High prevalence of skin cancer in World War II servicemen stationed in the Pacific theater

Primary Care Considerations for Elderly U.S. Veterans of World War II and the Korean War: A Narrative Review

Many of the United States' more than 18 million veterans obtain healthcare through the Department of Veterans Affairs' (VA) Veterans Health Administration system; however, recent legislative changes have expanded veterans' access to non-VA care in their communities, particularly for those who do not live near VA medical centers. Veterans are seen by physicians in outpatient practice across the United States and are admitted to non-VA hospitals; this is particularly salient for older veterans, who may require a more frequent and high level of care. We present a review of characteristics of U.S. veterans from two conflicts: World War II (WWII) and the Korean War. While non-VA clinicians are well equipped to provide care for patients of all different ages, veterans of armed conflicts have a unique constellation of exposures and cultural considerations that must be accounted for when providing them care. In this review, we describe characteristics of the generations of American veterans who served in WWII and the Korean War conflicts in a brief historical context. We then note conflict-specific exposures and potential long-term sequelae to watch for during physical examinations and to monitor thereafter, age-specific health and emotional concerns, and best practices for providing care to this cohort of veterans.

The Genetics of Early-Stage Melanoma in a Veteran Population

To improve understanding of the genetic signature of early-stage melanomas in Veterans, hotspot mutation profiling using next-generation sequencing (NGS) was performed on melanoma tissue samples from patients at the Iowa City Veterans Affairs Medical Center (VAMC). Genetic analysis identified BRAF (36.3%), TP53 (25.9%), NRAS (19.3%), CDKN2A (11.1%), KIT (8.1%), and BAP1 (7.4%) mutations with the highest prevalence. Although common variants in BRAF were detected at lower rates than what is reported for the general population, 55.6% of cases showed activating mutations in the RAS/RAF pathways. Variants in TP53 and KIT were detected at higher rates than in the general population. Veterans with prior history of melanoma were at significantly higher odds of having TP53 mutation (OR = 2.67, p = 0.04). This suggests that TP53 may be a marker for recurrent melanoma and possibly alternative exposures in the military population. This study provides new information regarding the genetics of melanoma in a Veteran population and early-stage melanomas, highlighting risk factors unique to this population and contributing to the conversation about preventing melanoma deaths in US Military personnel.

Occupational Exposures and Environmental Health Hazards of Military Personnel

BACKGROUND

Military personnel are frequently exposed to environmental pollutants that can cause a variety of diseases.

METHODS

This review analyzed publications regarding epidemiological and biomonitoring studies on occupationally-exposed military personnel.

RESULTS

The exposures include sulfur mustard, organ chlorines, combustion products, fuel vapors, and ionizing and exciting radiations. Important factors to be considered are the lengths and intensities of exposures, its proximity to the sources of environmental pollutants, as well as confounding factors (cigarette smoke, diet, photo-type, healthy warrior effect, etc.). Assessment of environmental and individual exposures to pollutants is crucial, although often omitted, because soldiers have often been evaluated based on reported health problems rather than on excessive exposure to pollutants. Biomarkers of exposures and effects are tools to explore relationships between exposures and diseases in military personnel. Another observation from this review is a major problem from the lack of suitable control groups.

CONCLUSIONS

This review indicates that only studies which analyzed epidemiological and molecular biomarkers in both exposed and control groups would provide evidence-based conclusions on exposure and disease risk in military personnel.

Sun Exposure Prevention Practices Within U.S. Naval Aviation

INTRODUCTION

Occupational exposure to ultraviolet radiation is a critical concern for those serving in the U.S. Military. Work and mission requirements predispose members to significant sun exposure, while sun-protective behavior often comes second to mission accomplishment. Prior research implicated institutional practices and constraints as preventing the routine use of sun protection modalities, but no large-scale studies have assessed service members' perceptions regarding sun protection modalities available to them in their work environment or their daily sun protection practices.

