The association of indoor tanning and melanoma in adults: systematic review and meta-analysis

Incidence and mortality trends of primary cutaneous melanoma: A 50-year Rochester Epidemiologic Project study

Background

National cancer reporting-based registry data, although robust, lacks granularity for incidence trends. Expert opinion remains conflicted regarding the possibility of melanoma overdiagnosis in the context of rising incidence without a corresponding rise in mortality.

Objective

To characterize 10- and 50-year trends in melanoma incidence and mortality.

Methods

Multicenter, population-based epidemiologic study utilizing the Rochester Epidemiology Project for Olmsted County, Minnesota residents diagnosed with melanoma from 01/01/1970 to 12/21/2020. Age- and sex-adjusted incidence and disease-specific mortality are calculated.

Results

Two thousand three hundred ten primary cutaneous melanomas were identified. Current age- and sex-adjusted incidence rates increased 11.1-fold since 1970s (P < .001). Over the last decade, there is an overall 1.21-fold (P < .002) increase, with a 1.36-fold increase (P < .002) among females and no significant increase among males (1.09-fold increase, P < .329). Melanoma-specific mortality decreased from 26.7% in 1970s to 1.5% in 2010s, with a hazard ratio (HR) reduction of 0.73 (P < .001) per 5-year period. Increased mortality was associated with Breslow thickness (HR 1.35, P < .001), age at diagnosis (HR 1.13, P = .001) left anatomic site (HR 1.98, P = .016), and nodular histogenic subtype (HR 3.08, P < .001).

Limitations

Retrospective nature and focused geographic investigation.

Conclusion

Melanoma incidence has continued to increase over the past decade, most significantly in females aged 40+. Trend variations among age and sex cohorts suggests external factors beyond overdiagnosis may be responsible. Disease-specific mortality of melanoma continues to decrease over the last 50 years.

Tanning bed use in Germany between 2015 and 2022: Representative data of 28,000 individuals on indoor tanning, risk awareness and reasons for use

BACKGROUND

Tanning beds were classified as first-group carcinogens in 2009. Nonetheless, research shows that people in industrialized Western countries use tanning beds. Based on the National Cancer Aid Monitoring (NCAM) including representative data on 28,000 individuals from Germany, we quantified the prevalence as a trend from 2015 to 2022, identified determinants of tanning bed use and analysed risk awareness and reasons for use.

METHODS

We used NCAM data from 2015 to 2022 to analyse the trends in the prevalence of tanning bed use (n = 28,000). To determine the characteristics of tanning bed users, risk awareness and reasons, we combined data from the waves 2019 to 2022 (n = 16,000, 49.2% female, 16-65 years) in a pooled dataset to have sufficient power to detect even smaller associations.

RESULTS

Tanning bed use decreased to 5.1% in 2022. The use of tanning beds in spas, fitness and beauty facilities increased, except during the COVID-19 pandemic, while the use in tanning salons decreased. Typical tanning bed users were female, middle-aged, occupied, higher educated, had an immigrant background and were former or current smokers. Risk awareness was the lowest among the current users. The most frequently mentioned reasons were relaxation, enhancement of attractiveness and pre-tanning.

DISCUSSION

Our nationwide representative data showed that the prevalence of indoor tanning has decreased. Of concern are the lower risk awareness among current users and the shift in place of use towards facilities associated with health and wellness. To further reduce the use of tanning beds, targeted information, educational campaigns and extended legislation are considered helpful.

Multifaceted approach toward mapping out the anticancer properties of small molecules via in vitro evaluation on melanoma and nonmelanoma skin cancer cells, and in silico target fishing

Melanoma and nonmelanoma skin cancers are among the most prevalent and most lethal forms of skin cancers. To identify new lead compounds with potential anticancer properties for further optimization, in vitro assays combined with in-silico target fishing and docking have been used to identify and further map out the antiproliferative and potential mode of action of molecules from a small library of compounds previously prepared in our laboratory. From screening these compounds in vitro against A375, SK-MEL-28, A431, and SCC-12 skin cancer cell lines, 35 displayed antiproliferative activities at the micromolar level, with the majority being primarily potent against the A431 and SCC-12 squamous carcinoma cell lines. The most active compounds 11 (A431: IC50  = 5.0 μM, SCC-12: IC50  = 2.9 μM, SKMEL-28: IC50  = 4.9 μM, A375: IC50  = 6.7 μM) and 13 (A431: IC50  = 5.0 μM, SCC-12: IC50  = 3.3 μM, SKMEL-28: IC50  = 13.8 μM, A375: IC50  = 17.1 μM), significantly and dose-dependently induced apoptosis of SCC-12 and SK-MEL-28 cells, as evidenced by the suppression of Bcl-2 and upregulation of Bax, cleaved caspase-3, caspase-9, and PARP protein expression levels. Both agents significantly reduced scratch wound healing, colony formation, and expression levels of deregulated cancer molecular targets including RSK/Akt/ERK1/2 and S6K1. In silico target prediction and docking studies using the SwissTargetPrediction web-based tool suggested that CDK8, CLK4, nuclear receptor ROR, tyrosine protein-kinase Fyn/LCK, ROCK1/2, and PARP, all of which are dysregulated in skin cancers, might be prospective targets for the two most active compounds. Further validation of these targets by western blot analyses, revealed that ROCK/Fyn and its associated Hedgehog (Hh) pathways were downregulated or modulated by the two lead compounds. In aggregate, these results provide a strong framework for further validation of the observed activities and the development of a more comprehensive structure-activity relationship through the preparation and biological evaluation of analogs.

Fecal microbiota transplantation and its repercussions in patients with melanoma refractory to anti-PD-1 therapy: scope review

INTRODUCTION

despite being extremely effective in some cases, up to 70% of patients with melanoma do not respond to anti-PD-1/PD-L1 (primary resistance) and many of the responders eventually progress (secondary resistance). Extensive efforts are being made to overcome this resistance through new strategies, especially aimed at modulating the intestinal microbiota.

OBJECTIVE

to assess whether fecal microbiota transplantation (FMT), associated with immunotherapy, is beneficial in the clinical course of patients with refractory melanoma.

METHODS

this is a scope review, based on studies collected on the MEDLINE, ScienceDirect, The Cochrane Library, Embase and BMJ Journals; using the terms: "Antibodies, Monoclonal"; "Drug Resistance, Neoplasm"; "Fecal Microbiota Transplantation"; "Host Microbial Interactions"; "Immunotherapy"; "Melanoma"; and "Microbiota". Clinical trials, in English, with relevant data on the subject and fully available were included. A cut-off period was not determined, due to the limited amount of evidence on the topic.

RESULTS

crossing the descriptors allowed the identification of 342 publications and, after applying the eligibility criteria, allowed the selection of 4 studies. From the analyses, it was observed that a considerable part of those studied overcame resistance to immune checkpoint inhibitors after FMT, with better response to treatment, less tumor growth and increased beneficial immune response.

CONCLUSION

it is noted that FMT favors the response of melanoma to immunotherapy, translated into significant clinical benefit. However, further studies are necessary for the complete elucidation of the bacteria and the mechanisms involved, as well as for the translation of new evidence to oncological care practice.

Increasing Incidence and Decreasing Mortality of Cutaneous Melanoma in Middle-Aged Adults: An Epidemiologic Study in Olmsted County, Minnesota

OBJECTIVE

To identify changes in the incidence and mortality of cutaneous melanoma in the fastest-growing segment of the US population, middle-aged adults.

PATIENTS AND METHODS

Using the Rochester Epidemiology Project, patients aged 40 to 60 years with a first lifetime diagnosis of cutaneous melanoma between January 1, 1970, and December 31, 2020, while a resident of Olmsted County, Minnesota, were identified.

