Occupational ultraviolet light exposure increases the risk for the development of cutaneous squamous cell carcinoma: a systematic review and meta-analysis

A Food Odorant, α-Ionone, Inhibits Skin Cancer Tumorigenesis by Activation of OR10A6

SCOPE

This study aims to investigate the anticancer properties of α-ionone in squamous cell carcinoma (SCC).

METHODS AND RESULTS

The expression of OR10A6 together with olfactory receptor signaling components is demonstrated in A431 human SCC cells via RT-PCR and qRT-PCR analysis. OR10A6 activation in A431 cells using the ligand α-ionone inhibits proliferation and migration but induces apoptosis which is confirmed by proliferation assay, colony formation, and western blotting. The mechanism involves the core proteins of the Hippo pathway, where the phosphorylation of large tumor suppressor kinase (LATS), yes-associated protein (YAP), and transcriptional coactivator with PDZ-binding motif (TAZ) is confirmed by western blotting. However, the anticancer effects of α-ionone are abrogated in A431 cells with OR10A6 gene knockdown. In A431 xenograft mouse model, the injection of α-ionone suppresses tumor growth, induces apoptosis, and increases phosphorylation of the LATS-YAP-TAZ signaling axis in the Hippo pathway. None of these effects are observed in xenografted tumors with OR10A6 gene knockdown.

CONCLUSION

These findings collectively demonstrate that activation of ectopic OR OR10A6 by α-ionone in SCC cells stimulates the Hippo pathway and suppresses tumorigenesis both in vitro and in vivo, suggesting a novel therapeutic candidate for the treatment of SCC.

Estimating occupational disease burden: a way forward

Estimates of occupational disease burden provide important information on which effective policy and regulations can be developed. However, there is no direct way that these data can be obtained, and most burden estimates are derived by merging different data from diverse sources to synthesize estimates of the number of people made ill or who have died from workplace exposures. In recent years, several research groups have published estimates of occupational health burden at national or global scales; these are not always consistent. The World Health Organisation and the International Labour Organisation have taken on the task of producing occupational disease burden estimates for several workplace agents, which we assume are to be seen as the definitive global, regional, and national data. In this commentary, we critique the WHO/ILO approach for their estimates of the non-melanoma skin cancer burden from solar ultraviolet radiation and some of their results for hazardous particulates. We provide recommendations for researchers undertaking occupational burden estimates that they should report along with their data.

Sonnenschutz bei Beschäftigten im Freien. Entwicklung und Validierung von standardisierten Fragebögen für Verhalten und Wissen

BACKGROUND AND OBJECTIVES

Outdoor workers are at increased risk of developing non-melanoma skin cancer. We aimed to address the lack of validated German-language measurement instruments for outdoor workers' sun safety behavior and knowledge by compiling and validating two questionnaires.

PARTICIPANTS AND METHODS

By expert consensus, items for the assessment of protective behavior (OccuSun) were compiled based on existing instruments. For knowledge, a translation of the Skin Cancer and Sun Knowledge (SCSK) scale was selected. After a pre-test, a validation study including 68 outdoor workers (62% female) was conducted in 2020.

RESULTS

The retest reliability was r = 0.93 (95% confidence interval: 0.86-0.96) for the protection score and rs = 0.78 (0.67-0.86) for the knowledge score. Protective behaviors were correlated with respective diary data (0.38 ≤ rs ≤ 0.74, p < 0.001) and skin pigmentation changes (-0.23 ≥ rs ≥ -0.42, 0.007 ≤ p ≤ 0.165) but not with self-reported sunburn frequency (0.21 ≥ rs ≥ -0.04).

CONCLUSIONS

Among German outdoor workers, two questionnaires for the assessment of sun protection behavior (OccuSun) and knowledge (SCSK) demonstrated good reliability. The OccuSun had generally good validity. Both instruments are fit for subsequent validation to determine their sensitivity to change.