METHODS

The study employed a cross-sectional survey distributed to active duty (AD) U.S. Navy service members assigned to 1 of 19 aircraft squadrons based in Southern California and deployed on missions across the Pacific theater of operations. The intent was to evaluate rates of sunburn, sun-protective practices, and perceptions regarding sun exposure and prevention practices in their workplace. The study and survey tool received approval from the Naval Medical Center San Diego Institutional Review Board. Statistical analysis of survey answers was performed to assess for trends in response rates overall and response rates within sociodemographic groups. Pearson's chi-squared tests were utilized to assess for significance where appropriate. P-values <.05 were used to determine statistically significant trends in response rates.

RESULTS

One thousand surveys were distributed, of which 896 surveys were completed. The response rate was 89.6%. Eight hundred and eighty-eight surveys were included in the analysis. The surveyed population was consistent with the demographics of the U.S. Navy as a whole. 55.1% of survey respondents reported sunburn within the past year, higher than the rate reported in a previously surveyed civilian population. Reports of sunburn within the past year were not significantly different in regard to gender (P = .88), age (P = .53), and years of AD (P = .48). Increasing rank did show a significant correlation with reports of sunburn (P = .0) (Table S1). 62.2% of those surveyed reported frequent/routine use of some form of sun protection. This was lower than the rate reported in a previously surveyed civilian population. A large majority of service members surveyed (75.9%) reported using sunscreen with a sun protection factor >15.29.1% of survey respondents reported working in direct sunlight always/almost always. This was lower than the rates reported in a previously surveyed U.S. Air Force population of aviation maintainers. Low rates of respondents reported frequent reminders to use sun protection (18.9%), and fewer reported the routine or frequent use of sunscreen while at work (12.3%). A higher percentage reported regular use of sunscreen during outdoor leisure activities (36.5%), suggesting a barrier to use in the workplace.

CONCLUSIONS

U.S. Military personnel report higher rates of sunburn and lower rates of routine use of sun protection practices compared to a previously surveyed civilian population. The overall rates of sun protection use while in the work setting are low both overall and compared to reports of routine use during outdoor leisure activities. Reported rates of reminders to use sunscreen are low, suggesting that increased education regarding the risk of excessive sun exposure and tools for effective sun protection are still needed.

Ultraviolet Radiation Exposure, Risk, and Protection in Military and Outdoor Athletes

Overexposure to ultraviolet radiation (UVR) from the sun is associated with deleterious health effects including, but not limited to, increased risk of skin cancers. Military personnel and those who participate in outdoor exercise or sports represent two potential populations at elevated risk of negative health consequences of UVR exposure due to large amounts of time spent outdoors, often in harsh UVR environments. Despite exposure to high and/or frequent doses of UVR in recreational and tactical athletes, adequate sun-protection practices are often disregarded or not well understood by many within these at-risk populations, resulting in heightened risk of negative UVR effects. The focus of this review is to examine the available literature regarding UVR exposure, risk of adverse health effects of UVR exposure, and sun protection practices in outdoor exercisers, athletes, and military personnel.

Skin cancer in the military: A systematic review of melanoma and nonmelanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel

BACKGROUND

Occupational sun exposure is a well-studied risk factor for skin cancer development, but more work is needed to assess melanoma and nonmelanoma skin cancer risk among US military personnel to improve education and screening efforts in this population.

OBJECTIVE

To conduct an extensive review of skin cancer risks for US military personnel to inform preventive education, diagnosis, and treatment efforts to better protect these individuals from future skin cancer development.

METHODS

A systematic review of published studies on the subject of melanoma and nonmelanoma skin cancer in military personnel was conducted.

RESULTS

A total of 9 studies describing skin cancer incidence in the US military were identified, with 4 studies specific to melanoma. The study findings reveal an increased risk for melanoma associated with service in the military or prisoner of war status. Service in tropical environments was associated with an increased incidence of both melanoma and nonmelanoma skin cancer among World War II soldiers. Two studies found that increased melanoma risk was also branch dependent, with the highest rates among the United States Air Force. Several of the reviewed studies implicated increased sun exposure during military service and lack of sufficient sun protection as the causes of higher rates of skin cancer among US military and veteran populations as compared with among the nonmilitary population in the United States.