RESULTS

A total of 858 patients with a primary cutaneous first-time melanoma were identified. The overall age- and sex-adjusted incidence rate increased from 8.6 (95% CI, 3.9 to 13.3) per 100,000 person-years in 1970-1979 to 99.1 (95% CI, 89.5 to 108.7) per 100,000 person-years in 2011-2020 (11.6-fold increase). There was a 52.1-fold increase in women and a 6.3-fold increase in men between these 2 periods. In recent years (2005-2009 vs 2015-2020), the incidence has stabilized in men (1.01-fold increase; P=.96) and continues to significantly increase in women (1.5-fold increase; P=.002). Among 659 patients with invasive melanoma, 43 deaths were due to melanoma, and male sex was significantly associated with an increased risk of death (hazard ratio, 2.95; 95% CI, 1.45 to 6.00). A more recent diagnosis of melanoma was significantly associated with a decreased risk of death due to melanoma (hazard ratio, 0.66 per 5-year increase in calendar year of diagnosis; 95% CI, 0.59 to 0.75).

CONCLUSION

Melanoma incidence has significantly increased since 1970. During the past 15 years, the incidence has continued to rise in middle-aged women (approximately 50% rise in incidence) but has stabilized in men. Mortality decreased in a linear fashion throughout this time.

[S3 guideline on skin cancer prevention: evaluation and updating procedure]

BACKGROUND

Originally published in 2014, the S3 guideline "Prevention of skin cancer" is the first evidence-based guideline available exclusively for primary and secondary prevention, which summarizes interprofessional consented recommendations for skin cancer risk reduction and early detection. Due to the large number of new publications and expanding focus, an update was deemed necessary.

METHODS

After a structured needs assessment, key questions were prioritized. The resulting systematic literature search resulted in a three-stage screening process. Recommendations formulated in working groups were approved in a formal consensus process, taking into account conflicts of interest, and finalized after a 6‑week public consultation process.

RESULTS

The needs assessment identified "skin cancer screening" (60.1%), "individual risk avoidance behaviors" (44.20%), and "risk factors" (43.48%) as topics of greatest interest. The prioritization phase resulted in 41 new key questions. A total of 22 key issues were re-evaluated in an evidence-based manner using 93 publications. As part of comprehensive guideline restructuring, 61 recommendations were newly developed and 43 were modified. The consultation phase resulted in no changes to recommendations and 33 changes to background material.

CONCLUSION

The identified need for change resulted in extensive modification and redrafting of recommendations. As the target group "nononcology patients" cannot be identified via cancer registries or certification systems, no quality indicators can be derived from the guideline. To transfer the guideline to health care, innovative, addressee-specific concepts are required, which will be discussed and implemented during the preparation of the patient guideline.

Obesity and immune-checkpoint inhibitors in advanced melanoma: A meta-analysis of survival outcomes from clinical studies

Obesity is a chronic inflammatory condition that has been associated with different types of cancer. However, its role in melanoma incidence, progression, and response to immune-checkpoint-inhibitors (ICI) is still controversial. On the one hand, increased levels of lipids and adipokines can promote tumor proliferation and several genes associated with fatty acid metabolism have been found to be upregulated in melanomas. On the other hand, immunotherapy seems to be more effective in obese animal models, presumably due to an increase in CD8 + and subsequent decrease in PD-1 + T-cells in the tumor microenvironment. In humans, several studies have investigated the role of BMI (body mass index) and other adiposity-related parameters as potential prognostic markers of survival in advanced melanoma patients treated with ICI. The aim of this research has been to systematically review the scientific literature on studies evaluating the relationship between overweight/obesity and survival outcomes in patients with advanced melanoma treated with ICI and to perform a meta-analysis on those sharing common characteristics. After screening 1070 records identified through a literature search, 18 articles assessing the role of BMI-related exposure in relation to survival outcomes in ICI-treated patients with advanced melanoma were included in our review. In the meta-analysis of the association between overweight (defined as BMI>25 or BMI 25-30), overall survival (OS), and progression free survival (PFS), 7 studies were included, yielding a summary HR of 0.87 (95% CI: 0.74-1.03) and 0.96 (95% CI: 0.86-1.08), respectively. Our results show that, despite few suggestive findings, the use of BMI as a valuable predictor of melanoma patients' survival in terms of PFS and OS should not be currently recommended, due to the limited evidence available.

Photoprotection in skin of color

As populations in many parts of the world are projected to become more racially diverse over the coming decades, we must better understand the unique characteristics of the skin of populations with skin of color (SOC). This review aims to highlight important physiologic and clinical considerations of photoprotection in SOC. Ultraviolet radiation and visible light affect dark and light skin differently. SOC populations have historically not been informed on photoprotection to the same degree as their light skinned counterparts. This has exacerbated dermatologic conditions in which SOC populations are disproportionately affected, such as hyperpigmentary disorders. Patients should be encouraged to utilize multiple methods of photoprotection, ranging from avoidance of sunlight during peak intensity hours, seeking shade, wearing sun-protective clothing and wide-brimmed hat, and applying sunscreen. Ideal sunscreens for SOC populations include those with UVA-PF/SPF ratios ≥ 2/3 and tinted sunscreens to protect against VL. Although there have been increased efforts recently, more research into photoprotection for SOC and targeted public education are required to disseminate photoprotection resources that are patient-centered and evidence-based.

Ultraviolet A radiation exposure and melanoma: a review

The incidence of cutaneous melanoma has been increasing worldwide, and melanoma disproportionately contributes to skin cancer mortality. The pathogenesis of melanoma involves genetic and environmental factors, and while the effects of ultraviolet B radiation on melanoma development are well researched, fewer studies have investigated the role of ultraviolet A (UVA) radiation. We comprehensively reviewed cell, animal and epidemiology studies on the association between UVA exposure and melanomagenesis. UVA radiation has been found to have negative effects on melanocytes due to the induction of oxidative stress, dysregulation of gene transcription and creation of mutagenic photoproducts in DNA. Animal studies demonstrate adverse effects of UVA on melanocytes, including the development of melanoma. Epidemiology studies, of varying quality, that examined participants' exposure to tanning devices which use UVA radiation primarily found that UVA exposure increased the risk for melanoma. Some studies reported larger associations with increased frequency of device use, suggestive of a dose-response relationship. Overall, we found that many studies supported a positive association between UVA exposure and melanoma on both molecular and population levels. Understanding the role of UVA in the development of melanoma will inform the implementation of preventive health interventions, such as those related to sunscreen development and use and increasing restrictions on indoor tanning.

An Epidemiological Update on Indoor Tanning and the Risk of Skin Cancers

Indoor tanning (sunbeds, solarium) uses artificial ultraviolet radiation (UVR) to stimulate cosmetic tanning of the skin. Indoor tanning has been officially classified as a human carcinogen in 2009 by the International Agency for Research on Cancer of the World Health Organization (WHO). The differences in the prevalence of sunbed use across countries and over the years highlight underlying legislative, climatic, and cultural differences. Indoor tanning-seeking behaviors may be driven by motivations for an appealing appearance, largely influenced by gender and age, and several misconceptions that a prevacation tan safeguards the skin, that sunbeds can be used to treat acne or to increase vitamin D, or that tanning is a healthy habit. This review provides an epidemiological update on the prevalence of sunbed use, who tends to use sunbeds and why, and details the current evidence on the association of sunbeds with skin cancers, including cutaneous melanoma, basal cell carcinoma (BCC), and cutaneous squamous cell carcinoma (cSCC). A statistically significant higher risk of cutaneous melanoma, BCC and cSCC with the use of sunbeds has been consistently demonstrated. This risk of skin cancer is even higher with the more frequent use of sunbeds, underscoring a dose-response relationship, and in those first exposed to sunbeds at a younger age. Preventive measures against sunbed use include legislation restricting sunbed use, educational campaigns to inform and discourage from indoor tanning, as well as using the internet, online advertising messages and the social media to reach larger audiences and to promote an untanned appearance.

