Sunlamp use and the risk of cutaneous malignant melanoma: a population-based case-control study in Connecticut, USA

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.

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.

Beyond T Staging in the "Treat-All" Era: Severity and Heterogeneity of Kaposi Sarcoma in East Africa

BACKGROUND

Although many patients with Kaposi sarcoma (KS) in sub-Saharan Africa are diagnosed with AIDS Clinical Trials Group (ACTG) T1 disease, T1 staging insufficiently captures clinical heterogeneity of advanced KS. Using a representative community-based sample, we detailed disease severity at diagnosis to inform KS staging and treatment in sub-Saharan Africa.

METHODS

We performed rapid case ascertainment on people living with HIV, aged 18 years or older, newly diagnosed with KS from 2016 to 2019 at 3 clinic sites in Kenya and Uganda to ascertain disease stage as close as possible to diagnosis. We reported KS severity using ACTG and WHO staging criteria and detailed measurements that are not captured in the current staging systems.

RESULTS

We performed rapid case ascertainment within 1 month for 241 adults newly diagnosed with KS out of 389 adult patients with suspected KS. The study was 68% men with median age 35 years and median CD4 count 239. Most of the patients had advanced disease, with 82% qualifying as ACTG T1 and 64% as WHO severe/symptomatic KS. The most common ACTG T1 qualifiers were edema (79%), tumor-associated ulceration (24%), extensive oral KS (9%), pulmonary KS (7%), and gastrointestinal KS (4%). There was marked heterogeneity within T1 KS, with 25% of patients having 2 T1 qualifying symptoms and 3% having 3 or more.

CONCLUSION

Most of the patients newly diagnosed with KS had advanced stage disease, even in the current antiretroviral therapy "treat-all" era. We observed great clinical heterogeneity among advanced stage patients, leading to questions about whether all patients with advanced KS require the same treatment strategy.

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.

Knowledge, attitudes and behaviours in relation to skin cancer prevention

BACKGROUND

The incidence of malignant melanoma is increasing faster than any other cancer, and it is now the second most common cancer in young adults. Most skin cancer prevention campaigns are based on the hypothesis that improved skin cancer knowledge leads to a change in sun-related behaviour.

AIM

The aim of this study was to analyse the relationship of good skin cancer knowledge in a high knowledge group-medical students-with sun-related behaviours and tanning attitudes in Ireland.

METHODS

A cross-sectional survey was conducted on university students studying medicine in a single institution.

RESULTS

The final analyses included 312 complete questionnaires. Two hundred three (65.27%) were female, and 108 (34.73%) were male. The majority (65.06%) were aged 21-25 years. The mean skin cancer knowledge score was 89.77%. There was a positive attitude to tanning with 201 (64.63%) participants feeling more attractive with a suntan and 174 (55.94%) feeling better about themselves with a suntan. More than half of participants, 196 (54.17%), got a suntan last year, 171 (54.81%) participants sunbathed, 188 (60.26%) got sunburned and 30 (9.61%) reported using sunbeds previously. Those with a positive attitude to tanning were more likely to sunbath, suntan and get sunburned. High skin cancer knowledge scores were positively associated with high-risk sun behaviours (Spearman's rank correlation coefficient = 0.156, P = 0.006).

CONCLUSION

Urgent action is needed to promote skin cancer prevention. This study adds to the evidence that melanoma prevention strategies should preferentially target tanning attitudes rather than skin cancer knowledge.

Indoor tanning and skin cancer in Canada: A meta-analysis and attributable burden estimation

BACKGROUND

Consistent epidemiologic and experimental studies have demonstrated that UV-emitting tanning devices cause melanoma and non-melanoma skin cancer. The purpose of this study was to estimate the relative risk of skin cancer associated with the use of indoor tanning devices relevant to Canada, to estimate the proportion and number of skin cancers in Canada in 2015 that were attributable to indoor tanning, and to explore differences by age and sex.

METHODS

Skin cancer cases attributable to the use of an indoor tanning devices were estimated using Levin's population attributable risk (PAR) formula. Relative risks for skin cancer subtypes that were relevant to Canada were estimated through meta-analyses and prevalence of indoor tanning was estimated from the 2006 National Sun Survey. Age- and sex-specific melanoma data for 2015 were obtained from the Canadian Cancer Registry, while estimated NMSC incidence data were obtained from the 2015 Canadian Cancer Statistics report.

RESULTS

Ever use of indoor tanning devices was associated with relative risks of 1.38 (95% CI 1.22-1.58) for melanoma, 1.39 (1.10-1.76) for basal cell carcinoma (BCC), and 1.49 (1.23-1.80) for squamous cell carcinoma (SCC). Overall, 7.0% of melanomas, 5.2% of BCCs, and 7.5% of SCCs in 2015 were attributable to ever of indoor tanning devices. PARs were higher for women and decreased with age.

CONCLUSION

Indoor tanning contributes to a considerable burden of skin cancer in Canada. Strategies aimed at reducing use should be increased and a total ban or restrictions on use and UV-intensity should be considered by health regulators.

Commercial tanning salons and melanoma risk

There have been many case-control studies of melanoma and the use of indoor tanning equipment. A recent meta analysis of 8 credible studies in North America estimated an overall significant odds ratio of 1.23. Three of these 8 studies also reported separately on commercial use and home use of indoor tanning equipment. For home use the overall odds ratio was a significant 1.53 while for commercial use there was a non significant 1.05.

Indoor Tanning and Melanoma Risk: Long-Term Evidence From a Prospective Population-Based Cohort Study

Indoor tanning is associated with increased risk of melanoma, but most evidence comes from case-control studies. Using data from the Norwegian Women and Cancer Study, a large prospective cohort study, we investigated the associations of age at initiation of indoor tanning, duration of tanning-device use, and dose response with melanoma risk and examined the role of indoor tanning in age at melanoma diagnosis. We used Poisson regression to estimate relative risks and 95% confidence intervals for the relationship of indoor tanning to melanoma risk and linear regression to examine age of indoor tanning initiation in relation to age at diagnosis. During follow-up of 141,045 women (1991-2012; mean duration follow-up = 13.7 years), 861 women were diagnosed with melanoma. Melanoma risk increased with increasing cumulative number of tanning sessions (for highest tertile of use vs. never use, adjusted relative risk = 1.32, 95% confidence interval (CI): 1.08, 1.63); P-trend = 0.006. Age at initiation <30 years was associated with a higher risk in comparison with never use (adjusted relative risk = 1.31, 95% CI: 1.07, 1.59). Moreover, women who started indoor tanning prior to 30 years of age were 2.2 years (95% CI: 0.9, 3.4) younger at diagnosis, on average, than never users. This cohort study provides strong evidence of a dose-response association between indoor tanning and risk of melanoma and supports the hypothesis that vulnerability to the harmful effects of indoor tanning is greater at a younger age.

