicator in elderly patients: a retrospective case series

PURPOSE

The incidence of non-melanoma skin cancer (NMSC) has been increasing over the past 30 years. Basal cell carcinoma and squamous cell carcinoma are the two most common subtypes of NMSC. The aim of this study was to estimate tumour control, toxicity, and aesthetic events in elderly patients treated with high-dose-rate (HDR) brachytherapy (BT) using Valencia applicator.

MATERIAL AND METHODS

From January 2012 to May 2015, 57 lesions in 39 elderly eligible patients were enrolled. All the lesions had a diameter ≤ 25 mm (median: 12.5 mm) and a depth ≤ 4 mm. The appropriate Valencia applicator, 2 or 3 cm in diameter was used. The prescribed dose was 40 Gy in 8 fractions (5 Gy/fraction) in 48 lesions (group A), and 50 Gy in 10 fractions (5 Gy/fraction) in 9 lesions (group B), delivered 2/3 times a week. The biological effective dose (BED) was 60 Gy and 75 Gy, respectively.

RESULTS

After median follow-up of 12 months, 96.25% lesions showed a complete response and only two cases presented partial remission. Radiation Therapy Oncology Group - European Organization for Research and Treatment of Cancer (RTOG/EORTC) G 1-2 acute toxicities were observed in 63.2% of the lesions: 56.3% in group A and 77.7% in group B. Late G1-G2 toxicities was observed in 19.3% of the lesions: 18.8% in group A and 22.2% in group B, respectively. No G3 or higher acute or late toxicities occurred. In 86% of the lesions, an excellent cosmetic result was observed (87.5% in group A and 77.8% in group B). Six lesions had a good cosmetic outcome and only 2.3% presented a fair cosmetic impact.

CONCLUSIONS

The treatment of NMSC with HDR-BT using Valencia surface applicator is effective with excellent and good cosmetics results in elderly patients. The hypofractionated course appears effective and no statistical differences were observed between the two groups analysed.

European Code against Cancer 4th Edition: Ultraviolet radiation and cancer

Ultraviolet radiation (UVR) is part of the electromagnetic spectrum emitted naturally from the sun or from artificial sources such as tanning devices. Acute skin reactions induced by UVR exposure are erythema (skin reddening), or sunburn, and the acquisition of a suntan triggered by UVR-induced DNA damage. UVR exposure is the main cause of skin cancer, including cutaneous malignant melanoma, basal-cell carcinoma, and squamous-cell carcinoma. Skin cancer is the most common cancer in fair-skinned populations, and its incidence has increased steeply over recent decades. According to estimates for 2012, about 100,000 new cases of cutaneous melanoma and about 22,000 deaths from it occurred in Europe. The main mechanisms by which UVR causes cancer are well understood. Exposure during childhood appears to be particularly harmful. Exposure to UVR is a risk factor modifiable by individuals' behaviour. Excessive exposure from natural sources can be avoided by seeking shade when the sun is strongest, by wearing appropriate clothing, and by appropriately applying sunscreens if direct sunlight is unavoidable. Exposure from artificial sources can be completely avoided by not using sunbeds. Beneficial effects of sun or UVR exposure, such as for vitamin D production, can be fully achieved while still avoiding too much sun exposure and the use of sunbeds. Taking all the scientific evidence together, the recommendation of the 4th edition of the European Code Against Cancer for ultraviolet radiation is: "Avoid too much sun, especially for children. Use sun protection. Do not use sunbeds."

Rationale, design, samples, and baseline sun protection in a randomized trial on a skin cancer prevention intervention in resort environments

INTRODUCTION

Exposure to solar ultraviolet radiation during recreation is a risk factor for skin cancer. A trial evaluated an intervention to promote advanced sun protection (sunscreen pre-application/reapplication; protective hats and clothing; use of shade) during vacations.

MATERIALS AND METHODS

Adult visitors to hotels/resorts with outdoor recreation (i.e., vacationers) participated in a group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Hotels/resorts were pair-matched and randomly assigned to the intervention or untreated control group. Sun. protection (e.g., clothing, hats, shade and sunscreen) was measured in cross-sectional samples by observation and a face-to-face intercept survey during two-day visits.