Photochemoprevention of ultraviolet Beam Radiation-induced DNA damage in keratinocytes by topical delivery of nanoformulated Epigallocatechin-3-gallate

Ultraviolet Beam (UVB) radiation is the main cause of skin cancer worldwide. Besides biocompatibility, the instability and limited skin permeability are the most challenging features of many effective photochemopreventive agents. (-)-Epigallocatechin-3-gallate (EGCG) is a natural polyphenolic compound extracted from Camellia sinensis that has been demonstrated to have antioxidant, anti-inflammatory, and anti-cancer properties. We evaluated the efficacy of three innovative EGCG nanoformulations in chemoprevention of UVB-induced DNA damage in keratinocytes. Results indicated that the EGCG nanoformulations reduced UVB-induced oxidative stress elevation and DNA damage. The nanoformulations also reduced the UVB-induced formation of pyrimidine and pyrimidone photoproducts in 2D human immortalized HaCaT keratinocytes and SKH-1 hairless mice through antioxidant effects and possibly through absorption of UVB radiation. In addition, EGCG nanoformulations inhibited UVB-induced chemokine/cytokine activation and promoted EGCG skin permeability and stability. Taken together, the results suggest the use of EGCG nanoformulations as potential natural chemopreventive agents during exposure to UVB radiation.

Epidemiology beyond its limits

In 1995, journalist Gary Taubes published an article in Science titled "Epidemiology faces its limits," which questioned the utility of nonrandomized epidemiologic research and has since been cited more than 1000 times. He highlighted numerous examples of research topics he viewed as having questionable merit. Studies have since accumulated for these associations. We systematically evaluated current evidence of 53 example associations discussed in the article. Approximately one-quarter of those presented as doubtful are now widely viewed as causal based on current evaluations of the public health consensus. They include associations between alcohol consumption and breast cancer, residential radon exposure and lung cancer, and the use of tanning devices and melanoma. This history should inform current debates about the reproducibility of epidemiologic research results.

Tanning Bed Legislation for Minors: A Comprehensive International Comparison

Tanning beds have been classified as carcinogenic to humans. As a result, many countries have enacted laws regulating the use of commercial tanning beds, including bans for minors. However, there is no international overview of the current legal status of access restrictions for minors that provides details on their specific design regarding age limits and possible exceptions to the statutory regulation. Therefore, we performed a comprehensive web search of current tanning bed legislation for minors on the three continents North America, Australia, and Europe. Our findings regarding the existence and concrete design of access restrictions are presented graphically, using maps. We found a wide variety of different legislations. In Australia, a total ban on tanning beds exists, while in New Zealand, tanning bed use is banned for minors. In Europe, about half of the countries have implemented a strict ban for minors. In North America, we found differences in the age limit for access restrictions between the states, provinces, and territories for those regions that implemented a ban for minors. In the United States, some states have rather “soft bans” that allow use by minors with different types of parental consent. The patchwork in legislation calls for harmonization. Therefore, our comparison is an important starting point for institutions such as the World Health Organization or the European Commission to advance their goals toward a harmonization of tanning bed legislation in general and for minors in particular.

Ambient UVR and Environmental Arsenic Exposure in Relation to Cutaneous Melanoma in Iowa

Intermittent sun exposure is the major environmental risk factor for cutaneous melanoma (CM). Cumulative sun exposure and other environmental agents, such as environmental arsenic exposure, have not shown consistent associations. Ambient ultraviolet radiation (UVR) was used to measure individual total sun exposure as this is thought to be less prone to misclassification and recall bias. Data were analyzed from 1096 CM cases and 1033 controls in the Iowa Study of Skin Cancer and Its Causes, a population-based, case-control study. Self-reported residential histories were linked to satellite-derived ambient UVR, spatially derived environmental soil arsenic concentration, and drinking water arsenic concentrations. In men and women, ambient UVR during childhood and adolescence was not associated with CM but was positively associated during adulthood. Lifetime ambient UVR was positively associated with CM in men (OR for highest vs. lowest quartile: 6.09, 95% confidence interval (CI) 2.21–16.8), but this association was not as strong among women (OR for highest vs. lowest quartile: 2.15, 95% CI 0.84–5.54). No association was detected for environmental soil or drinking water arsenic concentrations and CM. Our findings suggest that lifetime and adulthood sun exposures may be important risk factors for CM.

Plant-Derived Terpenoids: A Promising Tool in the Fight against Melanoma

Simple Summary

Despite the numerous therapies, melanoma remains the deadliest of all skin cancers; however, plant-derived terpenoids are defense molecules that have proven anti-cancer properties. In this review, we present the results of the search for anti-melanoma plant terpenoids. Additionally, we show the effects of combining terpenoids with standard drugs, radiation therapy, or other plant substances on melanoma cell lines and animal models. Finally, we present some examples of drug delivery systems that increase the uptake of terpenoids by melanoma tissue.

Abstract

Melanoma is responsible for the highest number of skin cancer-caused deaths worldwide. Despite the numerous melanoma-treating options, the fight against it remains challenging, mainly due to its great heterogeneity and plasticity, as well as the high toxicity of standard drugs. Plant-derived terpenoids are a group of plant defense molecules that have been proven effective in killing many different types of cancer cells, both in in vitro experiments and in vivo models. In this review, we focus on recent results in the search for plant terpenoids with anti-melanoma activity. We also report on the synergistic action of combining terpenoids with other plant-derived substances, MAP kinase inhibitors, or radiation. Additionally, we present examples of terpenoid-loaded nanoparticle carriers as anti-melanoma agents that have increased permeation through the cancer tissue.

Knowledge and Attitudes of Cypriots on Melanoma Prevention: Is there a Public Health Concern?

Background

Melanoma is the deadliest type of skin cancer. It is the eighth most common cancer in males and the tenth in females in Cyprus, an island in the Mediterranean with a high ultraviolet (UV) index. Cyprus is expected to be strongly affected by climate change and consequently, melanoma will likely become an increasing public health problem. Melanoma prevention is possible; however, it is unknown if people living in Cyprus are aware of melanoma and prevention methods. To this end, we used a validated survey to evaluate the level of melanoma knowledge and factors associated with it in the Cypriot population.

Methods

We conducted a 47-item survey with sections on demographics, knowledge of melanoma and risk factors, attitudes toward relevant health practices, and protective behaviors among six hundred Cypriot residents from October 2015 to April 2016.

Results

Our results revealed that only 59% of participants check their skin for moles, 87% protect their skin from the sun during summer holidays, and 57% do not take measures to protect their skin from the sun during non-holiday periods. Protective behavior was positively associated with educational level (P=0.016) and district of residence (P<0.0001). Melanoma knowledge was positively associated with education level (P=0.002) and district of residence (P=0.004). Level of Concern was positively associated with age (P=0.026) and education level (P=0.041).

Conclusions

There are gaps in melanoma knowledge and prevention practices in the study population. Further education on melanoma and its prevention should be specifically targeted to individuals of lower education levels as well as teenagers, such that protective behaviors for melanoma are adopted early in life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12324-0.

Skin Cancer Risk Perception and Tanning Bed Use: A Population-Based Survey to Identify Persons at Risk for Melanoma in Olmsted County, Minnesota

BACKGROUND

Cutaneous melanoma is strongly associated with tanning bed use.

OBJECTIVE

To describe local residents' knowledge, attitudes, and behavior regarding skin cancer and tanning bed use and to estimate prevalence of high risk for melanoma.

MATERIALS AND METHODS

A survey was mailed to 886 local residents (549, aged 18-39 years; 337, aged ≥40 years). Logistic and linear regression and univariate and multivariable analysis were used to assess perceived risk and skin cancer knowledge.

RESULTS

The response rate was 21%; 55% of the younger group and 37% of the older group had used indoor tanning, and prevalence of high risk for melanoma according to a skin cancer risk calculator was 18% in the younger group and 33% in the older group. Individuals with high risk scores were more likely to correctly perceive that they were at high risk for skin cancer. Most participants with high risk scores and those who previously used tanning beds reported low likelihood of future indoor tanning.