Tanning bed use and melanoma: Establishing risk and improving prevention interventions

PURPOSE

Exposure to ultraviolet radiation (UVR) from indoor tanning devices is thought to cause melanoma and other negative health consequences. Despite these findings, the practice of indoor tanning in the United States remains prevalent. In this paper we aim to present a clear discussion of the relationship between indoor tanning and melanoma risk, and to identify potential strategies for effective melanoma prevention by addressing indoor tanning device use.

BASIC PROCEDURES

We reviewed relevant literature on the risks of indoor tanning, current indoor tanning legislation, and trends in indoor tanning and melanoma incidence. Study was conducted at the University of Southern California, Los Angeles, CA between the years of 2014 and 2015.

MAIN FINDINGS

Our findings reaffirm the relationship between indoor tanning and melanoma risk, and suggest a widespread public misunderstanding of the negative effects of indoor tanning.

PRINCIPAL CONCLUSIONS

This review argues for an aggressive initiative to reduce indoor tanning in the United States, to design prevention efforts tailored towards specific high risk groups, and the need to better inform the public of the risks of indoor tanning.

Association Between Indoor Tanning and Melanoma in Younger Men and Women

IMPORTANCE

In the United States and Minnesota, melanoma incidence is rising more steeply among women than men younger than 50 years. To our knowledge, no study has examined age- and sex-specific associations between indoor tanning and melanoma to determine if these trends could be due to greater indoor tanning use among younger women.

OBJECTIVE

To examine associations between indoor tanning and melanoma among men and women younger than 50 years.

DESIGN, SETTING, AND PARTICIPANTS

Population-based case-control study conducted in Minnesota of 681 patients (465 [68.3%] women) diagnosed as having melanoma between 2004 and 2007, and 654 controls (446 [68.2%] women), ages 25 to 49 years.

EXPOSURE

Indoor tanning, defined as any use, first age of use, and total sessions.

MAIN OUTCOMES AND MEASURES

Crude and adjusted odds ratios (ORs) and 95% CIs were calculated for melanoma in relation to indoor tanning exposure for men and women by diagnosis or reference age (<30, 30-39, 40-49 years). Sex-specific associations for indoor tanning and melanoma by anatomic site were examined.

RESULTS

Compared with women aged 40 to 49 years, women younger than 40 years initiated indoor tanning at a younger age (16 vs 25 years, P < .001) and reported more frequent indoor tanning (median number of sessions, 100 vs 40, P < .001). Women younger than 30 years were 6 times more likely to be in the case than the control group if they tanned indoors (crude OR, 6.0; 95% CI, 1.3-28.5). Odds ratios were also significantly elevated among women, ages 30 to 49 years (adjusted OR, 3.5; 95% CI, 1.2-9.7 for women 30-39 years; adjusted OR, 2.3; 95% CI, 1.4-3.6 for women 40-49 years); a dose response was observed among women regardless of age. Among men, results by age were inconsistent. The strongest OR for indoor tanning by anatomic site was for melanomas arising on the trunk of women (adjusted OR, 3.7; 95% CI, 1.9-7.2).

CONCLUSIONS AND RELEVANCE

Indoor tanning is a likely factor for the steeper increase in melanoma rates in the United States among younger women compared with men, given the timing of when women initiated indoor tanning relative to diagnosis. The melanoma epidemic can be expected to continue unless indoor tanning is restricted and reduced.

Red meat and fruit intake is prognostic among patients with localized cutaneous melanomas more than 1mm thick

BACKGROUND

As the 10-year mortality for localized cutaneous melanoma more than 1.00 mm thick approaches 40% following complete resection, non-therapeutic interventions that can supplement recommended active surveillance are needed. Although guidelines recommending nutrition, physical activity and tobacco cessation for cancer survivors have been published, data describing their associations with melanoma survivorship are lacking.

METHODS

Analysis of modifiable lifestyle behaviors collected on the 249 cases with melanomas more than 1.00 mm thick enrolled in the Connecticut Case-Control Study of Skin Self-Examination study was conducted. Independent associations with melanoma-specific survival were evaluated through Cox proportional hazards modeling adjusting for age, gender, Breslow thickness, ulceration and the presence of microsatellites. Independently significant variables were then combined into a single model and backwards elimination was employed until all remaining variables were significant at p<0.05.

RESULTS

Following adjustment for age, Breslow thickness and anatomic site of the index melanoma, daily fruit consumption was associated with improved melanoma-specific survival (HR=0.54; 95% CI: 0.34-0.86) whereas at least weekly red meat consumption was associated with worse outcomes (HR=1.84; 95% CI: 1.02-3.30). Natural red (HR=0.44; 95% CI: 0.22-0.88) or blond (HR=0.52; 95% CI: 0.29-0.94) hair were also favorably prognostic. Higher fish consumption was of borderline significance for improved survival only when considered independently (HR=0.65; 95% CI: 0.40-1.05); no association was seen following adjustment for red meat and fruit consumption (p>0.10).

CONCLUSIONS

Dietary choices at the time of diagnosis are associated with melanoma-specific survival in patients with melanomas more than 1.00 mm thick. Further validation of our findings in larger cohorts with repeated post-diagnostic measures is warranted to further evaluate whether dietary modification during the survivorship period can improve melanoma-specific survival.

Indoor tanning in businesses and homes and risk of melanoma and nonmelanoma skin cancer in 2 US case-control studies

BACKGROUND

Indoor tanning increases skin cancer risk. Beyond early research describing melanoma and sun lamps, few recent reports describe where individuals indoor tan and whether skin cancer risk varies by location (business, home-based).

OBJECTIVE

We sought to assess where individuals tanned indoors and skin cancer risk by tanning device location.

METHODS

Multivariate logistic regression was conducted in 2 US case-control studies of melanoma (1161 cases, 1083 controls, ages 25-59 years) and early-onset basal cell carcinoma (375 cases, 382 controls, age<40 years) conducted between 2004 and 2010.

RESULTS

Most indoor tanners (86.4%-95.1%), especially younger individuals, tanned exclusively in businesses. Persons who used indoor tanning exclusively in businesses were at increased risk of melanoma (odds ratio 1.82, 95% confidence interval 1.47-2.26) and basal cell carcinoma (odds ratio 1.69, 95% confidence interval 1.15-2.48) compared with non-users. Melanoma risk was also increased in the small number who reported tanning indoors only at home relative to non-users (odds ratio 4.14, 95% confidence interval 1.75-9.78); 67.6% used sun lamps.

LIMITATIONS

Self-reported tanning and potential recall bias are limitations.

CONCLUSION

Business-only tanning, despite claims of "safe" tanning, was positively associated with a significant risk of melanoma and basal cell carcinoma. Home tanning was uncommon and mostly from sun lamps, which were rarely used by younger participants. Regardless of location, indoor tanning was associated with increased risk of skin cancer.

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

BACKGROUND

Tanning beds are associated with increased risk of melanoma.

OBJECTIVE

We sought to update the evidence of the association of melanoma and indoor tanning focusing on frequency of use and exposure to newer tanning beds.