Diagnosis and therapy of actinic keratosis

Actinic keratosis (AK) is considered a chronic and recurring in situ skin neoplasia, with a possible transformation into invasive squamous cell carcinoma (SCC). Among others, predominant risk factors for development of AK are UV-light exposure and immunosuppression. Basal epidermal keratinocyte atypia (AK I) and proliferation (PRO score) seem to drive malignant transformation, rather than clinical appearance of AK (Olsen I-III). Due to the invasiveness of punch biopsy, those histological criteria are not regularly assessed. Non-invasive imaging techniques, such as optical coherence tomography (OCT), reflectance confocal microscopy (RCM) and line-field confocal OCT (LC-OCT) are helpful to distinguish complex cases of AK, Bowen's disease, and SCC. Moreover, LC-OCT can visualize the epidermis and the papillary dermis at cellular resolution, allowing real-time PRO score assessment. The decision-making for implementation of therapy is still based on clinical risk factors, ranging from lesion- to field-targeted and ablative to non-ablative regimens, but in approximately 85% of the cases a recurrence of AK can be observed after a 1-year follow-up. The possible beneficial use of imaging techniques for a non-invasive follow-up of AK to detect recurrence or invasive progression early on should be subject to critical evaluation in further studies.

Skin Barrier- and Immune Response-Related Biomarkers of Solar UVR Exposure Comparing Indoor and Outdoor Workers

Outdoor workers have increased risk of developing keratinocyte cancer due to accumulated skin damage resulting from chronic and excessive exposure to UVR. This study aims to identify potential noninvasive biomarkers to assess chronic UVR exposure. We analyzed stratum corneum biomarkers collected from 2 skin locations and 2 occupational groups with contrasting solar UVR exposure: the forehead and retroauricular skin among outdoor workers and indoor workers. Using a linear mixed model adjusting for age and skin phototype, we compared biomarkers between both skin sites in indoor and outdoor workers. We measured markers of the immune response and skin barrier, including cytokines, GFs, 15-hydroxyeicosatetraenoic acid, cis- and trans-urocanic acid, and corneocyte topography, indicated by circular nano objects. Differences between the 2 skin sites were found for cis-urocanic acid, total urocanic acid, IL-1α, IL-1RA, IL-1RA/IL-1α, IL-18, 15-hydroxyeicosatetraenoic acid, CCL4, and circular nano objects. The levels of cis-urocanic acid and CCL4 also differed between indoor and outdoor workers. These findings underscore changes in both immune response and skin barrier induced by UVR. They indicate the potential utility of stratum corneum biomarkers in detecting both chronic UVR exposure in occupational setting and aiding in the development of preventive measures.

Diagnose und Therapie aktinischer Keratosen

Actinic keratosis (AK) is considered a chronic and recurring in situ skin neoplasia, with a possible transformation into invasive squamous cell carcinoma (SCC). Among others, predominant risk factors for development of AK are UV-light exposure and immunosuppression. Basal epidermal keratinocyte atypia (AK I) and proliferation (PRO Score) seem to drive malignant turnover, rather than clinical appearance of AK (Olsen I-III). Due to the invasiveness of punch biopsy, those histological criteria are not regularly assessed. Non-invasive imaging techniques, such as optical coherence tomography (OCT), reflectance confocal microscopy (RCM) and line-field confocal OCT (LC-OCT) are helpful to distinguish complex cases of AK, Bowen's disease and SCC. Moreover, LC-OCT can visualize the epidermis and the papillary dermis at cellular resolution, allowing real-time PRO Score assessment. The decision-making for implementation of therapy is still based on clinical risk factors, ranging from lesion- to field-targeted and ablative to non-ablative regimes, but in approximately 85% of the cases a recurrence of AK can be observed after a 1-year follow-up. The possible beneficial use of imaging techniques for a non-invasive follow-up of AK to detect recurrence or invasive progression early on should be subject to critical evaluation in further studies.

Sun protection in outdoor workers - Development and validation of standardized questionnaires for behavior and knowledge

BACKGROUND AND OBJECTIVES

Outdoor workers are at increased risk of developing non-melanoma skin cancer. We aimed to address the lack of validated German-language measurement instruments for outdoor workers' sun safety behavior and knowledge by compiling and validating two questionnaires.

PARTICIPANTS AND METHODS

By expert consensus, items for the assessment of protective behavior (OccuSun) were compiled based on existing instruments. For knowledge, a translation of the Skin Cancer and Sun Knowledge (SCSK) scale was selected. After a pre-test, a validation study including 68 outdoor workers (62% female) was conducted in 2020.

