Sun exposure and risk of melanoma

Country of origin, age at migration and risk of cutaneous melanoma: a migrant cohort study of 1,100,000 Israeli men

Cutaneous melanoma (CM) is a common cancer with increasing incidence in many parts of the world where light-skinned populations live. We conducted a large-scale nationally representative migrant cohort study to assess country of origin and age at migration as predictors of CM, controlling for possible confounders. Data on 1,086,569 Israeli Jewish males, who underwent a general health examination before compulsory military service at ages 16-19 between the years 1967-2005, were linked to Israel National Cancer Registry to obtain incident CM up to 2006. Cox proportional hazards was used to model time to event. Overall, 1562 incident cases were detected during 19.3 million person-years of follow-up. Origin was a strong independent predictor of CM. Incidence was higher for European (hazard ratio [HR] = 4.08, 95% confidence interval [CI]: 3.55-4.67) and Israeli origin (HR = 2.92, 95% CI: 2.25-3.79) compared to N. African/Asian origin, adjusted for year of birth, years of education, residential socio-economic position, rural residence and body surface area (or height). Among those of European origin, the adjusted risk was significantly lower for those who immigrated after the age of 10 years (HR = 0.58, 95% CI: 0.45-0.73) but not for younger ages (HR = 1.02, 95% CI 0.84-1.23) compared to Israeli born. The high rates of CM among men of European origin and the almost twofold lower risk among those immigrating after age 10 provide solid support for the deleterious role of childhood sun exposure as a risk factor for melanoma. These findings will serve in directing public health and research efforts.

Sun protection practices among children with a family history of melanoma: a pilot study

The goal of this pilot study was to assess sun protection practices and correlates among children with a family history of melanoma, a high risk and understudied group. Sixty-eight melanoma cases, recruited through the Los Angeles County cancer registry, completed a survey. Survivors provided data on 110 children (mean age = 8.11 years). Although most children used sunscreen (79 %), half experienced a recent sunburn. The mean sun protection level for the sample was similar to levels observed among average risk children. Efforts to reduce sunburn frequency and improve sun protection among these vulnerable children appear warranted.

Primary school sun protection policies and practices 4 years after baseline--a follow-up study

Before the 2005 launch of the New Zealand SunSmart Schools Accreditation Programme (SSAP), 242 randomly sampled primary schools completed a mail survey about sun protection policies, practices, curriculum and environment. A 2009 follow-up included 189 (78%) and their mean Total Accreditation Score (TAS = total SSAP requirements met, range 0-12), increased by 0.8 (95% CI 0.5-1.2, P < 0.001) from 7.8 (95% CI 7.4-8.1) to 8.6 (95% CI 8.3-8.9) with evidence changes differed between regions (P = 0.024). The 2009 mean TAS varied by region (range 7.9-9.4, unadjusted P = 0.004, adjusted P = 0.013) with no clear pattern, but likely resource allocation association. TAS of schools acknowledging input from Health Promoting Schools demonstrated a tendency towards being statistically significantly higher by 0.5 (95% CI -0.1 to 1.1, P = 0.082), but statistically significantly higher by 1.1 (95% CI 0.5-1.7, P < 0.001) for schools acknowledging Cancer Society input. Lowest attainment was for the clothing (43%), shade (52%) and curriculum (55%) criteria. Key perceived barriers were cost, particularly of shade and limited support by parents and others. Schools which had not applied for accreditation identified lack of programme awareness and 'other priorities' as barriers; further information, better resourcing and training assistance as key needs. Observed positive change justifies increased support to consolidate gains and achieve sustainable universality.

High incidence of skin cancer in the Channel Islands

BACKGROUND

Previous studies looking at rates of malignant melanoma (MM) and nonmelanoma skin cancer (NMSC) in the UK have documented one of the highest rates in the southwest of England; however, the incidence of these tumours in Guernsey and Jersey, two of the Channel Islands, has not previously been reported.

AIMS

To determine the incidence of cutaneous MM and NMSC in the Channel Islands.

METHODS

Data for the period 2005-2009 were obtained from clinical and histopathological records for all MMs excised in the Channel Islands, and from the South-west Cancer Registry for MMs excised in the southwest of England and for NMSCs in both areas. The age-standardized incidence rate (ASRs) per 100,000 of the population in the Channel Islands were compared with those with the southwest of England, the UK and the rest of Europe where available. The MM characteristics of the Channel Islands were then compared with the southwest of England using standardized incidence ratios (SIRs).

RESULTS

The ASR/100,000 for cutaneous MM for 2005-2009 was 30 for the Channel Islands (31.3 for Jersey, 28.2 for Guernsey), 20.3 for the southwest of England, and 15.6 for the UK. Comparison with the rest of Europe indicated that the incidence of MM in the Channel Islands is one of the highest in Europe. The highest incidence of MM was in the over 65 years age group on both Guernsey and Jersey, and when divided into 5-year age bands, the 70-74 years age group had the highest rate. This suggests that this particular age group may have previously received greater exposure to some environmental factor that promotes MM development. The ASR/100,000 for NMSC was also higher for the Channel Islands (263.3) than for the southwest of England (174.6) for 2005-2009, and for the UK in 2009 (104.9).

CONCLUSIONS

This study indicates that the Channel Islands have a high incidence of skin cancer (both MM and NMSC). In addition, the data show that the ASRs in older people in this population group differ from those in mainland UK, showing higher rates in the over 65 years age group.