METHODS

We searched Scopus, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature on August 14, 2013. We included all observational studies that included patients with melanoma who had indoor tanned. Odds ratios (OR) with 95% confidence intervals (CI) were extracted and combined using generic inverse variance methods assuming a random effects model.

RESULTS

In all, 31 studies were included with data available on 14,956 melanoma cases and 233,106 controls. Compared with never using, the OR for melanoma associated with ever using indoor tanning beds was 1.16 (95% CI 1.05-1.28). Similar findings were identified in recent studies with enrollment occurring in the year 2000 onward (OR 1.22, 95% CI 1.03-1.45) and in subjects attending more than 10 tanning sessions (OR 1.34, 95% CI 1.05-1.71).

LIMITATIONS

The quality of evidence contributing to review results ranges from poor to mediocre.

CONCLUSION

Using tanning beds is associated with a subsequent melanoma diagnosis. Exposure from more than 10 tanning sessions is most strongly associated and there was no statistically significant difference in this association before and after 2000, suggesting that newer tanning technology is not safer than older models.

Practices of unregulated tanning facilities in Missouri: implications for statewide legislation

BACKGROUND

The incidence of skin cancer has increased in the United States, concomitant with increased UV radiation (UVR) exposure among young adults. We examined whether tanning facilities in Missouri, a state without indoor-tanning regulations, acted in accordance with the Food and Drug Administration's recommendations and consistently imparted information to potential clients about the known risks of UVR.

METHODS

We conducted a statewide telephone survey of randomly selected tanning facilities in Missouri. Each tanning facility was surveyed twice, in the morning (7 am-3 pm) and evening (3-10 pm), on different days, to determine intrasalon consistency of information provided to potential clients at different times.

RESULTS

On average, 65% of 243 tanning-facility operators would allow children as young as 10 or 12 years old to use indoor-tanning devices, 80% claimed that indoor tanning would prevent future sunburns, and 43% claimed that there were no risks associated with indoor tanning. Intrasalon inconsistencies involved allowable age of use, and UVR exposure type and duration. Morning tanning-facility employees were more likely to allow consumers to start with maximum exposure times and UV-A-emitting devices (P < .001), whereas evening employees were more likely to allow 10- or 12-year-old children to use indoor-tanning devices (P = .008).

CONCLUSIONS

Despite increasing evidence that UVR exposure in indoor-tanning devices is associated with skin cancer, ocular damage, and premature photoaging, tanning facilities in Missouri often misinformed consumers regarding these risks and lack of health benefits and inconsistently provided information about the Food and Drug Administration's guidelines for tanning devices.

Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis

OBJECTIVE

To estimate the burden of melanoma resulting from sunbed use in western Europe.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, ISI Web of Science (Science Citation Index Expanded), Embase, Pascal, Cochrane Library, LILACS, and MedCarib, along with published surveys reporting prevalence of sunbed use at national level in Europe.

STUDY SELECTION

Observational studies reporting a measure of risk for skin cancer (cutaneous melanoma, squamous cell carcinoma, basal cell carcinoma) associated with ever use of sunbeds.

RESULTS

Based on 27 studies ever use of sunbeds was associated with a summary relative risk of 1.20 (95% confidence interval 1.08 to 1.34). Publication bias was not evident. Restricting the analysis to cohorts and population based studies, the summary relative risk was 1.25 (1.09 to 1.43). Calculations for dose-response showed a 1.8% (95% confidence interval 0% to 3.8%) increase in risk of melanoma for each additional session of sunbed use per year. Based on 13 informative studies, first use of sunbeds before age 35 years was associated with a summary relative risk of 1.87 (1.41 to 2.48), with no indication of heterogeneity between studies. By using prevalence data from surveys and data from GLOBOCAN 2008, in 2008 in the 15 original member countries of the European Community plus three countries that were members of the European Free Trade Association, an estimated 3438 cases of melanoma could be attributable to sunbed use, most (n=2341) occurring among women.

CONCLUSIONS

Sunbed use is associated with a significant increase in risk of melanoma. This risk increases with number of sunbed sessions and with initial usage at a young age (<35 years). The cancerous damage associated with sunbed use is substantial and could be avoided by strict regulations.

Sunbeds and sunlamps: who used them and their risk for melanoma

Sunbed/sunlamp use was recently classified as carcinogenic. This report considers characteristics of those who use sunbeds/sunlamps and the effect of sunbed/sunlamp use on their risk for melanoma within a large case-control study carried out in 1991-1992. Females were more likely than males to have used sunbeds/sunlamps. Use by females increased strongly and significantly with younger ages and with the perceived ability to tan. For females, the individual risk for melanoma increased with typical session time and frequency of sessions. Use before age 20, current use and years of use were not significant. The use patterns of occasional and frequent users were very different. We estimate that typical 5-min sessions would increase the risk for melanoma by 19% for frequent users (10+ sessions) and by 3% for occasional users (1-9 sessions). Body sites that are not generally exposed to sunlight were more common sites of primary melanomas for frequent sunbed/sunlamp users. For males, measures of sunbed/sunlamp use were not significantly associated with melanoma risk.

Ultraviolet radiation and skin cancer

Skin cancer is the most common type of cancer in fair-skinned populations in many parts of the world. The incidence, morbidity and mortality rates of skin cancers are increasing and, therefore, pose a significant public health concern. Ultraviolet radiation (UVR) is the major etiologic agent in the development of skin cancers. UVR causes DNA damage and genetic mutations, which subsequently lead to skin cancer. A clearer understanding of UVR is crucial in the prevention of skin cancer. This article reviews UVR, its damaging effects on the skin and its relationship to UV immunosuppression and skin cancer. Several factors influence the amount of UVR reaching the earth's surface, including ozone depletion, UV light elevation, latitude, altitude, and weather conditions. The current treatment modalities utilizing UVR (i.e. phototherapy) can also predispose to skin cancers. Unnecessary exposure to the sun and artificial UVR (tanning lamps) are important personal attributable risks. This article aims to provide a comprehensive overview of skin cancer with an emphasis on carefully evaluated statistics, the epidemiology of UVR-induced skin cancers, incidence rates, risk factors, and preventative behaviors & strategies, including personal behavioral modifications and public educational initiatives.

Indoor tanning and risk of melanoma: a case-control study in a highly exposed population

BACKGROUND

Indoor tanning has been only weakly associated with melanoma risk; most reports were unable to adjust for sun exposure, confirm a dose-response, or examine specific tanning devices. A population-based case-control study was conducted to address these limitations.

METHODS

Cases of invasive cutaneous melanoma, diagnosed in Minnesota between 2004 and 2007 at ages 25 to 59, were ascertained from a statewide cancer registry; age-matched and gender-matched controls were randomly selected from state driver's license lists. Self-administered questionnaires and telephone interviews included information on ever use of indoor tanning, types of device used, initiation age, period of use, dose, duration, and indoor tanning-related burns. Odds ratios (OR) and 95% confidence intervals (CI) were adjusted for known melanoma risk factors.