LIMITATIONS

The reviewed articles have variable results; a prospective randomized controlled trial would be helpful to develop interventions that mitigate skin cancer risk in the US military.

CONCLUSION

This review identifies an abundance of evidence for an increased risk for skin cancer development among US active duty and veteran populations.

Costs of Keratinocyte Carcinoma (Nonmelanoma Skin Cancer) and Actinic Keratosis Treatment in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) provides health care to large numbers of veterans afflicted with keratinocyte carcinoma (KC).

OBJECTIVE

To estimate the number of veterans treated for KCs and the related diagnosis, actinic keratosis (AK) and the costs of treating these conditions over a 1-year period.

MATERIALS AND METHODS

The authors conducted a cross-sectional analysis of veterans diagnosed with KC or AK during fiscal year 2012 using administrative data on outpatient encounters and prescription drugs provided or paid by VHA. Marginal costs of each condition were estimated from a regression model. The authors estimated counts of outpatient encounters, procedures, and costs related to KC and AK care.

RESULTS

In 2012, there were 49,229 veterans with basal cell carcinoma, 26,310 veterans with squamous cell carcinoma, and 8,050 veterans with unspecified invasive KC. There were also 197,041 veterans with AK and 6,388 veterans with KC-related diagnoses. The VHA spent $356 million on KC and AK outpatient treatment for procedures, prescription drugs, and other dermatologic care during FY2012.

CONCLUSION

There was high prevalence of KC and AK and considerable spending to treat these conditions in VHA. Treatment costs are not generalizable to care provided by non-VHA providers where a facility fee was not incurred.

Etiology and pathogenesis of basal cell carcinoma

Basal cell carcinoma (BCC) is the most common cancer among Caucasians. It generally occurs on sun-exposed areas of the body, mostly on the head and neck (80%), trunk (15%), rarely on arms and legs. Basal cell carcinoma is a good example of a disease caused by a combination of genetic and environmental factors. Ultraviolet (UV) radiation plays a dual role in the development of BCC: it causes DNA damage and immunosuppression. UVA and UVB rays damage the DNA via various mechanisms. UVB radiation directly damages DNA within skin cells, causing cytosine → thymine mutations at dipyrimidine sites, whereas UVA radiation is 10.000 times less mutagenic, but it is significantly more present in the natural UV radiation. Also, UVA photons have lower energy than UVB photons and do not induce mutations. UV radiation exerts immune suppression by decreasing the antigen presenting cells ability and by producing immunosuppressive cytokines, such as interleukin-10 (IL-10) and tumor necrosis factor alpha (TNF-α). Mediators of UV-induced immunosuppression are DNA and cis-urocanic acid. Several studies showed a significant association between the development of BCC and sun-exposure during childhood and adolescence, and a strong relation with family history of skin cancer. Exposure to ionizing radiation increases the risk of nonmelanoma skin cancers by three times, while the risk is proportional to the radiation dose. Chemical carcinogens, such as arsenic, tar, psoralen, and pesticides, increase risks for nonmelanoma skin cancers, predominantly for squamous cell carcinoma (SCC). Regarding genetic predisposition, there is glutathione S-transferase (GST) as an important part of cellular defense against endogenous and exogenous chemicals. Several polymorphisms in GST family members have been associated with impaired detoxification, thus influencing the risk for some cancers, including nonmelanoma skin cancers. Cytochrome P450 enzymes are involved in detoxification of photosensitizing agents, and thus involved in BCC carcinogenesis. PTCH is a tumor suppressor gene first identified in patients with Gorlin syndrome. Abnormal activation of this gene and its pathways result in various types of tumorigenesis. BCC is associated with homozygous PTCH gene deletion. With regard to acquired genetic mutations, it was found that aggressive BCCs are significantly associated with increased p53 protein expression, probably representing the mutated form, although that assertion could not be established with certainty. Considering the apparently limited contribution of DNA damage and chromosome instability to the expression of BCC phenotype, the relevance of p53 mutations for BCC growth remains to be demonstrated. Data on the role of Bcl-2 gene family in the development of BCC are scarce. It is unclear whether Bcl-2 has a functional role in the development of BCC, or it only indicates the level of gene expression in tumor stem cells. Activation of Ras gene may play an important role during early stages in the development of nonmelanoma skin cancers, and it is often found on UV-exposed skin in BCC, actinic keratosis and SCC. Concerning immunologic factors, studies have shown that tumor necrosis factor-α (TNF-α) is the critical mast cell product involved in ultraviolet-induced immunosuppression: mast cells contain high quantities of TNF-α which is released after activation; the level of TNF-α is increased in the skin exposed to UV radiation disrupting the morphology and function of Langerhans cells, the principal antigen-presenting cells of the skin. An animal study suggests that the degree of susceptibility to ultraviolet-B-induced local immunosuppression depends on TNF-α level within the epidermis after UVB. It has been established that mast cell-derived histamine stimulates prostaglandin E2 (PGE2) production from keratinocytes. PGE2 alters the cytokine balance in favor of the immunosuppressive interleukin-10 (IL-10) against the immunostimulatory IL-12; histamine also increases suppressor T-cell function by binding to the H2 receptors, which in turn release higher levels of immune suppressive cytokines including IL-10 and induce apoptosis of antigen-presenting cells. All this results in a shift of the immune response from T helper 1 (Th1) cytokine profile to T helper 2 (Th2) cytokine profile, inhibiting antigen-presenting cells to induce antitumor activity.