RESULTS

Initially, 41 hotel/resorts (11%) participated but 4 dropped out before posttest. Hotel/resorts were diverse (employees=30 to 900; latitude=24° 78' N to 50° 52' N; elevation=2ft. to 9726ft. above sea level), and had a variety of outdoor venues (beaches/pools, court/lawn games, golf courses, common areas, and chairlifts). At pretest, 4347 vacationers were observed and 3531 surveyed. More females were surveyed (61%) than observed (50%). Vacationers were mostly 35-60years old, highly educated (college education=68%) and non-Hispanic white (93%), with high-risk skin types (22%). Vacationers reported covering 60% of their skin with clothing. Also, 40% of vacationers used shade; 60% applied sunscreen; and 42% had been sunburned.

CONCLUSIONS

The trial faced challenges recruiting resorts but result showed that the large, multi-state sample of vacationers were at high risk for solar UV exposure.

The Sustainability of an Occupational Skin Cancer Prevention Program

OBJECTIVE

Sustainability of prevention programs is a public health goal.

METHODS

The effectiveness of Go Sun Smart, an occupational skin cancer prevention program, was evaluated 5 to 7 years out from the conclusion of a controlled randomized dissemination trial that compared an enhanced versus basic dissemination strategy at 53 ski areas enrolled in the trial.

RESULTS

Employees (n = 2940) at ski areas in the enhanced condition reported fewer sunburns but did not differ from employees in the basic condition on other sun-protection measures. Significant differences for all sun-protection practices were identified at ski areas that displayed nine or more Go Sun Smart materials or a combined total of nine or more Go Sun Smart and other sun safety messages.

CONCLUSIONS

Exposure to prevention messages is an important determinant of program effectiveness and potentially of program sustainability.

Histopathological study of perilesional skin in patients diagnosed with nonmelanoma skin cancer

BACKGROUND

Epidemiological and clinical data suggest that actinic damage to the skin is an important predictor of skin carcinogenesis.

AIM

To investigate the association of squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) with sun-damage alterations seen by histopathology.

METHOD

In the current prospective study, perilesional skin of SCC or BCC lesions was evaluated for presence of alterations associated with chronic photodamage. Presence of scarring, perineural/perivascular invasion, haemorrhage/haemorrhagic crust, ulceration/erosion and margin involvement were also assessed.

RESULT

Of 6038 included lesions, 4523 (74.9%) were BCCs and 1515 (25.1%) were SCCs. Presence of actinic damage was five times more frequent in SCC than in BCC (OR = 5.29, 95% CI 4.44-6.00, P < 0.001), and diagnosis of SCC was twice as common in photo-exposed than nonphoto-exposed body sites (OR = 2.34, 95% CI 2.03-2.70, P < 0.001). There were twofold higher odds for actinic damage in SCC compared with Bowen disease (OR = 2.015, 95% CI 1.55-2.61, P < 0.001). Assessing the different BCC histological subtypes, we found that nodular BCC had at least twofold higher odds (OR = 2.63, 95% CI 2.09-3.32), infiltrative BCC had 48% higher odds (OR = 1.487, 95% CI 1.18-1.87) and basosquamous BCC had fourfold higher odds (OR = 4.10, 95% CI 3.01-5.57) of having actinic damage compared with superficial BCC.

CONCLUSIONS

Histological verification of ultraviolet-associated alterations in the perilesional skin in patients with NMSC in our study confirms the aetiopathogenic link between sun exposure and epithelial carcinogenesis on a histopathological basis. This correlation was stronger for SCCs than for BCCs.

Sustained use of an occupational sun safety program in a recreation industry: follow-up to a randomized trial on dissemination strategies

The sustainability of evidence-based programs is needed to obtain long-term benefits. To assess sustainability of Go Sun Smart (GSS), an occupational skin cancer prevention program disseminated to the North American ski industry. Fifty-three of the 68 ski areas from the original dissemination trial participated in 2012 and 2013, 5 to 7 years after program distribution by enhanced or basic dissemination strategies. Sustained use was measured by: (1) on-site observation of sun protection communication and (2) an online survey with senior managers. In the sustainability assessment, sun safety communication had declined, and dissemination strategy did not affect continued use. Managers held weaker attitudes about skin cancer importance and program fit, but more managers provided free/reduced-cost sunscreen than in the dissemination trial. Manager turnover was a key factor in program discontinuance. Sustainability remains a challenge. Additional research is needed to determine the best strategies for sustainability.