RESULTS

Among 1,167 cases and 1,101 controls, 62.9% of cases and 51.1% of controls had tanned indoors (adjusted OR 1.74; 95% CI, 1.42-2.14). Melanoma risk was pronounced among users of UVB-enhanced (adjusted OR, 2.86; 95% CI, 2.03-4.03) and primarily UVA-emitting devices (adjusted OR, 4.44; 95% CI, 2.45-8.02). Risk increased with use: years (P < 0.006), hours (P < 0.0001), or sessions (P = 0.0002). ORs were elevated within each initiation age category; among indoor tanners, years used was more relevant for melanoma development.

CONCLUSIONS

In a highly exposed population, frequent indoor tanning increased melanoma risk, regardless of age when indoor tanning began. Elevated risks were observed across devices.

IMPACT

This study overcomes some of the limitations of earlier reports and provides strong support for the recent declaration by the IARC that tanning devices are carcinogenic in humans.

Critique of the International Agency for Research on Cancer's meta-analyses of the association of sunbed use with risk of cutaneous malignant melanoma

The International Agency for Research on Cancer (IARC) reported meta-analyses of the association of cutaneous malignant melanoma (CMM), finding significant correlations with ever use of sunbeds and first use of sunbeds prior to age 35 years; it did not claim that the associations showed causal links. However, some observational studies in the meta-analysis included individuals in the UK with skin phenotype at increased genetic risk of CMM without adjustment for skin phenotype. Treating the five UK studies separately from the other 14 corrected this oversight. In the original study, the summary relative risk (RR ) of CMM with respect to sunbed use was 1.15 (95% confidence interval [CI], 1.00-1.31). In this study, the similar RR was 1.20 (95% CI, 1.03-1.38). The RR for the five UK studies was 2.09 (95% CI, 1.14-3.84), whereas the RR for the other 14 studies was 1.09 (95% CI, 0.96-1.24). For first use of sunbeds prior to age 35 years, the IARC found a summary RR of 1.75 (95% CI, 1.35-2.36). This study plotted the RRs versus latitude of each study population, with a linear regression analysis carried out for all but the one UK study. The RR increased at 0.077 per degree of latitude and the regression explained 67% of the variance. It is also argued that factors other than sunbed use explain the increasing worldwide trends in CMM. Because solar-UV-simulating sunbeds induce production of vitamin D, the health benefits of their use greatly outweigh any possible risks.

Behaviors associated with ultraviolet radiation exposure in a cohort of adult survivors of childhood and adolescent cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

Previous research from the Childhood Cancer Survivor Study (CCSS) has shown that risk of skin cancer is strongly associated with exposure to radiation therapy. The potential role of ultraviolet radiation exposure in survivors has not been described.

METHODS

The CCSS is a retrospective cohort study designed to investigate late effects among 5-year survivors of children and adolescents diagnosed with cancer between 1970-1986. Data regarding current sun protection behavior were collected on 9298 survivors and 2950 sibling controls. Median age at follow-up was 31 years (range, 17-54).

RESULTS

In this cohort, childhood cancer survivors and siblings showed similar patterns of sunscreen use (67% vs 66%). Survivors were significantly less likely to report having sunbathed in the previous year (none vs any in previous year: relative risk (RR)=0.92; 95% confidence interval (CI)=0.89-0.95) or use artificial tanning (none vs any in previous year: RR=0.76; 95% CI=0.70-0.83). Compared with survivors without radiation therapy, survivors with radiation exposure showed increased use of sunscreen (RR=1.06; 95% CI=1.03-1.10), and less sunbathing (none vs any in previous year: RR=0.89; 95% CI=0.86-0.92) or artificial tanning (none vs any in previous year: RR=0.62; 95% CI=0.56-0.69). In adjusted multivariable analysis, statistically significant factors for regular sunscreen use in the past summer (vs never/rarely) in the survivor population were being female, having lighter skin complexions, having previously been examined for skin cancer, and having skin that burned when in the sun unprotected.

CONCLUSIONS

Survivors of childhood cancer self-reported lower tanning practices than siblings. However, because of the potential increased risk of skin cancer from therapy-related exposures, future research should be directed at intervention studies to further reduce UV exposures.

What impact would effective solarium regulation have in Australia?

1) Leading international health organisations are concerned about high use of artificial tanning services and the associated risk of skin cancer. Similar concerns exist about the growing Australian solarium industry. 2) Pre-teens appear to be ignoring sun safety messages in their desire to tan and use solaria. 3) A significantly elevated risk of melanoma exists among people exposed to artificial ultraviolet radiation; the risk is higher for those younger than 35 years at first solarium use. For all users, the risk of squamous cell carcinoma is more than doubled compared with non-users. 4) We estimated the numbers of new melanoma cases and melanoma-related deaths attributable to solarium use by younger people in the five most populous Australian states and indirectly quantified potential costs to the health system that could be saved by effective regulation of the solarium industry. 5) Annually, 281 new melanoma cases, 43 melanoma-related deaths and 2572 new cases of squamous cell carcinoma were estimated to be attributable to solarium use. 6) The annual cost to the health system--predominantly Medicare Australia--for these avoidable skin cancer cases and deaths is about $3 million. 7) By successfully enforcing solarium regulations that ban use by people younger than 18 years or with fair skin, favourable health and cost benefits could be expected.

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

Background

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

Methods

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

Results

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

Conclusion

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

Exposure to sunlamps, tanning beds, and melanoma risk

OBJECTIVE

To estimate the separate effects of sunlamp and tanning bed device use on melanoma risk.

METHODS

Population-based case-control study of 423 cases of melanoma and 678 controls in the state of New Hampshire. Exposure data, including sunlamp and tanning bed use, were collected by telephone interview. Associations were evaluated using logistic regression analyses.

RESULTS

About 17% of participants ever used a sunlamp, and most use (89%) occurred before 1980. The OR was 1.39 (95% CI 1.00-1.96) for ever using a sunlamp, 1.23 (95% CI 0.81-1.88) for those starting sunlamp use <20 years, and 1.71 (95% CI 1.00-2.92) for those starting >/=20 years. Data suggested increasing risk with number of sunlamp uses and with duration of use (tests of trend p = 0.02). The overall prevalence of tanning bed use was 22% and most use (83%) occurred after 1980. The OR was 1.14 (95% CI 0.80-1.61) for ever using a tanning bed; there was no evidence that risk increased with frequency or duration of use. The OR was 1.96 (95% CI 1.06-3.61) for having used both devices.

CONCLUSION

Results suggest a modest association between sunlamp use and melanoma risk, and increasing risk with greater frequency and duration of use. No association with tanning bed use was found, but sufficient lag time may not have elapsed to assess a potential effect.

Quantitative risk assessment of sunbeds: impact of new high power lamps

BACKGROUND

A survey of all sunbeds in a local authority area was carried out in 1998. Since then, there have been technological developments leading to new 'fast-tan' sunlamps which have become increasingly popular, along with unmanned sun parlours. In addition, new British and European sunbed standards have been set.

OBJECTIVES

To discover the commercial uptake of new high power sunlamps and to determine the impact on carcinogenic risk from sunbeds.