CONCLUSION

Female sex, high risk score, and previous indoor tanning were associated with participants' views of higher skin cancer risk. No specific knowledge gaps were identified. Understanding community residents' attitudes about skin cancer and indoor tanning can help guide interventions.

Use of Indoor Tanning Diagnosis Codes in Claims Data

The International Classification of Diseases: 10th Revision (effective from October 2015) included indoor tanning diagnosis codes for the first time. The majority of data on indoor tanning is self-reported. We used a large claims dataset to investigate the patients and settings in which indoor tanning International Classification of Diseases: 10th Revision codes are being used. We included encounters with the International Classification of Diseases: 10th Revision indoor tanning codes in Truven Health MarketScan data 2016–2018, which contain deidentified commercial insurance claims data for approximately 43 million patients. We used descriptive statistics to evaluate patient and encounter characteristics and normalized results using outpatient dermatology encounters. A total of 4,550 encounters were identified, 99.0% of which were outpatient, and 72.3% were with dermatology. Patients were majority female (85.0%) with ages ranging from 7 to 93. The Midwest region had the most indoor tanning encounters. Destruction of a premalignant lesion was performed in 15.1%, and biopsies were performed in 18.4% of encounters, suggesting that encounters may have been for skin cancer surveillance. Increased usage of indoor tanning International Classification of Diseases: 10th Revision codes in the coming years may strengthen the indoor tanning literature. Claims data are a potential tool to better understand patients who have a history of exposure to indoor tanning and their associated risk factors, comorbidities, behaviors, and healthcare utilization.

Factors associated with sunbed use among 3692 outpatients in 18 centers of the Italian Cancer League (LILT)

Indoor tanning is associated with an increased risk of skin cancer. Nonetheless, its use is still widespread. We aimed to investigate the socio-demographic and clinical characteristics of sunbed users in a group of participants in the skin cancer prevention campaign organized by the Italian Cancer League (LILT). During almost 2 years, 4409 individuals were screened in 18 centers. Participants reported having used sunbeds before the age of 15 years in 2.2% of cases, while after age 15 the prevalence of use was 22.2%. Participants with complete information were 3692. Sunbed users aged > 15 years were significantly more frequently females, young, living in Northern Italy, highly educated, and current or former smokers. They had darker phototype, more common nevi, had used sunbeds more frequently before the age of 15, reported a history of sunburns, and use of sunscreens. Indoor tanning is an important public health issue and a relevant target for primary prevention. However, not all countries have adopted the recommendations issued by the World Health Organization (WHO) on health risks associated with artificial tanning. A deeper insight into the topic may contribute to identify the best prevention strategies.

Indoor Tanning and the Risk of Overall and Early-Onset Melanoma and Non-Melanoma Skin Cancer: Systematic Review and Meta-Analysis

Simple Summary

Motivated by the increasing incidences of skin cancer, in 2015, Australian states banned indoor tanning to prevent exposure to artificial ultraviolet light. However, there has been no study investigating the association between indoor tanning and early-onset melanoma and non-melanoma skin cancer. In this study, we reviewed a total of 54 studies to examine the association between indoor tanning device use and overall and early-onset skin cancer. We found that indoor tanning is associated with increased risk for early-onset melanoma and NMSC, and has a dose–response relationship with first exposure at an early age and the frequency of exposure. Therefore, this study emphasizes the importance of avoiding indoor tanning risk in younger adults. Our findings provide evidence that supports policies regulating the excessive use of tanning devices, especially in the vulnerable younger population, to reduce the additional risk of skin cancer.

Abstract

The aim of this study was to examine the association between indoor tanning use and the risk of overall and early-onset (age < 50) melanoma and non-melanoma skin cancer (NMSC). To evaluate the association between indoor tanning and skin cancer, a systematic review of the literature published until July 2021 was performed using PubMed, EMBASE, and MEDLINE. Summary relative risk (RR) from 18 studies with 10,406 NMSC cases and 36 studies with 14,583 melanoma cases showed significant association between skin cancer and indoor tanning (melanoma, RR= 1.27, 95% CI 1.16–1.39; NMSC, RR = 1.40, 95% CI 1.18–1.65; squamous cell carcinoma (SCC), RR = 1.58, 95% CI 1.38–1.81; basal cell carcinoma (BCC), RR = 1.24, 95% CI 1.00–1.55). The risk was more pronounced in early-onset skin cancer (melanoma, RR = 1.75, 95% CI 1.14–2.69; NMSC, RR = 1.99, 95% CI 1.48–2.68; SCC, RR = 1.81, 95% CI 1.38–2.37; BCC, RR = 1.75, 95% CI 1.15–2.77). Moreover, first exposure at an early age (age ≤ 20 years) and higher exposure (annual frequency ≥ 10 times) to indoor tanning showed increasing risk for melanoma (RR = 1.47, 95% CI 1.16–1.85; RR = 1.52, 1.22–1.89) and NMSC (RR = 2.02, 95% CI 1.44–2.83; RR = 1.56, 95% CI 1.31–1.86). These findings provide evidence supporting primary prevention policies regulating modifiable behaviors to reduce the additional risk of skin cancer among younger adults.

The Incidence of Cutaneous Malignant Melanoma in Eastern Newfoundland and Labrador, Canada, from 2007 to 2015

BACKGROUND

The incidence of cutaneous malignant melanoma continues to increase worldwide and in Canada. It is unclear whether the increase in incidence and clinical characteristic trends of cutaneous malignant melanoma are similar in the province of Newfoundland and Labrador.

OBJECTIVE

The objective of this study is to examine the incidence and trends of cutaneous malignant melanoma in Eastern Newfoundland and Labrador.

METHODS

Patients aged 18 years or older diagnosed with cutaneous malignant melanoma were identified from the Eastern Health Authority's Cancer Registry. The diagnosis was confirmed by a pathologist via histological subtype. Patients were excluded if the diagnosis was unspecified, a nonmelanoma skin cancer or if there was a recurrence in the same lesion location. In total 298 patients diagnosed with cutaneous malignant melanoma from 2007 to 2015 were included in the analysis.

RESULTS

The total incidence increased from 4.1 to 15.6 cases/100,000 person-years, which represents a 283.0% increase from 2007 to 2015. The largest increases in incidence were seen in males and patients aged from 60 to 79 years. The most common lesion anatomical locations were the trunk in males and the lower extremity in females. The majority of cases had a Breslow thickness below 1.0 mm.

CONCLUSION

The incidence of cutaneous malignant melanoma in Eastern Newfoundland and Labrador is increasing at a faster rate than in any other region in Canada. Health care providers should work to be aware of the clinical trends and risk factors associated with this disease to facilitate early detection and prevent morbidity.

Laboratory testing of sunscreens on the US market finds lower in vitro SPF values than on labels and even less UVA protection

Background

New research has attributed increased significance to the causal link between ultraviolet A (UVA) radiation and immunosuppression and carcinogenesis. In the United States, sunscreens are labeled with only their sun protection factor (SPF) and an imprecise term “broad‐spectrum protection.” Sunscreen marketing and efficacy evaluations continue to be based primarily on skin redness (sunburn) or erythema. We sought to evaluate the ultraviolet (UV) protection offered by common sunscreen products on the US market using laboratory‐measured UV‐absorption testing and comparing with computer‐modeled protection and the labeled SPF values. This approach enables an investigation of the relationship between the labeled SPF and measured UVA protection, a factor that is ignored in current regulations.

Methods

Fifty‐one sunscreen products for sale in the United States with SPF values from 15 to 110 and labeled as providing broad‐spectrum protection were tested using a commercial laboratory. All products were evaluated using the ISO 24443:2012 method for sunscreen effectiveness. The final absorbance spectra were used for analysis of in vitro UV protection.

