Smoking behavior and association of melanoma and nonmelanoma skin cancer in the Women's Health Initiative

Tobacco smoking is associated with cutaneous squamous cell carcinoma but not with basal cell carcinoma or melanoma in adult subjects at risk of skin cancer: A cross-sectional study

INTRODUCTION

The relationship between tobacco smoking and cutaneous photodamage or malignancies is still unclear. In addition to smoking, both ultraviolet radiation and immunosuppression have an impact on carcinogenesis. The purpose was to study the association of smoking with cutaneous photoaging, actinic keratosis (AK), skin cancers, and pigment cell nevi in adult subjects at risk of any type of skin cancer.

METHODS

In this cross-sectional study at Kuopio University Hospital, Finland, between May 2017 and October 2020, 488 subjects (aged 21-79 years, 246 males and 242 females, 94 with immunosuppression) were examined for a variety of skin lesions, photoaging severity, nevi, tobacco pack-years (TPY), as well as for possible confounding factors.

RESULTS

In logistic regression analyses, no marked association was found between TPY and total skin photoaging, facial photoaging, AK, or nevi, especially when other confounding factors, such as age, were considered. In addition, TPY was not associated with melanoma, basal cell carcinoma, or any type of skin cancer. However, ever smokers produced an elevated crude odds ratio (OR=1.99; 95% CI: 1.02-3.88, p=0.043) for squamous cell carcinoma (SCC) compared to non-smokers. In further analysis, TPY of ≤10 produced an elevated multivariable adjusted odds ratio (AOR=4.90; 95% CI: 1.31-18.26, p=0.018) for SCC, but TPY >10 did not (AOR=1.14; 95% CI: 0.22-6.05, p=0.876).

CONCLUSIONS

Smoking was associated, though not dose-dependently, with an increased likelihood of SCC, but it was not associated with basal cell carcinoma or melanoma. However, the impact of smoking on cutaneous photoaging severity, AK, and nevi, appears to be weak.

Smoking Status and Survival in Patients With Early-Stage Primary Cutaneous Melanoma

Importance

While smoking is associated with a decreased incidence of cutaneous melanoma, the association of smoking with melanoma progression and death is not well defined.

Objective

To determine the association of smoking with survival in patients with early-stage primary cutaneous melanoma.

Design, Setting, and Participants

This cohort study performed a post hoc analysis of data derived from the randomized, multinational first and second Multicenter Selective Lymphadenectomy Trials (MSLT-I and MSLT-II). Participants were accrued for MSLT-I from January 20, 1994, to March 29, 2002; MSLT-II, from December 21, 2004, to March 31, 2014. Median follow-up was 110.0 (IQR, 53.4-120.0) months for MSLT-I and 67.6 (IQR, 25.8-110.2) months for MSLT-II. Patients aged 18 to 75 years with clinical stages I or II melanoma with a Breslow thickness of 1.00 mm or greater or Clark level IV to V and available standard prognostic and smoking data were included. Analyses were performed from October 4, 2022, to March 31, 2023.

Exposure

Current, former, and never smoking.

Main Outcomes and Measures

Melanoma-specific survival of patients with current, former, and never smoking status was assessed for the entire cohort and for nodal observation and among subgroups with sentinel lymph node biopsy (SLNB)-negative and SLNB-positive findings.