METHODS

Onsite spectral measurements, traceable to national standards, were conducted at all commercial sunbed premises within two local authorities and a quantitative risk assessment applied to the findings using a skin cancer model. Sunbed users were asked to complete a questionnaire regarding their reasons for using a sunbed and the risk associated with its use.

RESULTS

We found a 30% increase in the number of privately operated sunbeds since our 1998 survey. The median cancer-weighted exposure of all 133 sunbeds was comparable to that of Mediterranean sunlight. This was a significant increase compared to 1998. Moreover, 83% of sunbeds produced ultraviolet (UV) B radiation levels that exceeded the European standard. Fifteen per cent of respondents thought that there were no risks from use of sunbeds.

CONCLUSIONS

Sunbeds in current use carry a cancer risk comparable to Mediterranean sunlight. This is due to the use of new high power lamps. New British and European standards are being largely ignored with more than four out of five sunbeds exceeding the limit specified in the standard. There is a strong case for regulation of sunbed operators coupled to improved public education.

Risk factors for presumptive melanoma in skin cancer screening: American Academy of Dermatology National Melanoma/Skin Cancer Screening Program experience 2001-2005

BACKGROUND

Since its inception in 1985, the American Academy of Dermatology (AAD) National Melanoma/Skin Cancer Screening Program has strived to enhance early detection of cutaneous malignant melanoma (MM) by providing nationwide skin cancer education campaigns in combination with free skin cancer screenings.

OBJECTIVE

To analyze the AAD screening data from 2001 to 2005 in order to identify factors associated with MM detection, and thereby derive a model of increased likelihood for MM detection through visual skin examinations at screenings.

MATERIALS AND METHODS

Patients completed a standardized AAD pre-screening form with historical and phenotypic information. Clinicians then recorded suspected clinical findings noted at visual skin examination. Statistical analyses were conducted using SPSS 14 (SPSS Inc., Chicago, Ill).

RESULTS

Five factors, which can be remembered with the acronym HARMM, independently increased the likelihood of suspected MM being found in the 362,804 persons screened: History of previous melanoma (odds ratio [OR] = 3.3; 95% confidence interval [CI], 2.9-3.8); Age over 50 (OR = 1.2; 95% CI, 1.1-1.3); Regular dermatologist absent (OR = 1.4; 95% CI, 1.3-1.5); Mole changing (OR = 2.0; 95% CI, 1.9-2.2); and Male gender (OR = 1.4; 95% CI, 1.3-1.5). Individuals at highest risk (4 or 5 factors) comprised only 5.8% of the total population, yet accounted for 13.6% of presumptive MM findings, and were 4.4 times (95% CI, 3.8-5.1) more likely to be diagnosed with suspected MM than individuals at lowest risk (0 or 1 factor). Receipt of a total skin examination at screening independently increased the likelihood for identifying suspected MM (OR = 1.4; 95% CI, 1.3-1.6). However, significantly fewer screenees in the highest risk group versus those in the lowest risk group underwent total skin examinations (53.7% vs 62.5%).

LIMITATIONS

Risk factors studied limited to variables collected in screenee enrollment form.

CONCLUSIONS

A higher-risk subgroup of the skin cancer screening population can be identified through assessment of MM risk factors using the HARMM criteria. Refocusing efforts to provide a total skin examination to those individuals with multiple risk factors has the potential to both reduce costs and increase yields for suspected MM in future mass screening initiatives.

Melanoma, long wavelength ultraviolet and sunscreens: Controversies and potential resolutions

Although sunlight is known to cause melanoma, there has been considerable controversy as to the importance of short (UVB) and long (UVA) ultraviolet (UV) wavelengths in causing melanoma, leading to uncertainty in how best to prevent this cancer. This uncertainty has been compounded by the difficulties in assaying the UVA protection abilities of sunscreens, as compared to widely accepted measures of UVB screening by the sun protection factor (SPF). This review discusses the controversies surrounding UVA causation of melanoma in both human and animal models and the use of sunscreens to prevent melanoma. In addition, it details the development of an electron paramagnetic resonance (EPR) technique, initially used to determine the wavelength dependence (or action spectrum) of intramelanocyte radical generation to resolve these controversies in the Xiphophorus model. It is shown how this EPR technique allows a sunscreen protection factor to be determined, that is weighted to the melanocyte, and how this also allows study of the wavelength-dependent screening ability of sunscreens.

The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review

Exposure to solar ultraviolet (UV) radiation is a known cause of skin cancer. Sunbed use represents an increasingly frequent source of artificial UV exposure in light-skinned populations. To assess the available evidence of the association between sunbed use and cutaneous malignant melanoma (melanoma) and other skin cancers, a systematic review of the literature till March 2006 on epidemiological and biological studies on sunbed use was performed in Pubmed, ISI Web of Science, Embase, Pascal, Cochrane library, Lilacs and Medcarib. Search for keywords in the title and in the abstract was done systematically and supplemented by manual searches. Only case-control, cohort or cross-sectional studies were selected. Data were abstracted by means of a standardized data-collection protocol. Based on 19 informative studies, ever-use of sunbeds was positively associated with melanoma (summary relative risk, 1.15; 95% CI, 1.00-1.31), although there was no consistent evidence of a dose-response relationship. First exposure to sunbeds before 35 years of age significantly increased the risk of melanoma, based on 7 informative studies (summary relative risk, 1.75; 95% CI, 1.35-2.26). The summary relative risk of 3 studies of squamous cell carcinoma showed an increased risk. For basal cell carcinoma, the studies did not support an association. The evidence does not support a protective effect of the use of sunbeds against damage to the skin from subsequent sun exposure. Young adults should be discouraged from using indoor tanning equipment and restricted access to sunbeds by minors should be strongly considered.

Cutaneous malignant melanoma: facts about sunbeds and sunscreen

The incidence of cutaneous malignant melanoma is still increasing in most light-skinned populations. Sunscreen use has been proposed for the primary prevention of melanoma. However, sunscreen use may increase time spent in the sun when users are willing to acquire a tan or to stay in the sun for a long time, which may increase melanoma risk. When sun exposure is not associated with the desire to acquire a tan or stay in the sun for a long time, sunscreen use may prevent squamous cell skin carcinoma. Sun protection should give priority to clothing and sun exposure reduction. Over the last 20 years, tan acquisition through exposure to artificial sources of ultraviolet radiation has become frequent among fair-skinned adolescents and young adults. There is accumulating evidence that sunbed use is associated with melanoma when started before approximately 30 years of age.