Radiotherapy as a risk factor for malignant melanoma after childhood skin hemangioma

The aim of this study was to determine therapy-related risk factors for the development of melanoma after hemangioma. A cohort study was conducted among 4620 patients treated before 16 years of age for skin hemangioma in France. A nested case-control study was also conducted on 13 patients who developed a melanoma (cases) matched with five controls in cohort according to sex, age at the hemangioma diagnostic, the calendar year of occurrence of the hemangioma, and follow-up. The radiation dose received at the site of the melanoma and at the same site in controls was estimated, and named 'local dose'. A total of 13 melanomas were registered during an average follow-up of overall 35 years, the risk of developing melanoma after a hemangioma treatment was 2.5-fold higher [95% confidence interval (CI): 1.4-4.1] compared with that of the general population, this ratio being only 0.8 (95% CI: 0.05-3.6) in 896 patients who did not receive radiotherapy, but 3.0 (95% CI: 1.6-5.1) after radiotherapy. When adjusting on sex, age, and year of the treatment and follow-up duration, melanoma risk was 11.9 (95% CI: 1.4-123) times higher in patients treated with ytrium 90 than in the ones who did not received radiotherapy. In the case-control study, the risk of melanoma was not linked to the local radiation dose. Indeed, the increase in melanoma risk was observed even for very low local doses. Compared with the corresponding skin areas in patients who did not receive radiotherapy, the ones having received less than 0.001 Gy had a melanoma risk of 3.9 (95% CI: 0.5-32) and those who received more than 0.01 Gy had a risk of 6.9 (0.5-99). This study suggests that radiation therapy of skin hemangioma increases the risk of further melanoma, but we were not able to evidence a relation with the local dose. Nevertheless, childhood treated for hemangioma should be considered at risk for developing melanoma and suspicious pigmented lesions should be carefully evaluated even far from treated areas.

Visual images for skin cancer prevention: a systematic review of qualitative studies

Visual images play an important role in educating the public about skin cancer prevention. The objectives of this systematic review were to: 1) determine how visual images are evaluated in skin cancer and tanning qualitative research studies (including theoretical and methodological approaches) and 2) summarize and discuss the image-related findings of the studies with respect to cancer education and public health. Seven databases were searched (PubMed-MEDLINE, EMBASE, PsycINFO, Sociological Abstracts, Social Sciences Full Text, ERIC, and ABI/INFORM) using multiple search terms, including MeSH terms, resulting in 5330 citations. Studies were included if they were in English, peer-reviewed, qualitative in design or methodology, dealt with skin cancer or UV exposure, used visual images, and had a focus on the public or patients (i.e., not medical professionals). Eight studies met the inclusion criteria: seven content analyses and one focus group study. Content analysis studies in this review suggest the mass media portray Caucasian men and women as unprotected from the sun and with tanned skin, and thus, may inform behaviors related to skin cancer risk. The focus group study suggests visible minorities may benefit from the incorporation of images of melanoma on ethnic skin in cancer education materials. None of the studies used visual communication theory to explicitly guide the research, nor were standardized tools used for image assessment. The lack of guiding theory and standardized assessment instruments can introduce bias in how images are selected and used in research on skin cancer education.

Ultraviolet radiation and melanoma

Melanoma is a particularly aggressive type of skin cancer, and its incidence has been increasing steadily since the 1970s. This article will review the extensive epidemiologic data demonstrating that ultraviolet radiation (UVR) exposure, from the sun or artificial tanning beds, is the most important environmental risk factor for melanoma; the multiple detrimental effects of UVR on human skin, including DNA damage through the formation of dimeric photoproducts, gene mutations, oxidative stress, inflammation, and immunosuppression, all of which contribute to melanomagenesis; and the evidence that protection from UVR exposure, whether by melanin or by sunscreen, reduces the risk of developing melanoma.

Compliance with age and skin type restrictions following the introduction of indoor tanning legislation in Melbourne, Australia

BACKGROUND/PURPOSE

The study aimed to establish compliance of indoor tanning businesses with 2009 legislation, particularly with requirements to provide information on skin cancer and exclude people under 18 or with fair skin.

METHODS

Compliance was tested through surveys and in-person visits to 30 businesses in Melbourne, Australia. Research assistants presented as potential customers with different profiles: young adults eligible to use a sunbed, young adults with fair skin, under age customers who prompted with their age and under age customers who concealed their age and claimed to be 18 if asked.

RESULTS

Communicating the risks of skin cancer during the visit improved from 70% in 2003, prior to the introduction of legislation, to 97% in 2009. While there were improvements in restricting access to sunbeds among high-risk groups, compliance of indoor tanning businesses with age and skin type restrictions remained less than optimal. Almost half (47%) allowed access to fair-skinned research assistants, compared with 90% in 2003. Only one of the 30 operators allowed access to a teenager who prompted with her age; in 2003, 52% of under age teenagers were granted access without parental consent. However, when teenagers concealed their age or claimed to be 18, 80% of operators granted them access.

CONCLUSIONS

The findings suggest that regulation of the indoor tanning industry is a better approach to this health issue than voluntary standards and/or education. Nonetheless, inadequate compliance with requirements to exclude high-risk groups lends weight to calls for stricter monitoring and enforcement, or an absolute ban.

Solar UV exposure of children in a summer school in Valencia, Spain

Ultraviolet (UV) exposure is the major environmental factor involved in the development of skin cancers and occurs mainly during outdoor activities. During summer schools, children receive regular and significant solar ultraviolet erythemal radiation (UVER) while practising outdoor activities. Personal dosimeters (VioSpor) were attached to the shoulders of schoolchildren and used to quantify their exposure to UVER. The study took place in Valencia, Spain, during July 2008, with three age groups (7-8, 9-10 and 11-12 years old) and involved about 15 schoolchildren. The median (25, 75 percentiles) twice-daily UV exposure values for all groups was 5.49 (3.59, 8.00) standard erythemal doses (SEDs), where 1 SED is defined as effective 100 Jm(-2) when weighted with the CIE erythemal response function. Exposure ratio (ER) is defined as the ratio between the personal dose on a selected body site and the corresponding ambient dose received on a horizontal plane during the same exposure period. The median (25, 75 percentiles) ER value for all groups in the study was 5.9% (4.1, 8.7).