RESULTS

The retest reliability was r = 0.93 (95% confidence interval: 0.86-0.96) for the protection score and rs = 0.78 (0.67-0.86) for the knowledge score. Protective behaviors were correlated with respective diary data (0.38 ≤ rs ≤ 0.74, p < 0.001) and skin pigmentation changes (-0.23 ≥ rs ≥ -0.42, 0.007 ≤ p ≤ 0.165) but not with self-reported sunburn frequency (0.21 ≥ rs ≥ -0.04).

CONCLUSIONS

Among German outdoor workers, two questionnaires for the assessment of sun protection behavior (OccuSun) and knowledge (SCSK) demonstrated good reliability. The OccuSun had generally good validity. Both instruments are fit for subsequent validation to determine their sensitivity to change.

Smart Watches Lack Skin Smarts: Current and Future Dermatologic Applications in Device Metrics

INTRODUCTION

Smartwatches have proven life-saving in medical specialties such as cardiology. Smartwatches actively warn us of arrhythmia risk and loud noise exposure. However, dermatologic health metrics are rarely monitored, and users are never alerted of potential skin health issues. Furthermore, the role of these devices within dermatology has not been evaluated in the literature. This study aims to analyze the current data points monitored by smartwatches and discuss potential adaptations to support dermatologic patient education and improve clinical management.  Methods: The top three smartwatches per global market share were identified and analyzed to determine the health data points they monitor and the alerts they provide. These data points were grouped and compared based on their corresponding body systems.  Results: Cardiovascular health comprises the highest percentage of data points collected with an average of 41% while dermatologic health averaged only 11%.  Conclusion: Dermatology is grossly underrepresented in current smartwatch devices. There is an important need to expand the dermatologic health metrics tracked by adapting existing smartwatch technology. From proactive cancer prevention to disease-specific reactive interventions, smartwatches can play a significant role in improving dermatological health and reducing healthcare costs.

Characteristics of Hispanic patients with nonmelanoma skin cancer undergoing Mohs micrographic surgery: a review of the literature

BACKGROUND

Nonmelanoma skin cancer (NMSC) is the most common cancer worldwide and is frequently treated with Mohs micrographic surgery (MMS); however, data regarding characteristics of Hispanic patients undergoing MMS for NMSC are limited.

OBJECTIVE

To review the characteristics of Hispanic patients undergoing MMS for NMSC in the United States.

METHODS

A systematic review of PubMed articles from inception through September 2022 providing data for Hispanic patients undergoing MMS for NMSC was completed.

RESULTS

Overall, six publications met inclusion criteria and provided data for 2,856 Hispanic patients that underwent MMS for 2,955 NMSCs. Results demonstrate 60% of Hispanic patients were male, and the majority of NMSCs were basal cell carcinoma (BCC) (71%), followed by squamous cell carcinoma (SCC) (21%). Additionally, a larger percentage of pigmented BCC was found in the Hispanic population. While there is conflicting data in the literature, Hispanic patients may also have larger MMS defects when controlled for additional variables. Finally, over 64% of NMSCs in Hispanic patients were in high-risk locations.

CONCLUSION

Literature regarding the characteristics of Hispanic patients undergoing MMS for NMSC demonstrates most patients were male, BCC was the most common tumor subtype, and the majority of NMSCs were in high-risk locations.

Ultraviolet B phototherapy does not increase the risk of skin cancer among patients with atopic dermatitis: A population-based retrospective cohort study

BACKGROUND

UV-B phototherapy is a common treatment modality for patients with atopic dermatitis (AD), but its long-term safety in terms of cutaneous carcinogenic risk has not been studied.

OBJECTIVE

To investigate the risk of skin cancer among patients with AD receiving UV-B phototherapy.

METHODS

We conducted a nationwide population-based cohort study from 2001 to 2018 to estimate the risk of UV-B phototherapy for skin cancer, nonmelanoma skin cancer, and cutaneous melanoma in patients with AD.