A multicentre epidemiological study on sunbed use and cutaneous melanoma in Europe

A large European case-control study investigated the association between sunbed use and cutaneous melanoma in an adult population aged between 18 and 49 years. Between 1999 and 2001 sun and sunbed exposure was recorded in 597 newly diagnosed melanoma cases and 622 controls in Belgium, France, The Netherlands, Sweden and the UK. Fifty three percent of cases and 57% of controls ever used sunbeds. The overall adjusted odds ratio (OR) associated with ever sunbed use was 0.90 (95% CI: 0.71-1.14). There was a South-to-North gradient with high prevalence of sunbed exposure in Northern Europe and lower prevalence in the South (prevalence of use in France 20%, OR: 1.19 (0.68-2.07) compared to Sweden, prevalence 83%, relative risk 0.62 (0.26-1.46)). Dose and lag-time between first exposure to sunbeds and time of study were not associated with melanoma risk, neither were sunbathing and sunburns (adjusted OR for mean number of weeks spent in sunny climates >14 years: 1.12 (0.88-1.43); adjusted OR for any sunburn >14 years: 1.16 (0.9-1.45)). Host factors such as numbers of naevi and skin type were the strongest risk indicators for melanoma. Public health campaigns have improved knowledge regarding risk of UV-radiation for skin cancers and this may have led to recall and selection biases in both cases and controls in this study. Sunbed exposure has become increasingly prevalent over the last 20 years, especially in Northern Europe but the full impact of this exposure on skin cancers may not become apparent for many years.

Tanning and skin cancer

Skin cancer is a large and growing problem in the United States. Sun and other ultraviolet (UV) light exposures play a key role in the development of skin cancer. Pediatricians can play an important role in counseling patients and are in a position to help educate children and their families about skin cancer. The purpose of this review is to familiarize pediatricians with the magnitude of the skin cancer problem and the evidence that ultraviolet light exposure, particularly indoor tanning, contributes to this problem. We reviewed the literature on ultraviolet light and skin cancer (based on a MEDLINE search of articles using the headings "ultraviolet light" and "skin cancer") and found that skin cancer is the most rapidly growing cause of cancer deaths in the United State. There is strong epidemiologic evidence for the relationship between UV exposure and nonmelanoma skin cancer and growing evidence for the relationship between indoor tanning and melanoma. We recommend that pediatricians counsel children and their parents about UV protection. Measures such as use of sunscreen and hats for outdoor play, both at home and in school, should be encouraged.

Tanning beds, sunlamps, and risk of cutaneous malignant melanoma

BACKGROUND

A number of studies have been conducted evaluating the risk of cutaneous malignant melanoma after exposure to sunlamps and/or sunbeds. The proportion of subjects in the individual studies who have reported exposure has, in general, been modest, and the resulting risk estimates for melanoma have been unstable with wide 95% confidence intervals (95% CI). The inconclusive results seen in individual studies have resulted in confusion as to the carcinogenicity of these devices.

METHODS

We conducted a systematic review and meta-analysis of these studies. A review of the literature from Jan 1, 1984 to April 2004 using MEDLINE identified 12 case-control studies and 1 cohort study which quantitatively evaluated the use of sunlamps and/or sunbeds and subsequent melanoma. After applying exclusion/inclusion criteria, 9 case-control and 1 cohort study provided data for the analysis. Summary odds ratios (OR) and 95% CIs for sunlamp/sunbed use and subsequent melanoma were calculated using a random-effect model.

RESULTS

Ten studies provided data for assessment of melanoma risk among subjects who reported "ever" being exposed compared with those "never" exposed. A positive association was found between exposure and risk (summary OR, 1.25; 95% CI, 1.05-1.49). Significant heterogeneity between studies was present. Evaluation of the metrics "first exposure as a young adult" (5 studies) and "longest duration or highest frequency of exposure" (6 studies) also yielded significantly elevated risk estimates (summary OR, 1.69; 95% CI, 1.32-2.18, and 1.61; 95% CI, 1.21-2.12, respectively, with no heterogeneity in either analysis).

CONCLUSIONS

Results indicate a significantly increased risk of cutaneous melanoma subsequent to sunbed/sunlamp exposure.

Perspectives in melanoma prevention: the case of sunbeds

The incidence of cutaneous malignant melanoma (melanoma) and of basal cell carcinoma is still increasing in most fair-skinned populations. The fashion of intermittent exposure to solar ultraviolet (UV) radiations is considered the main cause of this increase. In 20 years time, tan acquisition through exposure to artificial sources of UV radiations has become frequent among fair-skinned adolescents and young adults. Modern sunbeds are powerful sources of UV radiations that do not exist in the nature, and repeated exposures to high doses of UVA constitute a new phenomenon in humans. A large prospective cohort study on 106,379 Norwegian and Swedish women conducted between 1991 and 1999 has provided evidence for a significant, moderate increase in melanoma risk among regular sunbed users. Failure of past case-control studies to document with consistency the sunbed-melanoma association was probably due to a too short latency period between sunbed use and melanoma diagnosis, and to too few subjects with high total durations of sunbed use. Regulations of sunbed installation, operation and use should become standardised across the 25 European Union countries. Enforcement of regulations in tanning parlours remains inadequate. In contrast, the existence of regulations is presented by many tanning salon operators as a guarantee that sunbed use is safe. We stress the need for the control of information disseminated by the "tanning industry" on suppositions that sunbed use is safer than sun exposure, and on the hypothetical health benefits of tanning. New fluorescent UV lamps are proposed that have a spectrum similar to the midday sun. Given the known association between intermittent sun exposure and melanoma, public-health authorities should reconsider the soundness of the commercialisation of these lamps.

Bronzeamento e risco de melanoma cutâneo: revisão da literatura

Estudos epidemiológicos sugerem a relação entre comportamentos relacionados ao bronzeamento e risco elevado de melanoma. Nesse sentido, realizou-se revisão sobre essa temática que abrangeu o período correspondente aos anos de 1977 a 1998. Foram pesquisadas as bases de dados Medline e Embase (Excerpta Medica). A análise mostrou que entre os jovens, apesar do conhecimento sobre os riscos da exposição excessiva à radiação ultravioleta e sobre as práticas visando à proteção da pele, prevalece o hábito de expor-se intencionalmente ao sol. Esse hábito é alimentado por crenças e atitudes em relação ao bronzeado e estimulado por influência do grupo e de pessoas consideradas "referências". As práticas mais freqüentemente adotadas para bronzear a pele apresentam risco elevado para o desenvolvimento de melanoma. Conclui-se que a forma mais eficaz de prevenir o melanoma é divulgar nos meios de comunicação que a pele bronzeada não é saudável, pois foi danificada pela radiação ultravioleta solar; e iniciar campanhas com ações efetivas para mudar comportamentos, naquilo que os motiva e os alimenta.