Polymorphisms in nevus-associated genes MTAP, PLA2G6, and IRF4 and the risk of invasive cutaneous melanoma

An evolving hypothesis postulates that melanomas may arise through 'nevus-associated' and 'chronic sun exposure' pathways. We explored this hypothesis by examining associations between nevus-associated loci and melanoma risk across strata of body site and histological subtype. We genotyped 1028 invasive case patients and 1469 controls for variants in methylthioadenosine phosphorylase (MTAP), phospholipase A2, group VI (PLA2G6), and Interferon regulatory factor 4 (IRF4), and compared allelic frequencies globally and by anatomical site and histological subtype of melanoma. Odds-ratios (ORs) and 95% confidence intervals (CIs) were calculated using classical and multinomial logistic regression models. Among controls, MTAP rs10757257, PLA2G6 rs132985 and IRF4 rs12203592 were the variants most significantly associated with number of nevi. In adjusted models, a significant association was found between MTAP rs10757257 and overall melanoma risk (OR = 1.32, 95% CI = 1.14-1.53), with no evidence of heterogeneity across sites (Phomogeneity =.52). In contrast, MTAP rs10757257 was associated with superficial spreading/nodular melanoma (OR = 1.34, 95% CI = 1.15- 1.57), but not with lentigo maligna melanoma (OR = 0.79, 95% CI = 0.46-1.35) (Phomogeneity =.06), the subtype associated with chronic sun exposure. Melanoma was significantly inversely associated with rs12203592 in children (OR = 0.35, 95% CI = 0.16-0.77) and adolescents (OR = 0.61, 95% CI = 0.42-0.91), but not in adults (Phomogeneity =.0008). Our results suggest that the relationship between MTAP and melanoma is subtype-specific, and that the association between IRF4 and melanoma is more evident for cases with a younger age at onset. These findings lend some support to the 'divergent pathways' hypothesis and may provide at least one candidate gene underlying this model. Further studies are warranted to confirm these findings and improve our understanding of these relationships.

A randomised controlled trial using mobile advertising to promote safer sex and sun safety to young people

Mobile phone text messages (SMS) are a promising method of health promotion, but a simple and low cost way to obtain phone numbers is required to reach a wide population. We conducted a randomised controlled trial with simultaneous brief interventions to (i) evaluate effectiveness of messages related to safer sex and sun safety and (ii) pilot the use of mobile advertising for health promotion. Mobile advertising subscribers aged 16-29 years residing in Victoria, Australia (n = 7606) were randomised to the 'sex' or 'sun' group and received eight messages during the 2008-2009 summer period. Changes in sex- and sun-related knowledge and behaviour were measured by questionnaires completed on mobile phones. At follow-up, the sex group had significantly higher sexual health knowledge and fewer sexual partners than the sun group. The sun group had no change in hat-wearing frequency compared with a significant decline in hat-wearing frequency in the sex group. This is the first study of mobile advertising for health promotion, which can successfully reach most young people. Challenges experienced with project implementation and evaluation should be considered as new technological approaches to health promotion continue to be expanded.

Cisplatin regulates the MAPK kinase pathway to induce increased expression of DNA repair gene ERCC1 and increase melanoma chemoresistance

The incidence of malignant melanoma is growing rapidly worldwide and there is still no effective therapy for metastatic disease. Melanoma is the second most common cancer among young adults in the UK, where incidence rates have more than quadrupled since the 1970s. Increased expression of a number of DNA repair genes has been reported in melanoma and this likely contributes to its extreme resistance to conventional DNA-damaging chemotherapeutics. One such chemotherapeutic that is effective against a range of other cancers, but not melanoma, is cisplatin. The DNA repair proteins ERCC1 and XPF are needed to remove cisplatin-induced DNA damage and we have investigated the response of these proteins to cisplatin in melanoma. The expression of both genes is induced by cisplatin. Use of a MEK inhibitor showed that ERCC1, but not XPF induction was regulated by the mitogen-activated protein kinase (MAPK) pathway, with reduction in expression of DUSP6, the phosphatase that inactivates the extracellular signal-regulated kinase (ERK), being particularly important. DUSP6 overexpression prevented cisplatin induction of both ERCC1 and XPF, resulting in increased sensitivity to cisplatin. A novel ERCC1 mRNA was found that initiated upstream of the normal transcription initiation site, and was strongly regulated by both cisplatin and the MAPK pathway and its role in cisplatin resistance merits further study. The cisplatin induction of ERCC1 and XPF provides important insights into the resistance of melanoma to DNA-damaging chemotherapeutics, which is one of the major obstacles to melanoma treatment.

UV and children's skin

There is indicative epidemiological evidence that exposures of children younger than about 10 years are linked with an increased risk of the development of malignant melanoma as well as non-melanocytic skin cancers later in life. However, an important area of uncertainty relates to lack of knowledge of the sun-sensitivity of children's skin both absolutely and relative to that of adult's skin. For example the thickness of children's skin is very similar to that of adults but due to the nature of the anatomical structure of children's skin, there are indications of children's skin being adversely exposed on the top of the papilla before a significant exposure manifests itself as visible damage to the skin (for example erythema). This might also affect the induction of heavily UV-damaged cells persisting in the basal layer of the epidermis after UV-exposure which are supposed to be keratinocytic epidermal stem cells and may characterize an initiation step of non-melanoncytic skin cancer. For malignant melanoma the number of nevi received in dependence of UV-exposure in childhood is a clear risk factor. Recent data show that the bulge region of hair follicles hosting melanocytic stem cells are located deeper (more protected) in the skin in adults (terminal hair) as compared to pre-pubertal children (vellus hair). This may be an explanation for enhanced risk of malignant melanoma due to UV-exposure in pre-pubertal childhood.

Skin cancer--primary and secondary prevention (information campaigns and screening)--with a focus on children & sunbeds

Solar and artificial (sunbed) UV-exposure is the main risk factor for the development of epithelial skin cancer (basal cell carcinoma, BCC, and squamous cell carcinoma, SCC) as well for malignant melanoma (MM). UV exposure in childhood and adolescence is especially important. Therefore, adequate methods of primary prevention have continuously to be used and to be developed further to target these age-groups in order to reduce the risks of intensive UV-exposure. Primary prevention can effectively be combined with secondary prevention (early detection, screening) to reduce the burden of skin cancer and to decrease incidence, morbidity and mortality.

Menopausal hormone therapy and risks of melanoma and nonmelanoma skin cancers: women's health initiative randomized trials

BACKGROUND

Case-control studies have reported that exogenous estrogen use is associated with increased risk of skin cancer. The effects of menopausal hormone therapy on incidence of nonmelanoma skin cancer and melanoma were evaluated in post hoc analyses of the Women's Health Initiative randomized placebo-controlled hormone therapy trials of combined estrogen plus progestin (E + P) and estrogen only (E-alone).