Results

In vitro SPF values from laboratory‐measured UV absorption and computer modeling were on average just 59 and 42 percent of the labeled SPF. The majority of products provided significantly lower UVA protection with the average unweighted UVA protection factor just 24 percent of the labeled SPF.

Conclusion

Regulations and marketplace forces promote sunscreens that reduce sunburn instead of products that provide better, more broad‐spectrum UV protection. The production and use of products with broad spectrum UV protection should be incentivized, removing the emphasis on sunburn protection and ending testing on people.

Ultraviolet radiation and risk of cutaneous melanoma and squamous cell carcinoma in males and females in the Norwegian Offshore Petroleum Workers cohort

BACKGROUND

Increased risk of cutaneous melanoma and squamous cell carcinoma (SCC) has been reported among petroleum workers, but few studies include females, exposure data on ultraviolet radiation (UVR), and potential confounding factors. We aimed to examine UVR exposure in relation to risk of melanoma and SCC among male and female offshore petroleum workers. We also examined the association between UVR exposure and melanoma (Breslow) thickness.

METHODS

The Norwegian Offshore Petroleum Workers (NOPW) cohort (n = 27,917) holds information on sunbathing, indoor tanning, sunburns, sunscreen use, and other lifestyle factors recorded in 1998. Linkage to the Cancer Registry of Norway gave information on cancer diagnosis through 2017. We used Cox and logistic regression to estimate hazard ratios (HRs) of skin cancer and odds ratios (OR) of thick (≥1 mm) melanomas, respectively, with 95% confidence intervals (CIs).

RESULTS

Melanoma risk increased with increasing frequency of sunbathing after age 20 (ptrend  = 0.031), sunburn average intensity (ptrend  = 0.028), and sunscreen use (HR = 2.16; 95% CI: 1.42 -3.27 for almost always vs. never/rarely). The risk of thick melanoma was inversely associated with sunbathing frequency after age 20 (OR = 0.38; 95% CI: 0.16 - 0.90 for ≥4 weeks/year vs. 1 week/year). SCC risk increased with increasing frequency of indoor tanning after age 20 (HR = 2.72; 95% CI: 1.22 - 6.05 for ≥3 times/months vs. never), sunburn average intensity (ptrend  < 0.001), and sunscreen use (ptrend  < 0.001).

CONCLUSIONS

Our results support associations between UVR exposure and skin cancer risk in male and female offshore petroleum workers. This occupational group may be especially relevant for targeted sun protection advice.

Tanning Misinformation Posted by Businesses on Social Media and Related Perceptions of Adolescent and Young Adult White Non-Hispanic Women: Mixed Methods Study

BACKGROUND

Indoor ultraviolet (UV) tanning is common and consequential, increasing the risk for cancers including melanoma and basal cell carcinoma. At-risk groups include adolescents and young adults, who often report beliefs about benefits of tanning. Adolescent and young adults are also among the most ubiquitous social media users. As previous studies support that content about tanning is common on social media, this may be a way that young women are exposed to influential content promoting tanning, including health misinformation.

OBJECTIVE

The purpose of this study was to evaluate health misinformation promoted by indoor tanning businesses via social media and to understand young women's perceptions of this misinformation.

METHODS

This mixed methods study included (1) retrospective observational content analysis of indoor tanning salons' content on Facebook over 1 year and (2) qualitative interviews with a purposeful national sample of 46 White non-Hispanic women, age 16 to 23 years, who had recently tanned indoors. We assessed experiences with tanning businesses' posted content on social media through interviews. We used the constant comparative approach for qualitative analyses.

RESULTS

Content analysis findings included data from indoor tanning businesses (n=147) across 50 states, yielding 4956 total posts. Among 9 health misinformation topics identified, the most common was the promotion of UV tanning as a safe way to get Vitamin D (n=73, 1.5%). An example post was "Stop by Body and Sol to get your daily dose of Vitamin D." Another misinformation topic was promoting tanning for health benefits (n=31, 0.62%), an example post was "the flu is not a season, it's an inability to adapt due to decreased sun exposure…" A total of 46 participants completed interviews (age: mean 20 years, SD 2). Almost all participants (45/46, 98%) used Facebook, and 43.5% (20/46) followed an indoor tanning business on social media. Approximately half of participants reported seeing social media posts from tanning salons about Vitamin D, an example of a participant comment was "I have [seen that] a few times..." Among the participants, approximately half believed it was safe to get Vitamin D from indoor UV tanning; a participant stated: "I think it is a valid benefit to UV tanning."

CONCLUSIONS

Despite the low frequency (range 0.5%-1.5%) of social media posts promoting health misinformation, participants commonly reported viewing these posts, and their perceptions aligned with health misinformation. Health education campaigns, possibly using social media to target at-risk populations, may be an innovative approach for tanning prevention messages.

To ban or not to ban tanning bed use for minors: A cost-effectiveness analysis from multiple US perspectives for invasive melanoma

BACKGROUND

Tanning bed use is common among US adolescents, but is associated with increased melanoma risk. The decision to ban tanning bed use by adolescents should be made in consideration of the potential health benefits and costs.

METHODS

The US population aged 14 to 17 years was modeled by microsimulation, which compared ban versus no ban strategies. Lifetime quality-adjusted life years (QALYs) and costs were estimated from a health care sector perspective and two societal perspectives: with and without the costs of policy enforcement and the economic losses of the indoor-tanning bed industry.

RESULTS

Full adherence to the ban prevented 15,102 melanoma cases and 3299 recurrences among 17.1 million minors, saving $61in formal and informal health care costs per minor and providing an increase of 0.0002 QALYs. Despite the intervention costs of the ban and the economic losses to the indoor-tanning industry, banning was still the dominant strategy, with a savings of $12 per minor and $205.4 million among 17.1 million minors. Findings were robust against varying inspection costs and ban compliance, but were sensitive to lower excess risk of melanoma with early exposure to tanning beds.

CONCLUSIONS

A ban on tanning beds for minors potentially lowers costs and increases cost effectiveness. Even after accounting for the costs of implementing a ban, it may be considered cost effective. Even after accounting for the costs of implementing a ban and economic losses in the indoor-tanning industry, a tanning bed ban for US minors may be considered cost effective. A ban has the potential to reduce the number of melanoma cases while decreasing health care costs.

LAY SUMMARY

Previous meta-analyses have linked tanning bed use with an increased risk of melanoma, particularly with initial use at a young age. Yet, it remains unclear whether a ban of adolescents would be cost effective. Overall, a ban has the potential to reduce the number of melanoma cases while promoting a decrease in health care costs. Even after accounting for the costs of implementing a ban and the economic losses incurred by the indoor-tanning industry, a ban would be cost effective.

Appearance, Friends, and Feelings: A Two-Study Exploration of Young Women's Emotional Associations and Indoor Tanning Frequency

BACKGROUND

Knowledge of its potential cancer risk is often not enough to motivate individuals to avoid indoor tanning. Previous research has found that emotions toward indoor tanning and appearance motivations may prompt people to continue despite the risks.

METHODS

We conducted two online surveys of US young adult women. Study one included a convenience sample of female undergraduates (N = 502) at a university in the northwestern USA. Study two included young women from a nationwide US online panel (N = 270).

RESULTS

Results suggest that emotional associations, both positive and negative, with indoor tanning explain greater variances in indoor tanning behavior than demographics and previously established psychosocial predictors of tanning alone. Appearance motivations were also positively associated with indoor tanning in both samples.

CONCLUSIONS

This research has implications for health care providers and health communicators, as indoor tanning prevention messages and campaigns should consider the association between both positive and negative emotions on tanning behaviors as well as appearance motivations.

Epidemiology of Melanoma in the Czech Republic in East Bohemia in the Period 2002-2017 and the Effect of the Annual Sunshine Exposure

AIM

The evaluation of the trend in the occurrence of melanoma nodulare, melanoma superficiale, lentigo maligna and melanoma in situ in the period of 2002-2017 in East Bohemia region in the Czech Republic. We examine if the annual numbers of hours of sunshine could affect the number of patients with melanoma.