Exposure to the sun and sunbeds and the risk of cutaneous melanoma in the UK: a case-control study

Migration, latitude and case-control studies have clearly established a link between melanoma and sun exposure. This case-control study of melanoma was set up to examine the role of sun exposure and sunbeds in the pathogenesis of melanoma in the United Kingdom (UK), a country with low levels of ultraviolet radiation. The study included 413 cases and 416 controls. More than 10 severe sunburns compared with less than 10 sunburns was associated with an Odds Ratio (OR) of 1.98 (95% Confidence Interval (CI) 1.02-3.86) (P=0.04) when adjusted for age, gender and skin type. Sunburns before the age of 15 years were not associated with melanoma once adjustments for age, gender and skin were made. 31% of women and 16% of the men had used sunbeds. Sunbed users were younger than non-users (40 years versus 51 years, P<0.0001). Ever use of sunbeds gave an adjusted OR of 1.19 (95% CI 0.84-1.68) (P=0.33). The risk of melanoma did not increase with increasing hours or years of sunbed exposure. The risk associated with sunbed use was only significant for young individuals with fair skin for whom there was a significant OR of 2.66 (95% CI 1.66-6.09) (P=0.02) after adjustment for the sun exposure variables. Outdoor occupation and residence in hot countries were not associated with an increased risk of melanoma. The only significant associations in this study were with 10 or more sunburns and the use of a sunbed in young subjects with fair skin. Sunbed use is now becoming more prevalent in Caucasian populations and the results of this study suggest that sunbed usage may moderately affect individuals with sun-sensitive skin types. However, the magnitude of melanoma risk in association with natural and artificial sun exposure is small compared with phenotypic risk factors such as skin type and naevus counts. However, it is possible that the mean lag time of 7 years between exposure to sunbed and melanoma in this study may have led to an under-estimation of the long-term melanoma risk.

Tanning Devices - Fast Track to Skin Cancer?

The use of UVB and/or UVA emitting devices for cosmetic tanning is widespread in Western populations including young people and is especially prevalent in females. Several epidemiological studies, although not all, have shown a significant relationship between the use of tanning devices and malignant melanoma after, in some cases, adjustment for confounding factors such as solar ultraviolet radiation (UVR) exposure. A relationship between solar exposure, especially intermittent exposure, and malignant melanoma is well established so it is not surprising that a similar connection has been reported for the use of tanning devices. Several epidemiological studies show that childhood exposure to sunlight is a risk factor for malignant melanoma and this may also be the case for the use of tanning devices, especially if sunburns are obtained. Some studies have evaluated the relationship between the use of tanning devices and non-melanoma skin cancer and at least one has suggested an association. The use of tanning devices by a substantial minority of young people is a worrying trend in terms of a likely increased incidence of malignant melanoma, and possibly non-melanoma cancers in the future. Although two recent reviews by epidemiologists conclude that a clear link between tanning devices and malignant melanoma is yet to be proven, there is a strong case for effective legislation to prohibit the use of tanning devices by people under 18 yr of age.

Sunshine is good medicine. The health benefits of ultraviolet-B induced vitamin D production

Most public health statements regarding exposure to solar ultraviolet radiation (UVR) recommend avoiding it, especially at midday, and using sunscreen. Excess UVR is a primary risk factor for skin cancers, premature photoageing and the development of cataracts. In addition, some people are especially sensitive to UVR, sometimes due to concomitant illness or drug therapy. However, if applied uncritically, these guidelines may actually cause more harm than good. Humans derive most of their serum 25-hydroxycholecalciferol (25(OH)D3) from solar UVB radiation (280-315 nm). Serum 25(OH)D3 metabolite levels are often inadequate for optimal health in many populations, especially those with darker skin pigmentation, those living at high latitudes, those living largely indoors and in urban areas, and during winter in all but the sunniest climates. In the absence of adequate solar UVB exposure or artificial UVB, vitamin D can be obtained from dietary sources or supplements. There is compelling evidence that low vitamin D levels lead to increased risk of developing rickets, osteoporosis and osteomaloma, 16 cancers (including cancers of breast, ovary, prostate and non-Hodgkin's lymphoma), and other chronic diseases such as psoriasis, diabetes mellitus, hypertension, heart disease, myopathy, multiple sclerosis, schizophrenia, hyperparathyroidism and susceptibility to tuberculosis. The health benefits of UVB seem to outweigh the adverse effects. The risks can be minimized by avoiding sunburn, excess UVR exposure and by attention to dietary factors, such as antioxidants and limiting energy and fat consumption. It is anticipated that increasing attention will be paid to the benefits of UVB radiation and vitamin D and that health guidelines will be revised in the near future.

Biomarkers in melanoma: predisposition, screening and diagnosis

Melanoma's incidence and mortality for certain groups has appeared to level off after a steady increase over the last half century. This trend is suspected to be due to better detection and removal of thin, biological early melanomas. However, to date, no prospective evidence exists to clearly demonstrate the efficacy of prevention and early detection in decreasing melanoma mortlity. Nonetheless, many studies suggest that both self-assessment of risk factors or clinician examination can identify a proportion of patients at highest risk for melanoma who may benefit from behavior modification (primary prevention) and routine screening (secondary prevention). Compromising these goals is the fact that neither the clinical or histologic diagnosis of melanoma is 100% accurate. Clinical diagnosis of melanoma, based on evaluation of a skin lesion's color and shape, correlates best with the experience of the clinician. Ancillary technologies have been developed to improve clinical accuracy of suspicious skin lesions but a subset of melanomas exist that do not fall in the spectrum of the 'ABCDE' guidelines commonly used for melanoma identification. Similarly, at the histologic level (the 'gold standard' of diagnosis), overlap exists between benign and malignant melanocytic proliferations leading to both over and underdiagnosis of melanoma. A better understanding of melanoma's pathogenesis has identified disease-related biomarkers that may more reliably differentiate a melanocytic nevus from melanoma. In this paper, we review current and novel, potentially more accurate, biomarkers and supplementary technologies that can be used for the prevention, screening and diagnosis of melanoma.

Current concepts in the management of patients with melanoma

Melanoma is a significant health problem. Despite public education and free cancer screenings, the incidence and mortality of melanoma continues to rise; however, many currently diagnosed melanomas are thin lesions, suggesting that education and awareness is having an impact. In addition, there are still subsets of patients who need increased surveillance in order to increase their survival. Although large congenital nevi may be precursors of melanoma, small and medium congenital nevi have an insignificant risk for melanoma development. Large congenital nevi, which are axial in location, appear to be more likely to develop melanoma and are associated with melanocytosis and melanoma of the CNS, both of which portend a poor prognosis. Recently, the recommended margins of excision have become more conservative so that many of the surgical defects can be closed primarily. Lymphoscintigraphy and sentinel node biopsy have replaced elective node dissections, thus decreasing the morbidity associated with the surgical management of melanoma. Although controversy still exists as to whether or not sentinel lymph node biopsy alters a patient's prognosis, it has been shown to be a powerful prognostic indicator. Although most melanomas are managed by routine surgical excision, other modalities are sometimes employed. For example, cryosurgery or radiation therapy may be indicated in the frail, elderly individual with a large facial lentigo maligna. Mohs surgery is the treatment of choice for head and neck melanomas and those located in areas where maximum preservation of tissue is required and for desmoplastic and acral lentiginous melanomas. Much more work remains in the area of adjuvant therapy, chemotherapy, and immunotherapy. Dacarbazine remains the drug of choice in disseminated melanoma, but remissions are usually short lived. Interleukin and biochemotherapy has yielded good results but the percentage benefiting is small. Although high dose interferon increases disease-free and overall survival in some patients, it remains a controversial drug which is not easily tolerated. In the new staging system for melanoma, ulceration is second only to Breslow's thickness. In transit (satellite) lesions have also been included in this new system. The new system also recognizes that patients with only microscopic metastatic nodal disease fare better than patients with clinically enlarged metastatic nodes and that it is the number of nodes involved with metastases, not their size, that determines the patient's prognosis. Except for lesions <1mm thick, the Clark's level of invasion has been de-emphasized.