METHODS

Postmenopausal women aged 50-79 years were randomly assigned to conjugated equine estrogen (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) or placebo in the E + P trial if they had an intact uterus (N = 16,608) or to conjugated equine estrogen alone or placebo in the E-alone trial if they had a hysterectomy (N = 10,739); the mean follow-up was 5.6 and 7.1 years, respectively. Incident nonmelanoma skin cancers (n = 980 [E + P trial]; n = 820 [E-alone trial]) and melanomas (n = 57 [E + P trial]; n =38 [E-alone trial]) were ascertained by self-report. Incident cases of cutaneous malignant melanoma were confirmed by physician review of medical records. Incidences of nonmelanoma skin cancer and melanoma were compared between the two randomization groups within each trial using hazard ratios (HRs), with corresponding 95% confidence intervals (CIs) and Wald statistic P values from Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

Rates of incident nonmelanoma skin cancer and melanoma were similar between the active hormone (combined analysis of E + P and E-alone) and placebo groups (nonmelanoma skin cancer: HR = 0.98, 95% CI = 0.89 to 1.07; melanoma: HR = 0.92, 95% CI = 0.61 to 1.37). Results were similar for the E + P and E-alone trials when analyzed individually.

CONCLUSIONS

Menopausal hormone therapy did not affect overall incidence of nonmelanoma skin cancer or melanoma. These findings do not support a role of menopausal estrogen, with or without progestin, in the development of skin cancer in postmenopausal women.

Time trends and latitude dependence of uveal and cutaneous malignant melanoma induced by solar radiation

In order to evaluate the role of solar radiation in uveal melanoma etiology, the time and latitude dependency of the incidence rates of this melanoma type were studied in comparison with those of cutaneous malignant melanoma (CMM). Norway and several other countries with Caucasian populations were included. there is a marked north-south gradient of the incidence rates of CMM in Norway, with three times higher rates in the south than in the north. No such gradient is found for uveal melanoma. Similar findings have been published for CMM in other Caucasian populations, with the exception of Europe as a whole. In most populations the ratios of uveal melanoma incidence rates to those of CMM tend to decrease with increasing CMM rates. This is also true for Europe, in spite of the fact that in this region there is an inverse latitude gradient of CMM, with higher rates in the north than in the south.In Norway the incidence rates of CMM have increased until about 1990 but have been constant or even decreased (for young people) after that time, indicating constant or decreasing sun exposure. The uveal melanoma rates have been increasing after 1990. In most other populations the incidence rates of CMM have been increasing until recently while those of uveal melanoma have been decreasing. These data generally support the assumption that uveal melanomas are not generated by ultraviolet (UV) radiation and that solar UV, via its role in vitamin D photosynthesis, may have a protective effect.

Sun exposure, vitamin D receptor polymorphisms FokI and BsmI and risk of multiple primary melanoma

BACKGROUND

Sunlight exposure increases risk of melanoma. Sunlight also potentiates cutaneous synthesis of vitamin D, which can inhibit melanoma cell growth and promote apoptosis. Vitamin D effects are mediated through the vitamin D receptor (VDR). We hypothesized that genetic variation in VDR affects the relationship of sun exposure to risk of a further melanoma in people who have already had one.

METHODS

We investigated the interaction between VDR polymorphisms and sun exposure in a population-based multinational study comparing 1138 patients with a multiple (second or subsequent) primary melanoma (cases) to 2151 patients with a first primary melanoma (controls); essentially a case-control study of melanoma in a population of melanoma survivors. Sun exposure was assessed using a questionnaire and interview, and was shown to be associated with multiple primary melanoma. VDR was genotyped at the FokI and BsmI loci and the main effects of variants at these loci and their interactions with sun exposure were analyzed.

RESULTS

Only the BsmI variant was associated with multiple primary melanoma (OR=1.27, 95% CI 0.99-1.62 for the homozygous variant genotype). Joint effects analyses showed highest ORs in the high exposure, homozygous variant BsmI genotype category for each sun exposure variable. Stratified analyses showed somewhat higher ORs for the homozygous BsmI variant genotype in people with high sun exposure than with low sun exposure. P values for interaction, however, were high.

CONCLUSION

These results suggest that risk of multiple primary melanoma is increased in people who have the BsmI variant of VDR.

Heterogeneity in host risk factors for incident melanoma and non-melanoma skin cancer in a cohort of US women

Background

Melanoma, squamous cell carcinoma (SCC), and basal cell carcinoma (BCC) are 3 types of skin cancer that have distinct biologic characteristics and prognoses. We evaluated phenotypic differences in the risk of these cancers in US women.

Methods

We conducted a prospective study of 113 139 female nurses from 1984 to 2002. Over the 18 years of follow-up, there were 375 cases of melanoma, 495 cases of SCC, and 9423 cases of BCC.

Results

Women with melanoma were more likely to have a family history of melanoma (melanoma: RR 1.94, 95% confidence interval [CI] 1.36–2.76; SCC: RR 0.82, 95% CI 0.58–1.37; BCC: RR 1.49, 95% CI 1.38–1.62) and 6 or more moles on the left arm (melanoma: RR 3.66, 95% CI 2.15–6.24; SCC: RR 1.53, 95% CI 0.83–2.79; BCC: RR 1.48, 95% CI 1.28–1.72). Polytomous logistic regression analysis showed that age at diagnosis (P < 0.0001), family history of melanoma (P = 0.016), and number of moles on the left arm (P = 0.007) were significantly different across the 3 cancers.

Conclusions

This prospective observational study demonstrated that known phenotypic factors for skin cancer have a differential impact on the risk of melanoma, SCC, and BCC.