Introduction to skin cancer

The incidence of skin cancer has been increasing throughout the United States and much of the world. Although the mortality rate of nonmelanoma skin cancer is low, that type of skin cancer accounts for considerable morbidity, including cosmetic and functional impairment. Melanoma, although less common, is a life-threatening malignancy if not detected and treated early. Skin cancer also significantly contributes to the rising costs of health care in the United States. Prevention, early diagnosis, and treatment are critical in helping to reduce the incidence, morbidity, and mortality associated with skin cancer. This article provides an introduction to skin cancer, including the changing incidence, clinical presentation, and summary of treatment and prognosis.

Basal cell carcinoma and World War II–era cathode ray oscilloscope exposure

BACKGROUND

There is a high prevalence of skin cancer in World War II servicemen stationed in the Pacific theater as a result of various risk factors such as exposure to ultraviolet radiation and genetic predisposition.

OBJECTIVE

We sought to describe whether a possible association exists between basal cell carcinoma (BCC) development and the use of high-voltage cathode ray tube (CRT) oscilloscopes manufactured around 1940 to 1955, which were a source of X-radiation.

METHODS

We present a case series of 9 men aged 65 to 93 years who presented with similar head and neck distributions of BCC and a history of extensive use of early CRT oscilloscopes during and shortly after the World War II era. The patients were interviewed and their medical records reviewed to determine CRT exposure times and BCC location, subtype, and treatment. Representative BCC histologic sections were reviewed.

RESULTS

A total of 230 BCCs of the head and neck region were identified and mapped. Questionnaires determined a minimum exposure of 600 (range, 624-9600) hours within a 60-cm distance of early CRT screens in all patients. The average number of aggressive histologic subtypes was 23.5%. The average number of Mohs micrographic surgery layers required to obtain negative margins was 1.99 compared with 1.63 in the control group treated by the same Mohs micrographic surgeon (P < .002).

CONCLUSION

This descriptive study is the first to suggest that ionizing radiation from early CRT oscilloscopes may be a factor in the development of multiple BCCs of the head and neck with increased subclinical spread.

Self-reported dermatitis and skin cancer in California farm operators

BACKGROUND

High rates of skin diseases and higher non-melanoma skin cancer rates have been reported in farmers.

METHODS

Self-report of dermatitis and skin cancer was among the information collected from 1947 California farm operators, mostly men, in a telephone survey. The majority of the farmers cultivated fruits, nuts, or other field crops.

RESULTS

Dermatitis was reported by 8.9% of men and 15.8% of women during the previous 12 months. In a logistic regression model, female gender (OR 2.0, 95% confidence interval 1.3-3.0) and respiratory atopy (OR 1.4, 1.01-1.90) were the only significant independent risk factors for reported dermatosis. There was significantly less reporting of skin cancer among field farmers when compared to others. Regular sunscreen use was reported significantly more often by women (42%) as compared to men (11%).