Results

Of 6279 included patients, 3635 (57.9%) were men, and mean (SD) age was 52.7 (13.4) years. The most common tumor location was an extremity (2743 [43.7%]), and mean (SD) Breslow thickness was 2.44 (2.06) mm. Smoking status included 1077 (17.2%) current, 1694 (27.0%) former, and 3508 (55.9%) never. Median follow-up was 78.4 (IQR, 30.5-119.6) months. Current smoking was associated with male sex, younger age, trunk site, thicker tumors, tumor ulceration, and SLNB positivity. Current smoking was associated with a greater risk of melanoma-associated death by multivariable analysis for the entire study (hazard ratio [HR], 1.48 [95% CI, 1.26-1.75]; P < .001). Former smoking was not. The increased risk of melanoma-specific mortality associated with current smoking was greatest for patients with SLNB-negative melanoma (HR, 1.85 [95% CI, 1.35-2.52]; P < .001), but also present for patients with SLNB-positive melanoma (HR, 1.29 [95% CI, 1.04-1.59]; P = .02) and nodal observation (HR, 1.68 [95% CI, 1.09-2.61]; P = .02). Smoking at least 20 cigarettes/d doubled the risk of death due to melanoma for patients with SLNB-negative disease (HR, 2.06 [95% CI, 1.36-3.13]; P < .001).

Conclusions and Relevance

The findings of this cohort study suggest that patients with clinical stage I and II melanoma who smoked had a significantly increased risk of death due to melanoma. Smoking status should be assessed at time of melanoma diagnosis and may be considered a risk factor for disease progression.

The association between smoking and risk of skin cancer: a meta-analysis of cohort studies

PURPOSE

The association between smoking and the risk of skin cancers has been studied without reaching consistent findings. This study aims to assess this association through an updated meta-analysis of cohort studies.

METHODS

We retrieved cohort studies that investigated the temporal association between smoking and the risk of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM). Pooled relative risks (RRs) and confidence intervals (CIs) of the included articles were calculated for current, former, and heavy smoking compared with never smoking. Publication bias was detected using the Egger's regression.

RESULTS

A total of 15 studies, published between 1990 and 2018, were included. Current smoking was associated with a higher risk of SCC (pooled RR = 1.32, 95% CI 1.15, 1.52) but with a lower risk of BCC (pooled RR = 0.85, 95% CI 0.75, 0.96) and MM (pooled RR = 0.72, 95% CI 0.64, 0.82). No publication bias was detected, and no single study had a substantial impact on the pooled results. Similar results were detected for heavy smoking, while former smoking was not associated with the risk of skin cancer.

CONCLUSION

Current smoking and heavy smoking were associated with a higher risk of SCC but a decreased risk of BCC and MM, while former smoking was not associated with skin cancer risk.

Hormone replacement therapy and the risk of melanoma in post-menopausal women

STUDY QUESTION

Is hormone replacement therapy (HRT) associated with an increased risk of melanoma skin cancer or prognostic outcomes amongst post-menopausal women?

SUMMARY ANSWER

Whilst we found evidence of an association with melanoma risk, the lack of dose-response and associations observed with recent use, localised disease and intravaginal oestrogens suggests this is a non-causal association.

WHAT IS KNOWN ALREADY

Evidence on HRT and melanoma risk remains inconclusive, with studies providing conflicting results. Furthermore, evidence on melanoma survival is sparse, with only one previous study reporting protective associations with HRT use, likely attributable to immortal time bias.

STUDY DESIGN, SIZE, DURATION

We conducted a nation-wide population-based case-control study and a retrospective cohort study utilising the Danish healthcare registries. Case-control analyses included 8279 women aged 45-85 with a first-ever diagnosis of malignant melanoma between 2000 and 2015, matched by age and calendar time to 165 580 population controls. A cohort of 6575 patients with a diagnosis of primary malignant melanoma between 2000 and 2013 and followed through 2015 was examined to determine if HRT use had an impact on melanoma survival outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on prescriptions dispensed since 1995, ever-use of HRT was defined as having filled at least one prescription for HRT prior to the index date. In total, 2629 cases (31.8%) and 47 026 controls (28.4%) used HRT. Conditional logistic regression was used to calculate odds ratios (ORs) for melanoma risk according to HRT use, compared with non-use, adjusting for potential confounders. For cohort analyses, Cox proportional hazards models was used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for second melanoma incidence and all-cause mortality associated with HRT.