Neonatal UVB exposure accelerates melanoma growth and enhances distant metastases in Hgf-Cdk4(R24C) C57BL/6 mice

Genetically engineered mouse models offer new opportunities to experimentally investigate the impact of UV on melanoma pathogenesis. Here we irradiated a cohort of newborn 15 Hgf-Cdk4(R24C) mice on the pigmented C57BL/6 background with one erythemogenic dose of 6 kJ/m(2) UVB and compared the development of nevi and melanoma with a cohort of 30 untreated Hgf-Cdk4(R24C) mice. Neonatal UVB exposure decreased the latency and accelerated the growth of primary melanomas resulting in a significantly decreased time from melanoma onset to melanoma-related death (61 days vs. 96 days). Interestingly, we did not observe differences in the development of melanocytic nevi. Histopathological investigations revealed that UVB irradiation shifted the spectrum of melanomas toward a more aggressive phenotype with increased tumor cell proliferation, invasive growth and enhanced angiogenesis. Accordingly, we observed distal melanoma metastases in the lungs more frequently in the UV-irradiated than in the untreated cohort of Hgf-Cdk4(R24C) mice (73% vs. 47%). UVB-induced melanomas only contained very few infiltrating immune cells and expressed very low levels of proinflammatory chemokines. Taken together, our results demonstrate that neonatal UVB exposure promoted the early appearance of rapidly enlarging primary melanomas in Hgf-Cdk4(R24C) C57BL/6 mice which showed enhanced invasive and metastatic behaviour without a persistent tumor-associated inflammatory response. The preferential impact of UVB irradiation on the progression of melanoma without an effect on the development of nevi supports the hypothesis that the molecular targets of UVB are involved in bypassing the proliferative arrest of transformed melanocytes without alerting a cellular immune response.

Early-life sun exposure and risk of melanoma before age 40 years

OBJECTIVE

To examine associations between early-life sun exposure and risk of invasive cutaneous melanoma diagnosed between ages 18 and 39 years.

METHODS

Data were analysed from 606 cases and 481 controls from the Australian Melanoma Family Study, a population-based, case-control-family study. Self- and parent-reported sun exposure was collected by interview. Odds ratios (OR) were estimated using unconditional logistic regression, adjusted for potential confounders.

RESULTS

Self-reported childhood total sun exposure was not associated with melanoma overall, but was positively associated with melanoma diagnosed at 18-29 years of age (OR for highest vs. lowest quartile: 3.21, 95% confidence intervals (CI) 1.38-7.44; P (trend) 0.02; P (interaction) by age group 0.09). Analyses restricted to participants whose self-reported sun exposure was concordant with that recalled by their parents gave an OR for the highest versus lowest tertile of childhood total sun exposure of 2.28 (95% CI 1.03-5.04; P (trend) 0.05), and for any versus no severe childhood sunburn of 2.36 (95% CI 1.05-5.31). The association of self-reported severe sunburn with melanoma was evident only in people who tended to tan rather than burn and in people who had few nevi.

CONCLUSION

The association of early-life sun exposure with early-onset melanoma is influenced by host factors.

The Western Australian Melanoma Health Study: study design and participant characteristics

BACKGROUND

Cutaneous malignant melanoma is a major public health issue in Australia and other nations. A greater understanding of the genetic determinants and their interactions with environmental factors may lead to better interventions and control of the disease. The Western Australian Melanoma Health Study (WAMHS) is a population-based case-collection and biospecimen resource established to investigate the genetic epidemiology of melanoma. This manuscript discusses the design of the WAMHS and the characteristics of the participants.

METHODS

Participants were recruited through the Western Australian Cancer Registry, which is notified of all incident cancers in the state of Western Australia by law. Once the diagnosing doctor's consent was obtained, all eligible, resident Western Australian, adult cases of melanoma diagnosed between January 2006 and September 2009, were contacted by mail and invited to participate. Clinical, questionnaire-based phenotypic and blood samples for extraction of DNA, RNA and serum were collected from consenting cases. Clinical data consisted of all pathological data recorded by the cancer registry and the questionnaire, administered by telephone interview, covered major risk factors for melanoma, such as sun exposure history and skin type.

RESULTS

The final sample consisted of 1643 consenting cases out of 3420 cancer notifications (48.04%), of which 1455 cases completed one or more components of the study and 1157 completed all components. The WAMHS sample differed to all melanoma notifications only in age, with a bias towards older individuals (P<0.0001). No significant differences were observed in sex, melanoma site, Breslow thickness or Clark's level.

CONCLUSIONS

The WAMHS study is novel in its non-family based approach and focus on common (low penetrance) genetic determinants. This comprehensive resource will enable further steps to be taken towards understanding the complex pathways involved in melanoma.

Vacations to sunny destinations, sunburn, and intention to tan: A cross-sectional study in Denmark, 2007-2009

Background: Denmark has experienced an increase in melanoma incidence since the 1960s. Exposure to ultraviolet radiation is the main preventable cause of this cancer. We examined current travel to, and sun-related behaviour of Danes at, sunny destinations in relation to their risk for sunburn. Method: A population-based sample of 11,158 respondents aged 15—59 years completed three questionnaires in 2007—2009 that included items on exposure to ultraviolet radiation. Using logistic regression analysis we examined the relations between sunny vacations, sun-related behaviour, demographic factors and risk for sunburn. Results: During 2007—2009, 44.8—45.8% of the respondents travelled to a sunny destination at least once a year; 24% became sunburnt, and 69% tanned intentionally. The odds ratio for sunburn in general for people who went on a sunny vacation as compared with those who did not was 1.6 (1.5—1.7). Sunscreen use (1.9; 1.4—2.6) and intentional tanning (3.4; 2.8—4.1) were positively associated with sunburn on vacation. Conclusions: Taking a vacation in a sunny place is a risk factor for sunburn, especially for young people. The recommendation for sunscreen use should be re-evaluated, as intention to tan is the most important factor in sunburn on vacation and should be targeted more strategically.

[Update on photoprotection in children]

Children are one of the population groups in which the photo-protection must be maximised. Firstly, because they take part in outdoor activities more often than adults. Secondly, because the principal risk factor for all types of skin cancer is ultraviolet radiation, and in particular, cumulative exposure during childhood. Hence, decreasing exposure to ultraviolet radiation in childhood has the potential to significantly lower the incidence of most forms of skin cancer. Photoprotection includes behavioural measures to protect the skin from sun exposure, e.g. sun protective clothes, hats, sunglasses, and sunscreens. It is necessary to provide information on aphotoprotection to parents, and, above all, to children, using educational campaigns to increase knowledge of photoprotection to help change attitudes towards sun exposure. Dermatologists and Paediatricians play a essential role in this educational work. In this article we review the latest information regarding paediatric sun protection, the new sunscreens, and the recent sun protection educational programs.