Examination of the efficacy of an appearance-focused intervention to reduce UV exposure

This study designed and implemented an appearance-based skin cancer prevention intervention in college-aged females. One hundred and forty-seven respondents were randomly assigned to treatment or control groups. Treatment respondents received a short workbook describing the appearance damaging effects of indoor tanning. At short-term follow-up (2 weeks later) treatment respondents had significantly more negative attitudes toward indoor tanning, and reported fewer intentions to indoor tan. At 2-month follow-up, treatment respondents reported indoor tanning one-half as much as control respondents in the previous 2 months. This appearance-based intervention was able to produce clinically significant changes in indoor tanning use tendencies that could have a beneficial effect on the future development of skin cancer.

Use of indoor tanning sunlamps by US youth, ages 11-18 years, and by their parent or guardian caregivers: prevalence and correlates

BACKGROUND

Tanning parlors have become common in the United States. Artificial ultraviolet radiation exposure from this source may be harmful and may increase the risk of melanoma, particularly when done for recreational purposes during childhood and early adult years. Population-based data on the prevalence and correlates of this activity is important in the evaluation of potential public health interventions for skin cancer prevention.

STUDY DESIGN

In 1998, we conducted a population-based telephone survey of youth and their primary caregiver. The sample (N = 1192) was weighted to represent the population of US youth living in households with a primary caregiver. Interviewers used a standardized questionnaire to document the characteristics of the participant and their practices, attitudes, and experiences regarding ultraviolet exposures. METHOD OF ANALYSIS: Weighted prevalence and adjusted prevalence odds ratios (aPOR) and 95% confidence interval (95% CI) were estimated. Independent factors were evaluated with multivariate logistic regression.

RESULTS

Ten percent of youth and 8% of their primary caregivers used indoor tanning sunlamps in the previous year. Thirty percent of the youth whose caregivers used indoor tanning sunlamps did so themselves as well. Independent predictors associated with indoor tanning sunlamp use were as follows: age 17 to 18 years (aPOR = 11.1; 95% CI: 5.0, 25.0); female (aPOR = 8.3; 95% CI: 3.6, 19.2); having a parent who used indoor tanning sunlamps in the previous year (aPOR = 8.7; 95% CI: 4.0, 18.9); nonuser of Sun Protection Factor 15 sunscreen at the beach or pool (aPOR = 1.9; 95% CI: 1.0, 3.4); and low sun sensitivity (aPOR = 2.3; 95% CI: 1.0, 5.3).

CONCLUSION

A substantial minority of American youth engages in indoor tanning. However, it is particularly prevalent among older youth, girls, and youth whose parents themselves use indoor tanning sunlamps. The knowledge of these trends may help focus public health initiatives.

Nitric oxide-mediated depletion of Langerhans cells from the epidermis may be involved in UVA radiation-induced immunosuppression

Ultraviolet A (UVA) irradiation of the dorsal skin of mice reduced the contact hypersensitivity (CHS) response and the density of epidermal Langerhans cells (LC). The roles of nitric oxide (NO) and reactive oxygen species (ROS) in these biological effects of UVA were investigated. Topical application of N(G)-monomethyl-L-arginine acetate, an inhibitor of NO production, 2,2'-dipyridyl, an iron chelater, or 4-hydroxy-tempo, a superoxide dismutase mimicking agent, inhibited UVA-induced suppression of the CHS response. N(G)-monomethyl-L-arginine acetate but not the ROS inhibitors prevented UVA from reducing LC numbers in the epidermis. This suggests that NO but not ROS produced in response to UVA mediates a depletion of LC from the epidermis, probably by signaling these cells to migrate from the skin. This could be responsible for UVA-induced immunosuppression. UVA-induced ROS can also cause immunosuppression, but by a different mechanism. Agents that inhibit or modulate NO or ROS production may be useful for preventing damage caused by the UVA component of sunlight to the skin immune system.

Ultraviolet A and melanoma: a review

The incidence and mortality rates of melanoma have risen for many decades in the United States. Increased exposure to ultraviolet (UV) radiation is generally considered to be responsible. Sunburns, a measure of excess sun exposure, have been identified as a risk factor for the development of melanoma. Because sunburns are primarily due to UVB (280-320 nm) radiation, UVB has been implicated as a potential contributing factor to the pathogenesis of melanoma. The adverse role of UVA (320-400 nm) in this regard is less well studied, and currently there is a great deal of controversy regarding the relationship between UVA exposure and the development of melanoma. This article reviews evidence in the English-language literature that surrounds the controversy concerning a possible role for UVA in the origin of melanoma. Our search found that UVA causes DNA damage via photosensitized reactions that result in the production of oxygen radical species. UVA can induce mutations in various cultured cell lines. Furthermore, in two animal models, the hybrid Xiphophorus fish and the opossum (Mondelphis domestica), melanomas and melanoma precursors can be induced with UVA. UVA radiation has been reported to produce immunosuppression in laboratory animals and in humans. Some epidemiologic studies have reported an increase in melanomas in users of sunbeds and sunscreens and in patients exposed to psoralen and UVA (PUVA) therapy. There is basic scientific evidence of the harmful effects of UVA on DNA, cells and animals. Collectively, these data suggest a potential role for UVA in the pathogenesis of melanoma. To date evidence from epidemiologic studies and clinical observations are inconclusive but seem to be consistent with this hypothesis. Additional research on the possible role of UVA in the pathogenesis of melanoma is required.

Risk of cutaneous malignant melanoma in relation to use of sunbeds: further evidence for UV-A carcinogenicity

In a population-based, matched, case-control study from southern Sweden of 571 patients with a first diagnosis of cutaneous malignant melanoma and 913 healthy controls aged 16-80 years, the association between sunbed use and malignant melanoma was evaluated. A total of 250 (44%) cases and 372 (41%) controls reported ever having used sunbeds. A significantly elevated odds ratio for developing malignant melanoma after regular exposure to sunbeds was found, adjusted for hair colour, raised naevi, skin type and number of sunburns (odds ratio (OR) 1.8, 95% confidence interval (CI) 1.2-2.7). A dose-response relationship between total number of sunbed uses and melanoma risk was only found up to the level of 250 times. The OR was higher in individuals younger than age 36 years (adjusted OR 8.1, 95% CI 1.3-49.5 for regular vs. never use). The association seemed to be true only for subjects with black/dark brown or light brown hair and among females. Lesions of the extremities showed the strongest association of increased risk with sunbed use. An increased risk was related to commercial exposure and to exposure during the winter. The results substantiate the hypothesis that exposure to sunbeds might increase the risk of developing malignant melanoma.