Basal cell carcinomas on sun-protected vs. sun-exposed body sites: a comparison of phenotypic and environmental risk factors

BACKGROUND

Basal cell carcinoma (BCC) is the most commonly diagnosed cancer in White populations. There are indications that risk factors for BCC may differ according to the anatomic site of the tumour but this is not well understood.

PURPOSE

To compare phenotypic and environmental risk factors for BCCs arising on sun-protected sites with that of those on sun-exposed sites.

METHODS

We conducted a case-case study in which people who had been diagnosed with incident BCC were recruited between February 2012 and September 2013 in Brisbane, Australia.

RESULTS

Fair skin (OR: 4.50; 95% CI: 1.22, 16.59), having more than 15 lesions frozen/burnt off compared to less than 5 (OR: 5.68; 95% CI: 1.78, 18.08) and severe acne (OR: 5.25; 95% CI: 1.34, 20.56) were associated with increased risk of BCC on sun-protected sites. The presence of more than 5 nevi on the body was associated with decreased risk (OR: 0.28; 95% CI: 0.11, 0.71).

CONCLUSIONS

BCCs on sun-protected sites arise as a result of excessive sun exposure, most likely combined with phenotypic susceptibility. The strong negative association with nevi also suggests that there are constitutional factors that underlie the propensity for BCCs to arise on these body sites.

Non-melanoma Skin Cancer in Canada Chapter 2: Primary Prevention of Non-melanoma Skin Cancer

BACKGROUND

Non-melanoma skin cancer (NMSC), including basal and squamous cell carcinoma (BCC and SCC), represents the most common malignancy.

OBJECTIVE

To provide guidance to Canadian health care practitioners regarding primary prevention of NMSC.

METHODS

Structured literature searches were conducted, using search terms including prevention, sunscreen, and sun prevention factor. All recommendations concern guidance that physicians should regularly discuss with their patients to help establish photoprotection habits. The GRADE system was used to assign strength to each recommendation.

RESULTS

Ultraviolet exposure is the major modifiable risk factor for NMSC. Aspects of photoprotection, including effective sunscreen use and avoidance of both the midday sun and artificial tanning, are discussed. Several widespread misunderstandings that undermine responsible public health measures related to sun safety are addressed.

CONCLUSIONS

Photoprotection represents both an individual priority and a public health imperative. By providing accurate information during routine patient visits, physicians reinforce the need for ongoing skin cancer prevention.

A general model to predict individual exposure to solar UV by using ambient irradiance data

Excessive exposure to solar ultraviolet (UV) is the main cause of skin cancer. Specific prevention should be further developed to target overexposed or highly vulnerable populations. A better characterisation of anatomical UV exposure patterns is however needed for specific prevention. To develop a regression model for predicting the UV exposure ratio (ER, ratio between the anatomical dose and the corresponding ground level dose) for each body site without requiring individual measurements. A 3D numeric model (SimUVEx) was used to compute ER for various body sites and postures. A multiple fractional polynomial regression analysis was performed to identify predictors of ER. The regression model used simulation data and its performance was tested on an independent data set. Two input variables were sufficient to explain ER: the cosine of the maximal daily solar zenith angle and the fraction of the sky visible from the body site. The regression model was in good agreement with the simulated data ER (R(2)=0.988). Relative errors up to +20% and -10% were found in daily doses predictions, whereas an average relative error of only 2.4% (-0.03% to 5.4%) was found in yearly dose predictions. The regression model predicts accurately ER and UV doses on the basis of readily available data such as global UV erythemal irradiance measured at ground surface stations or inferred from satellite information. It renders the development of exposure data on a wide temporal and geographical scale possible and opens broad perspectives for epidemiological studies and skin cancer prevention.