METHOD

In the peridod of 2002-2017, altogether 2230 patients with new diagnosis of melanoma were examined. We studied 1) If there is some trend in the occurrence of lentigo maligna and melanoma in situ, melanoma superficiale, and melanoma nodulare and if there is a difference in the age of patients with this diagnosis (adjusted calculation of specific kind of melanomas and adjusted calculation of age). 2) If the annual numbers of hours of sunshine affect the trend in the occurrence of melanoma and if the annual numbers of hours of sunshine affect the body site of melanoma.

RESULTS AND CONCLUSION

Our study confirmed that the number of patients with lentigo maligna and melanoma in situ had increased in East Bohemia region in the period of 2002-2017. The number of melanomas of nodular and superficial type does not increase. The total number of melanomas in this period does not increase either. No difference of the age of patients with melanoma nodulare, superficiale, lentigo maligna and melanoma in situ was confirmed. We confirmed no relation of the annual numbers of hours of sunshine to the number of melanoma and to the body site of melanoma.

Melanoma Incidence in Czech Republic, the Relation between Histology, Body Site of Melanoma, and Duration of Lesions

AIM

To evaluate the occurrence of melanoma in the period 1996-2017 in East Bohemia region in the Czech Republic.

METHOD

We studied the incidence of melanoma and the age of diagnosis (adjusted calculation) and the parameters such as histology, body site of lesions, the length of the duration of lesions in 2810 patients.

RESULTS AND CONCLUSION

No change in the occurrence of melanoma and in age of melanoma during this period was found. The difference between men and women was not confirmed in histology, but the difference between men and women was confirmed in the body site of lesion and in the length of duration of lesion. No relation between the length of duration of lesions from which melanoma had originated and its histology was confirmed. The relation was confirmed between histology and body site of melanoma. The relation between the body site and the length of duration of previous lesions was confirmed also. The increasing occurrence of melanoma on the trunk according to the duration of the previous lesions was confirmed.

The global burden of skin cancer: A longitudinal analysis from the Global Burden of Disease Study, 1990-2017

Background

Despite efforts toward the earlier detection and prevention of skin cancer, the prevalence of skin cancers continues to increase. Identifying trends in skin cancer burdens among populations can lead to impactful and sustainable interventions.

Methods

We assessed the global trends in skin cancer from 1990 to 2017 in 195 countries worldwide through the Global Burden of Disease Study (GBD) 2017 database.

Results

The rate of change in skin cancers between 1990 to 2017 varied among countries. Squamous cell carcinomas increased by 310% during this time, the highest among any neoplasm tracked by the GBD. Men experienced greater age-specific prevalence rates of keratinocyte carcinoma across all ages (P < .05). Women had a greater prevalence of melanoma until approximately age 50 years, after which the trend reversed until age 85 years. Men experienced greater age-specific death rates across all ages. The disability-adjusted life years (DALYs) of melanoma and keratinocyte carcinoma increased exponentially with age (P < .05).

Conclusion

The incidence, prevalence, and DALYs of skin cancers are increasing disproportionately among different demographic groups. As a worldwide epidemiological assessment, the GBD 2017 provides frequently updated measures of the skin cancer burden, which may help to direct resources and allocate funding to close the gap in global skin cancer disparities.

Evaluation for Skin Cancer and Precancer in Patients With Vitiligo Treated With Long-term Narrowband UV-B Phototherapy

Importance

Narrowband UV-B (NBUVB) phototherapy has been the mainstay in the treatment of vitiligo, but its long-term safety in terms of photocarcinogenesis has not been established.

Objectives

To investigate the risks of skin cancer and precancerous lesions among patients with vitiligo undergoing NBUVB phototherapy, based on the number of NBUVB phototherapy sessions.

Design, Setting, and Participants

This nationwide population-based retrospective cohort study enrolled 60 321 patients with vitiligo 20 years or older between January 1, 2007, and December 31, 2017. Patients and outcomes were identified through nationwide cohort data from the Korean national health insurance claims database, and frequency matching by age and sex was performed.

Exposures

The number of phototherapy sessions each patient received between 2008 and 2017. Patients were classified into 5 groups according to the number of phototherapy sessions (0 sessions, 20 105 patients; 1-49 sessions, 20 106 patients; 50-99 sessions, 9702 patients; 100-199 sessions, 6226 patients; and ≥200 sessions, 4182 patients). We also identifed patients who underwent at least 500 phototherapy sessions (717 patients).

Main Outcomes and Measures

Primary outcomes were the development of actinic keratosis, Bowen disease, nonmelanoma skin cancer, or melanoma after enrollment.

Results

Among the 60 321 patients with vitiligo in this study (33 617 women; mean [SD] age, 50.2 [14.9] years), the risks of Bowen disease (<50 sessions of phototherapy: hazard ratio [HR], 0.289 [95% CI, 0.060-1.392]; 50-99 sessions: HR, 0.603 [95% CI, 0.125-2.904]; 100-199 sessions: HR, 1.273 [95% CI, 0.329-4.924]; ≥200 sessions: HR, 1.021 [95% CI, 0.212-4.919]), nonmelanoma skin cancer (<50 sessions: HR, 0.914 [95% CI, 0.533-1.567]; 50-99 sessions: HR, 0.765 [95% CI, 0.372-1.576]; 100-199 sessions: HR, 0.960 [95% CI, 0.453-2.034]; ≥200 sessions: HR, 0.905 [95% CI, 0.395-2.073]), and melanoma (<50 sessions: HR, 0.660 [95% CI, 0.286-1.526]; 50-99 sessions: HR, 0.907 [95% CI, 0.348-2.362]; 100-199 sessions: HR, 0.648 [95% CI, 0.186-2.255]; ≥200 sessions: HR, 0.539 [95% CI, 0.122-2.374]) did not increase after phototherapy. The risk of actinic keratosis increased significantly for those who had undergone 200 or more NBUVB phototherapy sessions (HR, 2.269 [95% CI, 1.530-3.365]). A total of 717 patients with vitiligo underwent at least 500 sessions of NBUVB phototherapy; their risks of nonmelanoma skin cancer and melanoma were no greater than those of the patients who did not undergo NBUVB phototherapy (nonmelanoma skin cancer: HR, 0.563 [95% CI, 0.076-4.142]; melanoma: HR, not applicable).

Conclusions and Relevance

Our results suggest that long-term NBUVB phototherapy is not associated with an increased risk of skin cancer in patients with vitiligo and that NBUVB phototherapy may be considered a safe treatment.

Partnering With Massage Therapists to Communicate Information on Reducing the Risk of Skin Cancer Among Clients: Longitudinal Study

BACKGROUND

Skin cancer affects millions of Americans and is an important focus of disease prevention efforts. Partnering with non-health care practitioners such as massage therapists (MTs) can reduce the risk of skin cancer. MTs see clients' skin on a regular basis, which can allow MTs to initiate "helping conversations" (ie, brief behavioral interventions aimed at reducing the risk of skin cancer).

OBJECTIVE

The purpose of this study was to evaluate (1) the feasibility of recruiting, enrolling, and retaining Arizona MTs in an online electronic training (e-training) and (2) the preliminary efficacy of e-training on knowledge, attitudes/beliefs, and practice of risk reduction for skin cancer. We explored MTs' ability to assess suspicious skin lesions.

METHODS

We adapted the existing educational content on skin cancer for applicability to MTs and strategies from previous research on helping conversations. We assessed the feasibility of providing such e-training, using Research Electronic Data Capture (REDCap) tools for data capture. We assessed the preliminary efficacy using established self-report surveys at baseline, immediately post training, and at 3 and 6 months post training.