RESULTS

Among 6205 patients with AD, the risks of skin cancer (adjusted hazard ratio [HR], 0.91; 95% CI, 0.35-2.35), nonmelanoma skin cancer (adjusted HR, 0.80; 95% CI, 0.29-2.26), and cutaneous melanoma (adjusted HR, 0.80; 95% CI, 0.08-7.64) did not increase among patients with AD treated with UV-B phototherapy, compared with those who did not receive UV-B phototherapy. Additionally, the number of UV-B phototherapy sessions was not associated with an increased risk of skin cancer (adjusted HR, 0.99; 95% CI, 0.96-1.02), nonmelanoma skin cancer (adjusted HR, 0.99; 95% CI, 0.96-1.03), or cutaneous melanoma (adjusted HR, 0.94; 95% CI, 0.77-1.15).

LIMITATIONS

Retrospective study.

CONCLUSION

Neither UV-B phototherapy nor the number of UV-B phototherapy sessions was associated with an increased risk of skin cancers among patients with AD.

Skin Cancer Prevention across the G7, Australia and New Zealand: A Review of Legislation and Guidelines

Incidence rates of melanoma and keratinocyte skin cancers have been on the rise globally in recent decades. While there has been a select focus on personal sun protection awareness, to our knowledge, there is a paucity of legislation in place to help support citizens' efforts to protect themselves from the harmful effects of ultraviolet radiation (UVR). Given this, we conducted a comprehensive review of legislation and guidelines pertaining to a variety of sun protection-related topics in countries of the Group of Seven (G7), Australia and New Zealand. Australia was the only country to have banned tanning beds for individuals of all ages, while other select countries have instituted bans for minors. In workplace policy, there is very little recognition of the danger of occupational UVR exposure in outdoor workers, and thus very few protective measures are in place. With regard to sports and recreation, certain dermatological/professional associations have put forward recommendations, but no legislation was brought forward by government bodies outside of Australia and New Zealand. With regard to youth, while there are various guidelines and frameworks in place across several countries, adherence remains difficult in the absence of concrete legislation and standardization of procedures. Finally, only Australia and a few select jurisdictions in the United States have implemented sales tax exemptions for sunscreen products. In light of our findings, we have made several recommendations, which we anticipate will help reduce the rates of melanoma and keratinocyte cancers in years to come. However, minimizing UVR exposure is not without risk, and we, therefore, suggest the promotion of vitamin D supplementation in conjunction with sun protective practices to limit potential harm.

Advances in cutaneous squamous cell carcinoma

Human malignancies arise predominantly in tissues of epithelial origin, where the stepwise transformation from healthy epithelium to premalignant dysplasia to invasive neoplasia involves sequential dysregulation of biological networks that govern essential functions of epithelial homeostasis. Cutaneous squamous cell carcinoma (cSCC) is a prototype epithelial malignancy, often with a high tumour mutational burden. A plethora of risk genes, dominated by UV-induced sun damage, drive disease progression in conjunction with stromal interactions and local immunomodulation, enabling continuous tumour growth. Recent studies have identified subpopulations of SCC cells that specifically interact with the tumour microenvironment. These advances, along with increased knowledge of the impact of germline genetics and somatic mutations on cSCC development, have led to a greater appreciation of the complexity of skin cancer pathogenesis and have enabled progress in neoadjuvant immunotherapy, which has improved pathological complete response rates. Although measures for the prevention and therapeutic management of cSCC are associated with clinical benefit, the prognosis remains poor for advanced disease. Elucidating how the genetic mechanisms that drive cSCC interact with the tumour microenvironment is a current focus in efforts to understand, prevent and treat cSCC.

Barriers and Facilitators in the Creation of a Surveillance System for Solar Radiation-Induced Skin Cancers

Outdoor workers are exposed to many hazards, including solar ultraviolet radiation (UVR). Identifying, reporting, analyzing and tracking the exposures or health outcomes of outdoor workers have not generally been formally considered. This article aims to summarize the best practices/strategies for creating an occupational sun exposure or skin cancer surveillance system for outdoor workers and to understand the key barriers and facilitators to the development of such a system. For the design of a successful occupational safety and health (OSH) surveillance system five occupational surveillance strategies are summarized: exposure registry, disease registry, disease screening/medical surveillance, sentinel event surveillance, and disease surveillance via data linkage. Ten key considerations are identified, including identifying a clear goal, a defined target population and stakeholder involvement, five critical barriers are highlighted including underreporting and funding, and five vital facilitators are recognized including communication/collaboration and a simple reporting process.