Tanning and increased nevus development in very-light-skinned children without red hair

OBJECTIVE

To examine the relationship between tanning and nevus development in very-light-skinned children.

DESIGN

Prospective cohort nested within a randomized controlled trial. Skin examinations in 3 consecutive years (2004, 2005, and 2006) included full-body counts of nevi, skin color and tanning measurement using colorimetry, and hair and eye color evaluation by comparison with charts. Telephone interviews of parents provided sun exposure, sun protection, and sunburn history.

SETTING

Large managed-care organization and private pediatric offices in the Denver, Colorado, metropolitan area.

PARTICIPANTS

A total of 131 very-light-skinned white children without red hair and 444 darker-skinned white children without red hair born in Colorado in 1998.

MAIN OUTCOME MEASURES

Full-body nevus counts at ages 6 to 8 years.

RESULTS

Among very-light-skinned white children, geometric mean numbers of nevi for minimally tanned children were 14.8 at age 6 years; 18.8 at age 7 years; and 22.3 at age 8 years. Mean numbers of nevi for tanned children were 21.2 at age 6 years; 27.9 at age 7 years; and 31.9 at age 8 years. Differences in nevus counts between untanned and tanned children were statistically significant at all ages (P < .05 for all comparisons). The relationship between tanning and number of nevi was independent of the child's hair and eye color, parent-reported sun exposure, and skin phototype. Among darker-skinned white children, there was no relationship between tanning and nevi.

CONCLUSIONS

Very-light-skinned children who tan (based on objective measurement) develop more nevi than children who do not tan. These results suggest that light-skinned children who develop tans may be increasing their risk for developing melanoma later in life.

Baseline survey of sun protection policies and practices in primary school settings in New Zealand

The SunSmart Schools Accreditation Programme (SSAP) was launched as a national programme in October 2005 to help reduce the risk of excessive child exposure to ultraviolet radiation. As part of the need for evaluation, this paper reports the findings of a national survey of a randomly selected sample of approximately 12% of New Zealand primary schools prior to the national launch of the SSAP. Principals at 242 schools completed a mail survey (81% response rate) relating to school sun protection policies, practices, curriculum and environment. Survey responses were evaluated according to the 12 criteria of the SSAP, with schools assigned a score from 0 to 12. No school fully met all 12 accreditation criteria, although 2% of schools attained 11 criteria and another 2% attained 10. Nine per cent of schools attained three or fewer criteria. Overall, 7 was the most common score, achieved by 23%. School socio-economic decile rating and roll size were positively associated with higher scores (both P < 0.02). Continued support and resources are needed to encourage schools to address sun protection across the spectrum of curriculum, practices and environment and through commitment to written policy.

Rationales, design and recruitment for the Elfe longitudinal study

BACKGROUND

Many factors act simultaneously in childhood to influence health status, life chances and well being, including pre-birth influences, the environmental pollutants of early life, health status but also the social influences of family and school. A cohort study is needed to disentangle these influences and explore attribution.

METHODS

Elfe will be a nationally representative cohort of 20 000 children followed from birth to adulthood using a multidisciplinary approach. The cohort will be based on the INSEE Permanent Demographic Panel (EDP) established using census data and civil records. The sample size has been defined in order to match the representativeness criteria and to obtain some prevalence estimation, but also to address the research area of low exposure/rare effects. The cohort will be based on repeated surveys by face to face or phone interview (at birth and each year) as well as medical interview (at 2 years) and examination (at 6 years). Furthermore, biological samples will be taken at birth to evaluate the foetal exposition to toxic substances, environmental sensors will be placed in the child's homes. Pilot studies have been initiated in 2007 (500 children) with an overall acceptance rate of 55% and are currently under progress, the 2-year survey being carried out in October this year.

DISCUSSION

The longitudinal study will provide a unique source of data to analyse the development of children in their environment, to study the various factors interacting throughout the life course up to adulthood and to determine the impact of childhood experience on the individual's physical, psychological, social and professional development.

Adolescents' use of purpose built shade in secondary schools: cluster randomised controlled trial

OBJECTIVE

To examine whether students use or avoid newly shaded areas created by shade sails installed at schools.

DESIGN

Cluster randomised controlled trial with secondary schools as the unit of randomisation.

SETTING

51 secondary schools with limited available shade, in Australia, assessed over two spring and summer terms.

PARTICIPANTS

Students outside at lunch times.

INTERVENTION

Purpose built shade sails were installed in winter 2005 at full sun study sites to increase available shade for students in the school grounds.

MAIN OUTCOME MEASURE

Mean number of students using the primary study sites during weekly observations at lunch time.

RESULTS

Over the study period the mean change in students using the primary study site from pre-test to post-test was 2.63 (95% confidence interval 0.87 to 4.39) students in intervention schools and -0.03 (-1.16 to 1.09) students in control schools. The difference in mean change between groups was 2.67 (0.65 to 4.68) students (P=0.011).

CONCLUSIONS

Students used rather than avoided newly shaded areas provided by purpose built shade sails at secondary schools in this trial, suggesting a practical means of reducing adolescents' exposure to ultraviolet radiation.

TRIAL REGISTRATION

Exempt.

Vacations to waterside locations result in nevus development in Colorado children

Nevi are a main risk factor for malignant melanoma, and most nevi develop in childhood. This study examined the relationship between vacations and nevi in 681 White children born in 1998 who were lifetime residents of Colorado. Vacation histories were assessed through telephone interviews of parents, whereas nevus and phenotypic characteristics were assessed through skin exams at age 7. Multiple linear and logistic regression were used to assess the influence of vacations on counts of nevi <2 mm in size and the presence of any nevi > or = 2 mm after controlling for other variables. Each waterside vacation > or = 1 year before the exam at age 7 was found to be associated with a 5% increase in nevi <2 mm. Waterside vacations <1 year before the skin exam were not related to nevus count (<2 mm); regardless of timeframe, waterside vacations were not related to the presence of nevi > or = 2 mm. UV dose received on waterside vacations, number of days spent on waterside vacations, and nonwaterside vacations were not significantly related to nevi <2 or > or = 2 mm. These results suggest that there is a lag of at least 1 year in the development of new nevi after vacation sun exposure. It appears that a threshold dose of UV exposure is received quickly on each waterside vacation. Parents of young children should exercise caution in selection of vacation locations to reduce melanoma risk.