RESULTS

A total of 95 participants enrolled in the study, of which 77% (73/95) completed the assessments at 6 months (overall attrition=23%). Project satisfaction and e-training acceptability were high. Knowledge, personal behaviors (skin self-examination, clinical skin examination, sun protection frequency), and practice attitudes (appropriateness and comfort with client-focused communication) of risk reduction for skin cancer improved significantly and were sustained throughout the study.

CONCLUSIONS

The e-training was feasible and could be delivered online successfully to MTs. Participants were highly satisfied with and accepting of the e-training. As such, e-training has potential as an intervention in larger trials with MTs for reducing the risk of skin cancer.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/13480.

Solarium Use and Risk for Malignant Melanoma: Many Open Questions, Not the Time to Close the Debate

To shed further light on the ongoing debate whether sunbed use may increase melanoma risk, we have critically assessed the scientific literature that is at present available, focussing on a meta-analysis that we published recently. Our literature search identified several meta-analyses that report a weak association for ever-exposure to UV radiation from a solarium with melanoma risk. However, the quality of studies included in these meta-analyses and the resulting evidence levels and grades of recommendation were very low due to the lack of interventional trials and because of severe limitations of many of the observational studies. The results of cohort and case-control studies published until today do not prove causality, not even by the Hill criteria. The overall quality of these observational studies and the resulting evidence levels are low due to severe limitations (including unobserved or unrecorded confounding), which leads to bias. It must be recognized that in the majority of studies, published to date, many of the confounding factors, including sun exposure, sunburns and skin type, have not been adequately and systematically recorded and adjusted for. We conclude that the many limitations of the individual studies and the resulting low levels of evidence and grades of recommendation do at present not allow postulation of a causal relationship between solarium use and melanoma risk. At present, there is no convincing evidence that moderate/responsible solarium use increases melanoma risk.

A re-evaluation of teenage sunbed use following the introduction of banning legislation for under 18-year-olds

Background

There is little information on the effectiveness of introducing age restriction legislation alone to reduce the rate of sunbed usage by teenagers. Prior to the Public Health (Sunbed) Act of 2014 prohibiting the use of sunbeds in under 18-year-olds in Ireland we reported the rate of sunbed use at 7.5%.

Objectives

The aim of the study was to compare the rate of sunbed usage among Irish teenagers before and after the introduction of banning legislation to determine if it had the desired effect of reducing its rate of use.

Methods

In a cross-sectional survey, students from the same schools as in our previous study completed an anonymous, written questionnaire pertaining to sunbed usage.

Results

In total, 783 questionnaires, from 13 schools across Ireland, were completed. The rate of sunbed use in the current study was 7.2%, compared to 7.5% in the pre-ban study, (P = 0.76). A higher rate of sunbed use was observed in Dublin schools and female public students.

Conclusion

Our study suggests that legislation alone is ineffective at reducing sunbed usage in a teenage population. A multifaceted approach is required that includes enforcement of the legislation together with targeted public education and awareness campaigns using all aspects of the media.

Skin cancer and skin cancer risk behaviors among sexual and gender minority populations: A systematic review

BACKGROUND

Individuals of sexual and gender minorities may have different lifetime risk of skin cancer and ultraviolet radiation exposure than heterosexual persons.

OBJECTIVE

To systematically review the prevalence of skin cancer and behaviors that increase risk of skin cancer among sexual and gender minority populations.

METHODS

We performed a systematic literature review in PubMed/MEDLINE, Embase, Cochrane, and Web of Science, searching for articles through October 18, 2019, that investigated risk of skin cancer and behaviors among sexual and gender minority populations.

RESULTS

Sexual minority men have a higher lifetime risk of any skin cancer (odds ratio range: 1.3-2.1) and indoor tanning bed use (odds ratio range: 2.8-5.9) compared with heterosexual men, whereas sexual minority women may use indoor tanning beds less frequently than heterosexual women and do not have an elevated risk of lifetime history of skin cancer. Gender-nonconforming individuals have higher lifetime prevalence of any skin cancer compared with cisgender men.

LIMITATIONS

Most variables rely on self-reporting in their original studies.

CONCLUSIONS

Sexual minority men disproportionately engage in use of indoor tanning beds, which may result in increased lifetime risk of skin cancer. Recognition of this risk is important for providing appropriate screening for patients in this population.

Ultraviolet radiation and cutaneous melanoma: a historical perspective

In this article, we summarize the research that eventually led to the classification of the full ultraviolet (UV) radiation spectrum as carcinogenic to humans. We recall the pioneering works that led to the formulation of novel hypotheses on the reasons underlying the increasing burden of melanoma in light-skinned populations. It took long before having compelling evidence on the association between UV and melanoma, in particular, the importance of UV exposure during childhood for both the occurrence of melanoma and death. The role of UVA was established only after 2005. If molecular lesions caused by UV radiation are better known, the precise mechanism by which UV exposure drives melanoma occurrence and progression still needs to be elucidated. More research on the UV-melanoma relationships has led to more evidence-based sun-protection recommendations, especially for children, and to effective control of the artificial UV tanning fashion. Since around 1985-1995, the mortality because of melanoma has started to decrease in younger age groups in most light-skinned populations. If sun protection among children remain on top of public health agendas, there is a fairly great chance that melanoma mortality will stabilize and steadily decrease in all light-skinned populations. The introduction of effective therapies against metastatic disease will improve this reversal in mortality trends.

Sunbeds and melanoma risk: time to close the debate

PURPOSE OF REVIEW

In spite of the established scientific evidence on the association of sunbed use with melanoma risk, some have recently expressed scepticism about the carcinogenicity of indoor tanning. This may have raised confusion among both physicians and patients. The purpose of this review is to make the point about the real impact of sunbed use on melanoma risk in light of the most recently published evidence.

RECENT FINDINGS

Seven themes were covered: recent studies on age at first sunbed exposure and melanoma risk; sunbed use and melanoma at different body sites; sunbed use and development of additional primary melanomas; new studies on proportion of melanomas attributable to sunbed use; sunbed use and melanoma risk factors; economic burden of sunbed use; and recent debate over whether indoor tanning contributes to melanoma.

SUMMARY

We were able to apply all epidemiological criteria for causality to the relationship between sunbed use and melanoma. Together with the new evidence on the strength, dose response, and temporality of the association of sunbeds with melanoma, this will hopefully close the debate over whether indoor tanning contributes to melanoma.

Attitudes and practice among dermatologists regarding indoor tanning

The aim of this study was to explore dermatologists' practices and attitudes related to educating and counseling their adolescent patients about indoor tanning. An online survey was carried out with a convenience sample of 100 dermatologists. Findings indicated that the majority of the dermatologists are actively engaged in discussing tanning bed use and sun protection with their adolescent patients. Most expressed positive attitudes toward educating patients on the risks of tanning bed use. Limited time was the most commonly reported barrier for the lack of discussion regarding indoor tanning. Of note, more than half of the dermatologists (65%) had patients suffering from tanning addiction. For tanning-addicted patients, dermatologists can encourage lifestyle changes, the use of sunless tanning products, and referrals when the patient's needs extend beyond the scope of the dermatologist.

Prevalence of Indoor Tanning Among U.S. High School Students from 2009 to 2017

Indoor tanning exposes users to high levels of ultraviolet radiation, increasing skin cancer risk. The risk is greatest for those who begin indoor tanning at a young age. The objective of this study was to assess changes in indoor tanning prevalence over time among U.S. high school students, by sex, age, and race/ethnicity. We used cross-sectional data from the 2009, 2011, 2013, 2015, and 2017 national Youth Risk Behavior Survey to examine changes in indoor tanning prevalence from 2009 to 2017 and from 2015 to 2017. From 2009 to 2017 indoor tanning declined overall (15.6 to 5.6%; p < 0.001), across all age groups, and among white (37.4 to 10.1%; p < 0.001) and Hispanic (10.5 to 3.0%; p < 0.001) female students, and white (7.0 to 2.8%; p < 0.001) and Hispanic (5.8 to 3.4%; p < 0.001) male students. From 2015 to 2017, indoor tanning declined overall (7.3 to 5.6%; p = 0.04) and among white (15.2 to 10.1%; p = 0.03) and Hispanic (5.8 to 3.0%; p = 0.02) female students, and 16-year-old students (7.2 to 4.7%; p = 0.03). Indoor tanning has continued to decrease, particularly among white and Hispanic female students, dropping well below the Healthy People 2020 target for adolescents. However, continued efforts are needed to further reduce and sustain reductions in adolescent indoor tanning and address remaining research gaps.