Novel medical strategies combating nonmelanoma skin cancer

The incidence of nonmelanoma skin cancer (NMSC) continues to rise, partly because of aging, the frequency of early childhood sunburns, and sporadic extreme recreational sun exposure. A nonsurgical approach to selected cutaneous malignancy could possibly reduce the cost as well as morbidity of surgical treatment for NMSC. There has been growing interest in isolating compounds that could suppress or reverse the biochemical changes necessary for cutaneous malignancies to progress by pharmacologic intervention. By targeting diverse pathways recognized as important in the pathogenesis of nonmelanoma skin cancers, a combination approach with multiple agents or addition of chemopreventative agents to topical sunscreens may offer the potential for novel and synergistic therapies in treating nonmelanoma skin cancer. This preliminary information will expand to include more therapeutic options for NMSC in the future.

Sunlight exposure and photoprotection behaviour of white Caucasian adolescents in the UK

BACKGROUND

Sun exposure has positive and negative effects on health, yet little is known about the sun exposure behaviour of UK adolescents, including those more prone or less prone to sunburn.

OBJECTIVE

To examine sun exposure behaviour of UK white Caucasian adolescents including time spent outdoors, holiday behaviour, use of sunscreen and clothing, with assessment for differences between sun-reactive skin type groups.

METHODS

White Caucasian adolescents (12-15 years) attending schools in Greater Manchester completed a two-page questionnaire to assess sun exposure and photoprotective behaviour.

RESULTS

A total of 133 adolescents (median age 13.4 years; 39% skin type I/II, 61% skin type III/IV) completed the questionnaire. In summer, adolescents spent significantly longer outdoors at weekends (median 4 h/day, range 0.25-10) than on weekdays (2, 0.25-6; P < 0.0001). When at home in the UK during summer, 44% reported never wearing sunscreen compared to just 1% when on a sunny holiday. Sunscreen use was also greater (frequency/coverage) when on a sunny holiday than at home in the UK summer (P < 0.0001). Adolescents of skin types I/II (easy burning) spent significantly less time outdoors than skin types III/IV (easy tanning) on summer weekends (P < 0.001), summer weekdays (P < 0.05) and on a sunny holiday (P = 0.001). Furthermore, skin types I/II reported greater sunscreen use during summer in the UK and on sunny holiday (both P < 0.01), and wore clothing covering a greater skin area on a sunny holiday (P < 0.01) than skin types III/IV. There was no difference in sun exposure behaviour/protection between males and females.

CONCLUSION

The greater sun-protective measures reported by adolescents of sun-reactive skin type group I/II than III/IV suggest those who burn more easily are aware of the greater need to protect their skin. However, use of sunscreen during the UK summer is low and may need more effective promotion in adolescents.

Basal cell carcinoma in Singapore: a prospective study on epidemiology and clinicopathological characteristics with a secondary comparative analysis between Singaporean Chinese and Caucasian patients

BACKGROUND/OBJECTIVES

Susceptibility to and clinical presentation of basal cell carcinoma (BCC) differ in Asian and Caucasian populations. This study aims to evaluate the epidemiological and clinicopathological characteristics of BCC in a multiracial Singaporean population, with a secondary comparative analysis between Chinese and Caucasian patients.

METHODS

We prospectively studied patients with newly diagnosed, histologically confirmed BCC at the National Skin Centre, Singapore from 2004 to 2008.

RESULTS

In total, 274 BCC from 260 patients were studied, with 19 patients having two or more tumours. Their mean age was 67.5 years and 54% were male. Chinese comprised 80% and Caucasians 14%. The Chinese were 1.8-fold as likely as Caucasians to be older than 60 years, and experienced itch thrice more frequently. Caucasians developed multiple BCC threefold and truncal or upper limb BCC 2.9-fold more frequently than the Chinese. In terms of tumour subtype, morphoeic BCC was 2.7-fold more common in Caucasians. Pigmented BCC occurred 2.7-fold more often in the Chinese, most frequently on the head and neck of elderly Chinese.

CONCLUSIONS

Compared to the Chinese, BCC occurred more often in younger Caucasians, with a predilection for the trunk and upper limb, suggesting a greater role for recreational sun exposure as a risk factor. Pigmented BCC more commonly occurred on the head and neck of elderly Chinese and may be reflective of cumulative sun exposure as a risk factor. Aggressive morphoeic BCC was more common in Caucasians than in Singaporean Chinese patients.