Child sun protection: sun-related attitudes mediate the association between children's knowledge and behaviours

AIM

To describe and investigate the relationship among the sun-related knowledge, attitudes and behaviours of New Zealand primary schoolchildren and consider the roles of sex and school year level.

METHODS

A randomly selected, two-stage cluster sample of 488 children from 27 primary schools in five regions of New Zealand was surveyed regarding their sun-related knowledge, attitudes and behaviours. A scoring system was used to assign a knowledge, attitude and behaviour score to each child.

RESULTS

Although knowledge increased with school year level, there was a decline in sun protective attitudes and behaviours. There was little variation in knowledge, attitudes and behaviour between boys and girls, but sex-year level interactions were found for knowledge and behaviour. When considering children's knowledge, attitudes and behaviours simultaneously, knowledge was only significantly associated with behaviours when mediated by attitudes.

CONCLUSIONS

When targeting child sun protection and skin cancer prevention programmes, a focus on attitudes towards sun exposure and a suntan may prove beneficial in influencing sun-related behaviours.

Assessment of a new questionnaire for self-reported sun sensitivity in an occupational skin cancer screening program

Background

Sun sensitivity of the skin is a risk factor for the development of cutaneous melanoma and other skin cancers. Epidemiological studies on causal factors for the development of melanoma must control for sun sensitivity as a confounder. A standardized instrument for measuring sun sensitivity has not been established yet. It is assumed that many studies show a high potential of residual confounding for sun sensitivity. In the present study, a new questionnaire for the assessment of self-reported sun sensitivity is administered and examined.

Methods

Prior to an occupational skin cancer screening program, the 745 participating employees were asked to fill in a questionnaire for self-assessment of sun sensitivity. The questionnaire was developed by experts of the working group "Round Table Sunbeds" (RTS) to limit the health hazards of sunbed use in Germany. A sun sensitivity score (RTS-score) was calculated using 10 indicators. The internal consistency of the questionnaire and the agreement with other methods (convergent validity) were examined.

Results

The RTS-score was calculated for 655 study participants who were 18 to 65 years of age. The correlation of the items among each other was between 0.12 and 0.62. The items and the RTS-score correlated between 0.46 and 0.77. The internal consistency showed a reliability coefficient with 0.82 (Cronbach's alpha). The comparison with the Fitzpatrick classification, the prevailing standard, was possible in 617 cases with a rank correlation of r_s = 0.65. The categorization of the RTS-score in four risk groups showed correct classification to the four skin types of Fitzpatrick in 75% of the cases. Other methods for the assessment of sun sensitivity displayed varying agreements with the RTS-score.

Conclusion

The RTS questionnaire showed a sufficient internal consistency. There is a good convergent validity between the RTS-score and the Fritzpatrick classification avoiding shortcomings of the prevailing standard. The questionnaire represents a simple, reliable and valid instrument for the assessment of sun sensitivity. The questionnaire can be useful for epidemiological studies as well as for skin cancer prevention. Further development and standardization of sun sensitivity assessments is necessary to strengthen the evidence of epidemiological studies on causal factors of melanoma and other skin cancers.

[Sunburn in young people: population-based study in Southern Brazil]

OBJECTIVE

To assess the prevalence and risk factors for sunburn in young people.

METHODS

Population-based cross-sectional study using a multiple-stage sampling carried out with people living in the urban area of Pelotas, Southern Brazil, between October and December 2005. Data was collected from interviews with 1.604 subjects using a standardized pre-coded questionnaire about their family and another questionnaire applied to those aged between ten and 29 years for assessing the occurrence of sunburn episodes. Sunburn was defined as skin burning after sun exposure. Chi-square test with Yates' correction was used to compare proportions and Poisson regression with design effect control and robust adjustment of variance was applied in the multivariate analysis.

RESULTS

Of those aged between 10 and 29 years, 1,412 reported sun exposure in the last summer. Losses and refusals were 5.5%. A total of 48.7% of the interviewees reported sunburn in the last year. The following variables were associated with sunburn in the multivariate analysis: white skin (PR=1.41; 95% CI: 1.12;1.79); higher skin sensitivity to sun exposure (PR=1.84; 95% CI: 1.64;2.06); age between 15 and 19 years (PR=1.30; 95% CI: 1.12;1.50); belonging to the higher quartile of income (PR=1.20; 95% CI: 1.01;1.42); and irregular use of sunscreens (PR=1.23; 95% CI: 1.08;1.42).

CONCLUSIONS

The prevalence of sunburn in the population studied was high mainly among white young people with higher skin sensitivity, higher income and who used sunscreens irregularly. Sun exposure during safe times and with adequate protection should be promoted.

The SunWise Policy Intervention for School-Based Sun Protection: A Pilot Study

Skin cancer is highly preventable, but clearly there is a critical need to focus on better ways to disseminate information about known skin cancer prevention. The U.S. Environmental Protection Agency’s (EPA) SunWise Program is one channel for reaching children, teachers, and school nurses. In a pilot study designed to increase adoption of school-based sun protection policies, 28 schools were randomly assigned to one of three groups: Control, which included the EPA’s original SunWise curriculum toolkit; SunWise Policy, which included a revised toolkit emphasizing policy; and SunWise Policy plus Technical Assistance, which included the policy toolkit and 3 technical assistance phone calls. The enhanced SunWise Policy plus Technical Assistance intervention led to more new sun protection policies. Use of study interventions for improving sun protection practices such as policy toolkits or brief counseling can be easily interwoven into school hours by school nurses and other health educators.

The formation of specific action plans can enhance sun protection behavior in motivated parents

OBJECTIVE

To determine whether formulating specific plans with regard to sunscreen use can influence parental sun protection behavior (i.e., applying sunscreen to their child).