Association of Indoor Tanning Exposure With Age at Melanoma Diagnosis and BRAF V600E Mutations

There is limited information on how indoor tanning promotes melanoma development. We investigated indoor tanning use in patients with melanomas in sun-exposed skin and studied the clinicopathological and molecular characteristics in relation to indoor tanning exposure. Patients from a multidisciplinary clinic for cutaneous cancers completed standardized questionnaires on risk factors for melanoma as a component of medical history at their initial consultations. For this study, we included patients from December 2013 to May 2015. The 114 patients who reported indoor tanning exposure were younger at diagnosis than the 222 patients who did not (51.5 vs 64.0 years, two-sided P < .001). BRAF V600E genotype was more prevalent in ever-users than in nonusers (42.9% vs 28.3%, two-sided P = .04) and higher in ever-users who initiated indoor tanning prior to age 25 years compared with age 25 years or older (62.2% vs 31.1%, two-sided P = .003). There were more melanomas in intermittently sun-exposed skin in ever-users than nonusers (65.7% vs 51.9%, respectively, two-sided P = .02). Our data suggest indoor tanning may promote melanomas that arise in skin with low-chronic sun-induced damage through BRAF V600E-mediated melanomagenesis.

Nasal mucosal melanoma as a cause of epistaxis

A 43-year-old woman presented with an 8-week history of fatigue and recurrent right sided nasal bleeds progressing to significant pain and swelling on the right side of her face. Clinical examination revealed a friable mass in her right nasal passage. A biopsy and staging positron emission tomography-CT scan confirmed the diagnosis of a T4 N1 M1 BRAF wild type mucosal melanoma. The melanoma had metastasised to the right paranasal sinuses, right and left neck nodes, right submental node, right upper breast, liver, the subcutaneous fat of the left buttock and the right iliac bone as well as cerebral metastasis with further disease progression. Combination immunotherapy was started but initially suspended due to an adverse reaction to nivolumab and restarted in due course. Surgical debulking was carried out for symptomatic relief. This case report explores the delay in diagnosis of mucosal melanoma with its subsequent consequences and the lack of understanding of associated risk factors and optimal treatment.

Vitamin D and the skin: what should a dermatologist know?

Although first discovered in 1931, vitamin D has seen an increased interest in the scientific community over the past decades, including the dermatology field. Vitamin D promotes calcium and phosphorus absorption; however, the actions of vitamin D are not confined to bone. Indeed, there is now overwhelming and compelling scientific data that vitamin D plays a crucial role in a plethora of cellular function and in extra-skeletal health. Except for fatty fish livers, very few foods naturally contain vitamin D; and the major source of vitamin D comes from skin exposure to sunlight via ultraviolet B. Keratinocytes are unique in the body as not only do they provide the primary source of vitamin D for the body, but they also possess both the enzymatic machinery to metabolize the vitamin D produced to active metabolites. This has been referred to as the photoendocrine vitamin D system. Vitamin D regulates keratinocytes proliferation and differentiation; and plays a role in the defense against opportunistic infections. Multiple factors are linked to vitamin D status; and a growing number of dermatologic diseases has been linked to vitamin D status such as atopic dermatitis, psoriasis, vitiligo, and cutaneous cancers. In this article, we reviewed the potential determinants of vitamin D status, as its implications in dermatologic diseases.

Overview on vitamin D and sunbed use

Vitamin D seems to be associated with a protective effect in a vast range of diseases, including cardiovascular, autoimmune and oncologic conditions. Since ultraviolet (UV) B light is the most important prerequisite for the cutaneous synthesis of vitamin D, sunbeds are able to increase serum vitamin D levels, although only transiently in most cases. In this scenario, the artificial tanning industry relentlessly tries to promote the use of sunbeds as a 'safe' therapeutic measure to achieve an adequate serum vitamin D status. The World Health Organization classified UV-emitting tanning devices, as well as the whole UV spectrum, as group-1 carcinogens, as they significantly increase the risk of melanoma and non-melanoma skin cancer. In case of vitamin D deficiency or insufficiency, the current risk-benefit ratio is therefore in favour of vitamin D supplementation instead of sunbed use. Artificial tanning devices should never be considered as an option to achieve an appropriate vitamin D status. Their supposedly beneficial effects, vastly publicised by the artificial tanning industry, are not worth the carcinogenic risk associated with sunbed use.

Association of sunbed use with skin cancer risk factors in Europe: an investigation within the Euromelanoma skin cancer prevention campaign

INTRODUCTION

Sunbed use has been significantly associated with increased risk of melanoma and non-melanoma skin cancer (NMSC), but its relationship with melanoma's risk factors such as high nevus count, atypical nevi and lentigines is poorly studied. Euromelanoma is a skin cancer prevention campaign conducted all over Europe. It offers a once-a-year screening during which participants' data, including sunbed use and phenotype, are collected via questionnaires.

OBJECTIVES

To investigate the association of sunbed use with nevus count, atypical nevi, lentigines and suspicion of skin cancer.

METHODS

To ensure reliability of the data, we defined inclusion and exclusion criteria for countries' eligibility for the risk analysis. Multivariate logistic regression models (including age, gender, education, skin type, family history of melanoma, personal history of skin cancer, any sun exposure and any sunscreen use) were used to calculate summary odds ratios (SORs) of each clinical endpoint for ever sunbed use.

RESULTS

Overall, 227 888 individuals from 30 countries completed the Euromelanoma questionnaire. After the data quality check, 16 countries were eligible for the multivariate analysis, for a total of 145 980 participants (64.8% females; median age 43 years; 62.3% highly educated; 28.5% skin type I-II; 11.0% ever sunbed use). Ever sunbed use was independently associated with nevus count >50 [SOR = 1.05 (1.01-1.10)], atypical nevi [SOR = 1.04 (1.00-1.09)], lentigines [SOR = 1.16 (1.04-1.29)] and suspicion of melanoma [SOR = 1.13 (1.00-1.27)]. Conversely, no significant association was found between ever sunbed use and suspicion of NMSC [SOR = 1.00 (0.91-1.10)].

CONCLUSIONS

Indoor tanning is significantly associated with well-recognized risk factors for melanoma (including high nevus count, presence of atypical nevi and lentigines) as well as suspicion of melanoma within the Euromelanoma screenees. In order to reduce the prevalence of melanoma risk factors, avoidance/discontinuation of sunbed use should always be encouraged, especially but not exclusively for individuals with high-risk phenotypes.

Indoor tanning and poor mental health among adolescents in New York City (2015)

This study explored relationships between mental health and indoor tanning among high school students in New York City using 2015 data from the Youth Risk Behavior Surveillance System. Those more likely to use indoor tanning were females (odds ratio = 6.26, 95% confidence interval = 6.08–6.45) and non-Hispanic White (odds ratio = 1.10, 95% confidence interval = 1.06–1.14). Being bullied on school property (odds ratio = 1.30, 95% confidence interval = 1.25–1.34), having attempted suicide (odds ratio = 2.08, 95% confidence interval = 1.99–2.18), and having sought counseling (odds ratio = 1.22, 95% confidence interval = 1.18–1.26) were significantly associated with indoor tanning. This study indicates that engaging in indoor tanning is associated with a number of mental health factors.