CONCLUSIONS

More in-depth studies are needed to get information on the role of agrochemicals as risk factors for dermatitis and skin cancer.

Skin Cancer in an Atomic Veteran: Cause or Coincidence?

BACKGROUND

Some military personnel who were exposed to ionizing radiation during atomic weapons tests subsequently developed skin cancer, but the cause-effect relationship is unclear.

OBJECTIVE

To explore the possible relationship between exposure to atomic tests and the development of skin cancer.

METHODS

We reviewed available literature regarding the effects of radiation on the skin and the case history of a patient in whom more than 300 basal cell carcinomas developed over a 30-year period after exposure to radiation during atomic testing.

RESULTS AND CONCLUSIONS

Ionizing radiation can cause skin cancer, usually basal cell carcinoma. In some veterans of atomic testing, skin cancer may have been initiated by ionizing radiation and promoted by ultraviolet radiation. We conclude that exposure to ionizing radiation during atomic weapons testing contributed to the excessive number and location of basal cell carcinomas in our patient.

Delayed effects of accidental cutaneous radiation exposure: fifteen years of follow-up after the Chernobyl accident

BACKGROUND

During the Chernobyl accident in 1986, 237 individuals were identified as having the most severe exposure to ionizing radiation. In the period between 1998 and 2000, 99 long term survivors out of this group were reassessed for radiation-induced cutaneous lesions.

OBJECTIVE

To identify sequelae of accidental cutaneous irradiation.

METHODS

Detailed dermatologic examinations, including biopsies of suspicious cutaneous lesions for histopathologic examination and 20 MHz sonography, were performed in all patients.

RESULTS

Twenty-two of the 99 patients displayed radiation-induced cutaneous lesions. Epidermal atrophy, telangiectases, and pigment alterations were present in all these individuals. Keratotic lesions were found in 14 patients. Cutaneous fibrosis was documented in 8 individuals by the use of 20 MHz sonography, while a radiation ulcer was found in 5. In one patient, two basal cell carcinomas were found.

CONCLUSION

The life-long follow-up of irradiated persons is of great importance in order to identify cutaneous neoplasms at an early treatable stage.

Multiple synchronous pigmented basal cell carcinomas following radiotherapy for Hodgkin's disease

BACKGROUND

Multiple basal cell carcinomas (BCCs) are infrequently seen in patients under 30 years of age. Their occurrence at a young age is often linked to some genodermatosis, including Nevoid Basal Cell Carcinoma Syndrome (NBCCS). The exposure to ionizing radiation is also considered to be a predisposing factor in the development of BCCs.

METHODS

We report the case of a 35-year-old patient who presented with seven synchronous, nodular, brownish-pigmented BCCs, confined within the radiation-treated cutaneous areas, 15 years after receiving Cobalt-60 (60Co) irradiation for Hodgkin's disease.

RESULTS

On the basis of clinical, radiological, and anamnestic data we excluded a NBCCS, thus proposing irradiation as the cause of the multiple synchronous pigmented BCCs.

CONCLUSIONS

Previous therapeutic ionizing radiation leads to an increased risk of BCCs confined to the region of the body to which radiotherapy was delivered. We consider our patient's BCCs represents a late adverse effect of the treatment with Cobalt-60.

The outcome of local radiation injuries: 14 years of follow-up after the Chernobyl accident