METHOD

In the spring of 2005, an electronic survey on sun protection behavior was performed among 436 parents in the Netherlands. Participants were randomly allocated to a 'questionnaire-only' control group or an experimental group, in which they were asked to formulate implementation intentions, i.e., specific action plans detailing when, where and how they would use sunscreen to protect their child from the sun in the upcoming summer. Parental sunscreen use was assessed at a 5-month follow-up.

RESULTS

Although the intervention had no overall effect, a significant groupxintention interaction effect existed (p=0.02). Implementation intentions were effective in the subgroup of highly motivated participants, increasing adequate parental sunscreen use by 13.5%. Implementation intentions did not increase parents' intentions towards sunscreen use, indicating that their behavioral effect was not due to heightened motivation.

CONCLUSIONS

This is the first study to report on the efficacy of implementation intentions in the area of sun protection behavior and skin cancer prevention. The results add further support to the growing body of evidence that implementation intention formation can be an important strategy to facilitate behavioral enactment, particularly in motivated respondents.

Cancer risk among residents of Rhineland-Palatinate winegrowing communities: a cancer-registry based ecological study

Aim

To investigate the cancer risk among residents of Rhineland-Palatinate winegrowing communities in an ecological study.

Methods

On the basis of the Rhineland-Palatinate cancer-registry, we calculated age-adjusted incidence rate ratios for communities with a medium area under wine cultivation (>5 to 20 percent) and a large area under wine cultivation (>20 percent) in comparison with communities with a small area under wine cultivation (>0 to 5 percent). In a side analysis, standardized cancer incidence ratios (SIR) were computed separately for winegrowing communities with small, medium and large area under wine cultivation using estimated German incidence rates as reference.

Results

A statistically significant positive association with the extent of viniculture can be observed for non-melanoma skin cancer in both males and females, and additionally for prostate cancer, bladder cancer, and non-Hodgkin lymphoma in males, but not in females. Lung cancer risk is significantly reduced in communities with a large area under cultivation. In the side-analysis, elevated SIR for endocrine-related tumors of the breast, testis, prostate, and endometrium were observed.

Conclusion

This study points to a potentially increased risk of skin cancer, bladder cancer, and endocrine-mediated tumors in Rhineland-Palatinate winegrowing communities. However, due to the explorative ecologic study design and the problem of multiple testing, these findings are not conclusve for a causal relationship.

Childhood social class and cancer incidence: results of the globe study

Despite increased recognition of the importance of investigating socio-economic inequalities in health from a life course perspective, little is known about the influence of childhood socio-economic position (SEP) on cancer incidence. The authors studied the association between father's occupation and adult cancer incidence by linking information from the longitudinal GLOBE study with the regional population-based Eindhoven Cancer Registry (the Netherlands) over a period of 14 years. In 1991, 18,973 participants (response rate 70.1%) of this study responded to a postal questionnaire, including questions on SEP in youth and adulthood. Respondents above the age of 24 were included (N=12,978). Cox regression was used to calculate hazard ratios (HR) for all cancers as well as for the five most frequently occurring cancers by respondent's educational level or occupational class, and by father's occupational class (adjusted for respondent's education and occupation). Respondents with a low educational level showed an increased risk of all cancers, lung and breast cancer (in women). Respondents with a low adult occupational level showed an increased risk of lung cancer and a reduced risk of basal cell carcinoma. After adjustment for adult education and occupation, respondents whose father was in a lower occupational class showed an increased risk of colorectal cancer as compared to those with a father in the highest social class. In contrast, respondents whose father was in a lower occupational class, showed a decreased risk of basal cell carcinoma as compared to those with a father in the highest occupational class. The association between childhood SEP and cancer incidence is less consistent than the association between adult SEP and cancer incidence, but may exist for colorectal cancer and basal cell carcinoma.

ASIP and TYR pigmentation variants associate with cutaneous melanoma and basal cell carcinoma

Fair color increases risk of cutaneous melanoma (CM) and basal cell carcinoma (BCC). Recent genome-wide association studies have identified variants affecting hair, eye and skin pigmentation in Europeans. Here, we assess the effect of these variants on risk of CM and BCC in European populations comprising 2,121 individuals with CM, 2,163 individuals with BCC and over 40,000 controls. A haplotype near ASIP, known to affect a similar spectrum of pigmentation traits as MC1R variants, conferred significant risk of CM (odds ratio (OR) = 1.45, P = 1.2 x 10(-9)) and BCC (OR = 1.33, P = 1.2 x 10(-6)). The variant in TYR encoding the R402Q amino acid substitution, previously shown to affect eye color and tanning response, conferred risk of CM (OR = 1.21, P = 2.8 x 10(-7)) and BCC (OR = 1.14, P = 6.1 x 10(-4)). An eye color variant in TYRP1 was associated with risk of CM (OR = 1.15, P = 4.6 x 10(-4)). The association of all three variants is robust with respect to adjustment for the effect of pigmentation.

Prevalence and sociodemographic correlates of beliefs regarding cancer risks

BACKGROUND

Inaccurate beliefs about cancer risk may contribute to unhealthy lifestyle behaviors and poor adherence to recommended screening and prevention guidelines. To address this issue the current study assessed the prevalence and sociodemographic correlates of scientifically unsubstantiated beliefs about cancer risk in a representative sample of the US population.

METHODS

Nine hundred fifty-seven US adults with no history of cancer were surveyed by telephone. The survey included 12 statements about cancer risk, risk factors, and prevention that were framed to be contrary to the consensus of current scientific evidence.

RESULTS

Participants were inconsistent in their ability to identify the statements as false, and appraisal accuracy was associated with several sociodemographic characteristics. Five of the 12 misconceptions were endorsed as true by at least a quarter of the respondents, and uncertainty was higher than 15% for 7 statements. At the same time, more than two-thirds of the participants were able to identify 7 statements as false and, on average, respondents endorsed fewer than 3 statements as true. Respondents who were male, older, non-White, less educated, and of lower income were most likely to hold inaccurate beliefs.

CONCLUSIONS

A notable percentage of the participants in this study hold beliefs about cancer risk at odds with the prevailing scientific evidence. Because the population segments with the least accurate knowledge also bear the greatest burden of cancer, areas for public education and intervention efforts are identified.