MAIN RESULTS AND THE ROLE OF CHANCE

High use of HRT was associated with an OR of 1.21 (95% CI 1.13-1.29) for melanoma risk, with no evidence of a dose-response pattern. Results were most pronounced amongst recent high users (OR, 1.28; 95% CI 1.17-1.41), for localised disease (OR, 1.25; 95% CI 1.15-1.36) and for intravaginal oestrogen therapy (OR, 1.38; 95% CI 1.13-1.68). Compared with non-use, there was no evidence of an association for secondary melanoma for post-diagnostic new-use (fully adjusted HR, 1.56; 95% CI 0.64-3.80) or continuous HRT use (fully adjusted HR, 1.26; 95% CI 0.89-1.78). Similar associations were observed for all-cause mortality.

LIMITATIONS, REASONS FOR CAUTION

Despite the large sample size and the use of robust population-based registries with almost complete coverage, we lacked information on some important confounders including sun exposure.

WIDER IMPLICATIONS OF THE FINDINGS

Whilst we cannot rule out an association between HRT use and melanoma risk, the associations observed are also compatible with increased healthcare utilisation and thus increased melanoma detection amongst HRT users. No association between HRT use and melanoma survival outcomes was observed. This should provide some reassurance to patients and clinicians, particularly concerning the use of HRT in patients with a history of melanoma.

STUDY FUNDING/COMPETING INTEREST(S)

B.M.H. is funded by a Cancer Research UK Population Research Postdoctoral Fellowship. The funding source had no influence on the design or conduct of this study. A.P. reports participation in research projects funded by Alcon, Almirall, Astellas, Astra-Zeneca, Boehringer-Ingelheim, Servier, Novo Nordisk and LEO Pharma, all with funds paid to the institution where he was employed (no personal fees) and with no relation to the work reported in this article. The other authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Epidemiology and Risk Factors of Melanoma

The incidence of melanoma continues to increase worldwide. In the United States, melanoma is the fifth most common cancer in men and the sixth most common cancer in women. The risk factors contributing to melanoma have largely remained unchanged, but there is a new focus on modifiable risk factors including sun exposure and ultraviolet light. A large public initiative supported by the Centers for Disease Control focuses on educating the public on the risks of sun exposure and indoor tanning. Early detection and resection of melanoma lesions is necessary to prevent metastasis and reduce medical costs.

Cigarette Smoking and the Risk of Cutaneous Melanoma: A Case-Control Study

OBJECTIVE

Previous studies regarding cigarette smoking causing a lower risk of melanoma are inconclusive. Here, we re-examined melanoma risk in relation to cigarette smoking in a large, case-control study.

METHODS

In total 1,157 patients with melanoma diagnosed between 2003 and 2011 in the Netherlands and 5,595 controls from the Nijmegen Biomedical Study were included. Information concerning smoking habits and known risk factors for melanoma were obtained through self-administered questionnaires. Logistic regression analyses stratified by gender were performed to study the risk of cigarette smoking on melanoma risk, adjusted for age, marital status, highest level of education, skin type, sun vacation, use of solarium, time spent outdoors, and sun protective measures.

RESULTS

Among men, current and former smokers did not have a higher risk of melanoma compared to never smokers: adjusted odds ratio (OR) = 0.56 (95% confidence interval [CI]: 0.40-0.79) and adjusted OR = 0.50 (95% CI: 0.39-0.64), respectively. With an increasing number of years smoked the risk of melanoma decreased: <20 years: OR = 0.61 (95% CI: 0.46-0.80); 21-40 years: OR = 0.50 (95% CI: 0.37-0.68); >40 years: OR = 0.26 (95% CI: 0.15-0.44). No clear trend was found for the number of cigarettes smoked. Results for females were less clear and not statistically significant (current smoker: adjusted OR = 0.96, 95% CI: 0.74-1.26, former smoker: adjusted OR = 0.89, 95% CI: 0.73-1.08).

CONCLUSION

This study shows a strong inverse association between cigarette smoking and melanoma risk in men. Fundamental laboratory research is necessary to investigate the biological relation between smoking cigarettes and melanoma.