The Chernobyl nuclear power plant accident on April 26, 1986 was the largest in the history of the peaceful use of nuclear energy. Of the 237 individuals initially suspected to have been significantly exposed to radiation during or in the immediate aftermath of the accident, the diagnosis of acute radiation sickness (ARS) could be confirmed in 134 cases on the basis of clinical symptoms. Of these, 54 patients suffered from cutaneous radiation syndrome (CRS) to varying degrees. Among the 28 patients who died from the immediate consequences of accidental radiation exposure, acute hemopoietic syndrome due to bone marrow failure was the primary cause of death only in a minority. In 16 of these 28 deaths, the primary cause was attributed to CRS. This report describes the characteristic cutaneous sequelae as well as associated clinical symptoms and diseases of 15 survivors of the Chernobyl accident with severe localized exposure who were systematically followed up by our groups between 1991 and 2000. All patients presented with CRS of varying severity, showing xerosis, cutaneous telangiectasias and subungual splinter hemorrhages, hemangiomas and lymphangiomas, epidermal atrophy, disseminated keratoses, extensive dermal and subcutaneous fibrosis with partial ulcerations, and pigmentary changes including radiation lentigo. Surprisingly, no cutaneous malignancies have been detected so far in those areas that received large radiation exposures and that developed keratoses; however, two patients first presented in 1999 with basal cell carcinomas on the nape of the neck and the right lower eyelid, areas that received lower exposures. During the follow-up period, two patients were lost due to death from myelodysplastic syndrome in 1995 and acute myelogenous leukemia in 1998, respectively. Other radiation-induced diseases such as dry eye syndrome (3/15), radiation cataract (5/15), xerostomia (4/15) and increased FSH levels (7/15) indicating impaired fertility were also documented. This study, which analyzes 14 years in the clinical course of a cohort of patients with a unique exposure pattern, corroborates the requirement for long-term, if not life-long, follow-up not only in atomic bomb survivors, but also after predominantly local radiation exposure.

A comparison of melanoma mortality among WWII veterans of the Pacific and European theaters

PURPOSE

To determine whether cutaneous melanoma is associated with past military service in tropical locations, as a test of the 'critical period' sunlight exposure hypothesis.

METHODS

Mortality data from a longitudinal follow-up study of 5524 former prisoners of war (POW) and 3713 non-POW veteran controls, all white male veterans of World War II (WWII), were examined to determine whether death attributed to melanoma was associated with history of military service in Pacific or European theaters during WWII or with POW status. Deaths from colon cancer were used as a comparison outcome.

RESULTS

During 50 years of follow-up, there were 18 deaths from melanoma and 83 deaths from colon cancer among the cohort. Melanoma mortality varied with theater of war and POW status, whereas colon cancer mortality was similar for all subgroups. Pacific War POWs were at the highest risk overall (odds ratio (OR), 3.35; 95% confidence interval (CI), 0.39-28.76), whereas veterans of the Pacific War had nearly the same risk of melanoma (OR, 1.04; 95% CI, 0.09-11.94) compared with veterans of the European War. European theater POWs had a higher risk than non-POW veterans (OR, 2.76; 95% CI, 0.31-24.81). None of these differences, however, were statistically significant.

CONCLUSIONS

To the extent that POW status is associated with higher sun exposure, these data are consistent with the hypothesis that exposure to high levels of solar radiation in young adulthood is associated with a higher risk of melanoma mortality.

Basal cell carcinoma: what dentists need to know

BACKGROUND

Basal cell carcinoma, or BCC, is a malignant epithelial tumor of the skin, commonly seen in the head and neck. Because dentists routinely evaluate the head and neck, the authors present three examples of BCC of the face and jaw to help clinicians recognize the condition. They also provide a literature review regarding BCC's etiology, classification, treatment and prevention.

DESCRIPTION OF THE DISEASE

Sun exposure plays an important role in the development of BCC. The most susceptible people are those with minimal skin pigmentation. BCC is more frequently seen in men than in women. The most common form of BCC is the nodular type, which, if untreated, eventually ulcerates and may result in extensive local tissue destruction. The three cases described in this article highlight the range of BCC severity.

CLINICAL IMPLICATIONS

Oral health care providers may play an important role in the recognition and diagnosis of BCC involving the head and neck. Early recognition and diagnosis may lead to management that results in improved cure rates, with reduced morbidity and reduced treatment costs.