Dissemination of go sun smart in outdoor recreation: effect of program exposure on sun protection of guests at high-altitude ski areas

Go Sun Smart is a theory-based health communication program designed to influence sun-protection behaviors of employees and guests at high-altitude ski areas to reduce skin cancer risk. The effects of Go Sun Smart, in a Phase IV dissemination randomized posttest-only trial, on sun-protection behaviors of ski area guests are reported. Program use was assessed by on-site observation and guest message exposure, and sun protection was measured in intercept surveys at ski areas. Dissemination strategy-enhanced versus basic-was not significantly related to sun safety practices. Additional analyses examined the relation between message exposure and guests' sun safety practices. Ski areas displaying at least 6 Go Sun Smart materials in guest-only areas and 9 Go Sun Smart materials throughout the area increased guests' message exposure. Higher message exposure within the high-use ski areas was associated with improved sun protection by guests but not within the low-use ski areas. The authors underscore the importance of program implementation and message exposure on the success of evidence-based health communication efforts applied industrywide.

Estimating the risk of squamous cell cancer induction in skin following nonlinear optical imaging

High power femto-second (fs) laser pulses used for in-vivo nonlinear optical (NLO) imaging can form cyclobutane pyrimidine dimers (CPD) in DNA, which may lead to carcinogenesis via subsequent mutations. Since UV radiation from routine sun exposure is the primary source of CPD lesions, we evaluated the risk of CPD-related squamous cell carcinoma (SCC) in human skin due to NLO imaging relative to that from sun exposure. We developed a unique cancer risk model expanding previously published estimation of risk from exposure to continuous wave (CW) laser. This new model showed that the increase in CPD-related SCC in skin from NLO imaging is negligible above that due to regular sun exposure.

Early-onset basal cell carcinoma and indoor tanning: a population-based study

OBJECTIVE

Indoor tanning with UV radiation-emitting lamps is common among adolescents and young adults. Rising incidence rates of basal cell carcinoma (BCC) have been reported for the United States and elsewhere, particularly among those diagnosed at younger ages. Recent epidemiologic studies have raised concerns that indoor tanning may be contributing to early occurrence of BCC, and younger people may be especially vulnerable to cancer risk associated with this exposure. Therefore, we sought to address these issues in a population-based case-control study from New Hampshire.

METHODS

Data on indoor tanning were obtained on 657 cases of BCC and 452 controls ≤50 years of age.

RESULTS

Early-onset BCC was related to indoor tanning, with an adjusted odds ratio (OR) of 1.6 (95% confidence interval, 1.3-2.1). The strongest association was observed for first exposure as an adolescent or young adult, with a 10% increase in the OR with each age younger at first exposure (OR per year of age ≤23 = 1.1; 95% confidence interval, 1.0-1.2). Associations were present for each type of device examined (ie, sunlamps, tanning beds, and tanning booths).

CONCLUSIONS

Our findings suggest early exposure to indoor tanning increases the risk of early development of BCC. They also underscore the importance of counseling adolescents and young adults about the risks of indoor tanning and for discouraging parents from consenting minors to this practice.

Are interventions to promote sun-protective behaviors in recreational and tourist settings effective? A systematic review with meta-analysis and moderator analysis

BACKGROUND

Intermittent sun exposure and sunburn are risk factors for skin cancer that mostly occur in recreational/tourist settings. This review assesses the efficacy of skin cancer prevention interventions designed to promote sun-protective behaviors in recreational/tourist settings.

METHODS

Systematic review with meta-analyses of controlled trials with outcome measures of sun-protective behaviors and/or sunburn published until January 2011.

RESULTS

Twenty-three studies were included. We found no evidence for the efficacy of current interventions in reducing tanning or promoting protective clothing and seeking shade. Meta-analyses show a small heterogeneous effect for interventions on sun-protective behavior indices. Larger but heterogeneous effects were observed for self-reported sun exposure and sunburns. Modest methodological quality suggests risk of bias. Effective interventions were more likely to stimulate social norms supporting sun-protective behaviors and provide appearance-based information about photoaging illustrated with ultraviolet photographs.

CONCLUSION

There is weak and inconclusive evidence for the efficacy of interventions in promoting sun-protective behaviors.