Demographics, Risk Factors, and Incidence of Melanoma in Patients in the New England VA Healthcare system

INTRODUCTION

A recent study found that the incidence of melanoma and melanoma-related mortality was decreasing in residents of the New England region. However, it is unknown whether this trend is conserved in Veterans of New England who constitute more than 14% of the national Veteran population. Given this, our goal was to analyze the incidence of melanoma in patients of Veteran Integrated Service Network-1 (VISN-1) (geographically consisting of VA health care facilities in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) and to calculate an incidence rate ratio (IRR) of melanoma in VISN-1 compared to the general population. Additional goals were to ascertain the risk/susceptibility of this patient population with a view to improve quality of care and outcomes.

MATERIALS AND METHODS

Data for 523 cases of melanoma [2000-2011] were obtained from the regional branch of the Veterans Affairs Central Cancer Registry (VACCR) within the geographic area comprising VISN-1. A detailed retrospective chart review was conducted on these cases to gather demographic, risk factor, and clinical practice data. Demographic and incidence data from VISN-1 were compared to the general population via data from Surveillance, Epidemiology and End Results Program (SEER) from the same time period. Person-years (PY) were calculated for both populations to measure IRRs which was further standardized for age and gender.

RESULTS

VISN-1 patients were predominantly older (94.26% >50 years), Caucasian (99.43%) males (96.75%). Compared to the general population, VISN-1 patients experienced more invasive lesions defined as stage T1 or greater (4.33% vs. 57.12%, p < 0.001), but reduced melanoma-associated mortality (40.96% vs. 19.05%, p < 0.001) although all-cause mortality was approximately doubled (52.20% vs. 26.14%, p < 0.001). Metastatic disease-rates were similar in both [approximately 4% in both]. IRR of melanoma in VISN-1 patients was 0.36 (95% CI: 0.20-0.67; p = 0.0063) which persisted in all age groups/genders. 60.92% of VISN-1 patients had recreational sun-exposure history and 72.41% of tobacco use. 95.02% of melanomas were located in continuously/intermittently sun-exposed areas, 93.28% were surgically-treated with a median treatment delay of 31 days [range 18-48]. Median lost to follow-up was 0 day [range 0-681 days].

CONCLUSIONS

Compared to the general population, melanoma incidence was lower in the VISN-1 cohort, possibly due to decreased UV index in the New England region, protective effects of past tobacco use, improved access to care through the VA and regional public health educational efforts. Yet melanomas were more often invasive in the VISN-1 cohort due to advanced age and male sex both of which are associated with more advanced disease at diagnosis. A strength of this study is the calculation of IRR using PY as this method enhances accuracy of incidence calculations. The data were limited by the fact that the population was from one geographic region and consisted mainly of elderly Caucasian males. Descriptive variable data such as sun-protective habits and risk factors from military service are limited by potential recall bias given the retrospective study design. Further study is necessary to replicate these results and to compare our data to Veteran populations from different geographic regions within the USA.

The impact of airborne pollution on skin

Indoor and outdoor airborne pollutants modify our environment and represent a growing threat to human health worldwide. Airborne pollution effects on respiratory and cardiac health and diseases have been well established, but its impact on skin remains poorly described. Nonetheless, the skin is one of the main targets of pollutants, which reach the superficial and deeper skin layers by transcutaneous and systemic routes. In this review, we report the outcomes of basic and clinical research studies monitoring pollutant levels in human tissues including the skin and hair. We present a current understanding of the biochemical and biophysical effects of pollutants on skin metabolism, inflammatory processes and oxidative stress, with a focus on polyaromatic hydrocarbons and ground-level ozone that are widespread outdoor pollutants whose effects are mostly studied. We reviewed the literature to report the clinical effects of pollutants on skin health and skin ageing and their impact on some chronic inflammatory skin diseases. We also discuss the potential interactions of airborne pollutants with either ultraviolet radiation or human skin microbiota and their specific impact on skin health.