Squamous cell cancer: a practical approach

Cutaneous squamous cell carcinoma (SCC) is the second most common form of skin cancer and is treated frequently by dermatologists. For many years, the level of knowledge regarding treatment of SCC has taken a backseat to the treatment of basal cell carcinoma and malignant melanoma. As dermatologists become more surgically proficient and assume a leading role in the surgical care for cutaneous carcinoma, a thorough knowledge of the appropriate management of SCC is of paramount importance. In particular, it is essential to recognize that, unlike basal cell carcinoma, certain SCC have a significant metastatic potential and require more comprehensive care. This review targets the etiology, pathogenesis, clinical presentation, histopathology, and treatment of SCC. Particular attention is focused on providing appropriate care for SCC and recognizing and arranging appropriate management for high risk SCC.

The epidemiology of skin cancer

BACKGROUND

The incidence of skin cancer is increasing at an alarming rate.

OBJECTIVE

To discuss current epidemiologic data concerning the incidence, morbidity, environmental influences, predisposing, host conditions, precursor lesions, and prevention of melanoma and nonmelanoma (basal and squamous cell) skin cancer.

METHODS

The current literature was reviewed in order to provide current epidemiologic data for melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC).

RESULTS

Skin cancer is exceedingly common and the incidence is rising rapidly. Although the mortality rate for nonmelanoma skin cancer (NMSC) is decreasing, that of melanoma is increasing. Both NMSC and melanoma are associated with significant morbidity. Whereas chronic sun exposure is the main cause of NMSC, the development of melanoma appears to be related to intense, intermittent sun exposure. Ozone depletion has contributed to rising incidence rates of both NMSC and melanoma. In contrast to NMSC, there is not a direct relationship between ultraviolet radiation and melanoma. Genetic susceptibility significantly increases the lifetime risk of acquiring melanoma. There is no precursor lesion for BCC. Precursor lesions for invasive SCC include actinic keratoses and SCC in situ. Melanoma may arise from benign nevi and dysplastic nevi. Prevention of melanoma and NMSC is extremely important since prognosis improves with early detection. Prevention may be achieved by educating patients and physicians how to detect skin cancers early and by decreasing or eliminating exposure to ultraviolet light.

CONCLUSION

The incidence of skin cancer has reached epidemic proportions. Only through heroic efforts by health care professionals and the general public to prevent the development or progression of skin cancer will this epidemic be abated.

Multiple superficial basal cell carcinomas (basalomatosis) following cobalt irradiation

Basalomatosis is an uncommon skin condition characterized by the occurrence of multiple basal cell carcinomas. Many cases reported in the literature have been attributed to arsenic treatment in psoriasis patients. We report a patient with basalomatosis caused by cobalt-60 (60Co) irradiation. A 55-year-old farmer developed 43 basal cell carcinomas 20 years after treatment of an immunoblastoma with 60Co irradiation. All the tumours were located within the radiation fields. Other possible causes of basalomatosis, such as arsenic intoxication and basal cell naevus syndrome, were excluded. The patient's multiple superficial basal cell carcinomas probably represent a late adverse effect of the 60Co irradiation.

Skin cancer in African Americans

Skin cancer is the most common type of malignancy in the United States. Incidence within the African American population remains relatively low, but data is limited for this racial group, making accurate determination of incidence and mortality difficult. Factors implicated as causative in the pathogenesis of cutaneous malignancy in African Americans include, but are by no means limited to, sunlight, albinism, burn scars, X-rays, preexisting pigmented lesions, chronic inflammation, and chronic discoid lupus erythematosus. Anatomic distribution of lesions may be similar to that seen in whites for basal cell carcinoma but not for other skin cancers. For squamous cell carcinoma, melanoma, and cutaneous T-cell lymphoma, African Americans do not as well in terms of mortality as do whites. This difference probably is due either to the fact that African Americans have more advanced stages of disease at diagnosis than do whites or, in some cases, because the course of the disease is more aggressive in African Americans for reasons yet unknown. There is a need for heightened awareness of skin cancer in African Americans by patients and physicians. Emphasis should be on education and early diagnosis with the primary goal in mind being the reduction of incidence of and mortality due to skin cancer in African Americans. In addition, because of environmental factors, African Americans will be exposed to more solar ultraviolet radiation in the future. Strategies should be developed for public education to keep this exposure to low levels in this racial group.