Prevalence and associated factors of skin cancer in aged nursing home residents: A multicenter prevalence study

Non-melanoma-skin cancer is an emerging clinical problem in the elderly, fair skinned population which predominantly affects patients aged older than 70 years. Its steady increase in incidence rates and morbidity is paralleled by related medical costs. Despite the fact that many elderly patients are in need of care and are living in nursing homes, specific data on the prevalence of skin cancer in home care and the institutional long-term care setting is currently lacking. A representative multicenter prevalence study was conducted in a random sample of ten institutional long-term care facilities in the federal state of Berlin, Germany. In total, n = 223 residents were included. Actinic keratoses, the precursor lesions of invasive cutaneous squamous cell carcinoma were the most common epithelial skin lesions (21.1%, 95% CI 16.2 to 26.9). Non-melanoma skin cancer was diagnosed in 16 residents (7.2%, 95% CI 4.5 to 11.3). None of the residents had a malignant melanoma. Only few bivariate associations were detected between non-melanoma skin cancer and demographic, biographic and functional characteristics. Male sex was significantly associated with actinic keratosis whereas female sex was associated with non-melanoma skin cancer. Smoking was associated with an increased occurrence of non-melanoma skin cancer. Regular dermatology check-ups in nursing homes would be needed but already now due to financial limitations, lack of time in daily clinical practice and limited number of practising dermatologists, it is not the current standard. With respect to the worldwide growing aging population new programs and decisions are required. Overall, primary health care professionals should play a more active role in early diagnosis of skin cancer in nursing home residents. Dermoscopy courses, web-based or smartphone-based applications and teledermatology may support health care professionals to provide elderly nursing home residents an early diagnosis of skin cancer.

Cigarettes Smoking and Skin: A Comparison Study of the Biophysical Properties of Skin in Smokers and Non-Smokers

BACKGROUND

Tobacco smoke is toxic for cells and could be a damaging factor to skin. The purpose of this study was to compare the biophysical properties of skin in smokers and non-smokers.

MATERIALS AND METHODS

The study population consisted of 28 current smokers and 24 non-smokers. The hydration of the stratum corneum, trans epidermal water loss, pH, erythema, melanin content, sebum, friction and elasticity parameters (R0, R2, R5) of skin, epidermis and dermis thickness and echo-density were measured on middle forehead, right cheek and right inner arm of participants. Also volume, surface area and depth of right nasolabial folds were measured. The mean of these values in smokers were compared with non-smokers by independent sample T- test.

RESULTS

Gross elasticity was significantly lower in smokers on forehead (p= 0.048). Thickness of epidermis was higher in smokers in all measured sites but the differences were not statistically significant. Thickness of dermis was higher in smokers in all measured sites too, but only the difference on cheek was statistically significant (p= 0.009). Density of epidermis was lower in smokers in all measured sites, but only the difference on forehead was statistically significant (p= 0.019). Density of dermis was lower in smokers in all measured sites, but only the difference on arm was statistically significant (p= 0.028). Volume and area of nasolabial folds were higher in smokers, but only the difference of area was statistically significant (p = 0.031).

CONCLUSION

Tobacco smoking could affect the biophysical parameters of skin, especially thickness and density of dermis and epidermis and nasolabial folds.

Associations between smoking behavior-related alleles and the risk of melanoma

Several studies have reported that cigarette smoking is inversely associated with the risk of melanoma. This study further tested whether incorporating genetic factors will provide another level of evaluation of mechanisms underlying the association between smoking and risk of melanoma. We investigated the association between SNPs selected from genome-wide association studies (GWAS) on smoking behaviors and risk of melanoma using 2,298 melanoma cases and 6,654 controls. Among 16 SNPs, three (rs16969968 [A], rs1051730 [A] and rs2036534 [C] in the 15q25.1 region) reached significance for association with melanoma risk in men (0.01 < = P values < = 0.02; 0.85 < = Odds Ratios (ORs) <= 1.20). There was association between the genetic scores based on the number of smoking behavior-risk alleles and melanoma risk with P-trend = 0.005 among HPFS. Further association with smoking behaviors indicating those three SNPs (rs16969968 [A], rs1051730 [A] and rs2036534 [C]) significantly associated with number of cigarettes smoked per day, CPD, with P = 0.009, 0.011 and 0.001 respectively. The SNPs rs215605 in the PDE1C gene and rs6265 in the BDNF gene significantly interacted with smoking status on melanoma risk (interaction P = 0.005 and P = 0.003 respectively). Our study suggests that smoking behavior-related SNPs are likely to play a role in melanoma development and the potential public health importance of polymorphisms in the CHRNA5-A3-B4 gene cluster. Further larger studies are warranted to validate the findings.

The Impact of Smoking on Sentinel Node Metastasis of Primary Cutaneous Melanoma

BACKGROUND

Although a well-established causative relationship exists between smoking and several epithelial cancers, the association of smoking with metastatic progression in melanoma is not well studied. We hypothesized that smokers would be at increased risk for melanoma metastasis as assessed by sentinel lymph node (SLN) biopsy.

METHODS

Data from the first international Multicenter Selective Lymphadenectomy Trial (MSLT-I) and the screening-phase of the second trial (MSLT-II) were analyzed to determine the association of smoking with clinicopathologic variables and SLN metastasis.

RESULTS

Current smoking was strongly associated with SLN metastasis (p = 0.004), even after adjusting for other predictors of metastasis. Among 4231 patients (1025 in MSLT-I and 3206 in MSLT-II), current or former smoking was also independently associated with ulceration (p < 0.001 and p < 0.001, respectively). Compared with current smoking, never smoking was independently associated with decreased Breslow thickness in multivariate analysis (p = 0.002) and with a 0.25 mm predicted decrease in thickness.

CONCLUSION

The direct correlation between current smoking and SLN metastasis of primary cutaneous melanoma was independent of its correlation with tumor thickness and ulceration. Smoking cessation should be strongly encouraged among patients with or at risk for melanoma.

Epidemiology of Keratinocyte Carcinoma

Purpose of the review

To provide a synopsis of recent research advances in the epidemiology of keratinocyte carcinoma (KC), with a focus on indoor tanning and known risk factors for other forms of cancer such as cigarette smoking and alcohol drinking.

Recent findings

The evidence is strong enough to infer that use of UVR-emitting indoor tanning devices cause KC. Epidemiologic studies of cigarette smoking, alcohol drinking, and menopausal hormone therapy all show some suggestion for increased risk of KC but the evidence is not yet strong enough to determine if there is a true etiologic role. Body mass index is clearly inversely associated with KC risk but this is more likely to be due to lower UVR exposure in overweight and obese individuals than it is due to a true etiologic role.

Summary

The epidemic of KC continues unabated, and the causal role of indoor tanning is contributing to this unfavorable trend in KC incidence rates. Advances in understanding the etiology of KC should not divert attention away from the fact that the primary public health strategy to prevent KC is known: minimize population exposure to UVR from the sun and from UVR-emitting indoor tanning devices, particularly among those with sun-sensitive phenotypes.

Obesity as a risk factor for malignant melanoma and non-melanoma skin cancer

The dramatic increases in incidence of both obesity and many cancers including skin cancer emphasize the need to better understand the pathophysiology of both conditions and their connections. Melanoma is considered the fastest growing cancer and rates of non-melanoma skin cancer have also increased over the last decade. The molecular mechanisms underlying the association between obesity and skin cancer are not clearly understood but emerging evidence points to changes in the tumor microenvironment including aberrant cell signaling and genomic instability in the chronic inflammatory state many obese individuals experience. This article reviews the literature linking obesity to melanoma and non-melanoma skin cancer.