Skin Cancer-Related Health Behavior Interventions in the Context of the Health Belief Model

The incidence of skin cancer is increasing around the world every year. Although there are many reasons for the occurrence of skin cancer, UV radiation caused by sunlight is seen as the most important factor. Therefore, reducing exposure to UV radiation should be a top priority for skin cancer prevention. In addition, different demographic features also affect the amount of UV exposure. These include age, gender and professional groups. On the other hand, people can be exposed to UV radiation voluntarily. Sunbathing or using tanning devices can be shown as examples for this. For these reasons, interventions to reduce exposure to UV radiation should focus on demographic features and the desire to tan. At the same time, it is emphasized in the literature that theory-based and systematic interventions are more effective than others. In this context, we think that the Health Belief Model, which is an effective psychosocial model for health behaviors, will be useful in developing sun protection behaviors. In this review, interventions based on the Health Belief Model in the context of tanning behavior, age, gender, and outdoor activities for the prevention of skin cancer and the improvement of sun protection behaviors have been discussed.

Cutaneous Squamous Cell Carcinoma in Immunocompromised Patients—A Comparison between Different Immunomodulating Conditions

Background: Immunosuppression is strongly associated with an increased risk of developing cutaneous squamous cell carcinoma (cSCC). Studies on solid organ transplant recipients (SOTR) and chronic lymphocytic leukemia (CLL) patients have already demonstrated higher rates of aggressive cSCC tumors in these populations compared to immunocompetent controls. Studies on other immunosuppressed patient groups are scarce. This study was aimed at assessing the effects of different immunomodulating conditions on patients diagnosed with cSCC. We sought to compare the clinical features, treatments, and survival rates among the different study groups, as well as outcomes to those of immunocompetent controls with cSCC. Methods: A retrospective analysis of 465 cSCC patients, both immunosuppressed (IS) and immunocompetent controls. Etiologies for immunosuppression included SOTR, CLL, chronic kidney disease (CKD), psoriasis, rheumatoid arthritis (RA) and systemic lupus erythematous (SLE). Results: Compared to the control group, IS patients demonstrated several significant differences. These include higher rates of positive resection margins, higher recurrence rates, and multiple SCC tumors. Patients in the IS group, who were also given immunomodulating agents, demonstrated even lower survival rates. Cox regression analysis demonstrated statistically significant decreased overall survival (OS) rates for IS patients compared to the controls (OR = 1.9, p = 0.031). SOTR patients tend to have multiple cSCC tumors (35%), with the highest number of primary tumors compared to controls (2.54 tumors per patient on average, p < 0.001), but also compared to all other IS groups. The average SCC lesion size in the SOTR group was the smallest, measuring at 13.5 mm, compared to the control group and all other IS groups. Decreased survival rates were seen on Cox regression analysis compared to controls (HR = 2.4, p = 0.001), but also to all other IS groups. CLL patients also had the highest rates of positive margins compared to controls (36% vs. 9%, p < 0.01) and to all other IS groups. They were also most likely to get adjuvant or definitive oncological treatments, either radiotherapy or chemotherapy, compared to controls (36% vs. 15%, p = 0.02) and to other IS groups. Patients in the CKD group demonstrated the highest rates for multiple cSCC (OR = 4.7, p = 0.001) and the worst rates of survival on Cox regression analysis (HR = 3.2, p = 0.001). Both rheumatoid arthritis and psoriasis patients demonstrated the shortest disease-free survival rates (2.9y ± 1.1, 2.3y ± 0.7, respectively), compared to controls (4.1y ± 2.8) and to all other IS groups. Conclusions: Among cSCC patients, immunosuppression due to SOTR, CLL, CKD, RA, and psoriasis is associated with worse outcomes compared to controls and other IS groups. These patients should be regarded as high-risk for developing aggressive cSCC tumors. This study is the first to assess and compare cSCC outcomes among multiple IS patient groups.

Risk of cutaneous squamous cell carcinoma due to occupational exposure to solar ultraviolet radiation: Protocol for a systematic review and meta-analysis

Solar ultraviolet radiation (UVR) is the most significant occupational carcinogenic exposure in terms of the number of workers exposed (i.e., outdoor workers). Consequently, solar UVR-induced skin cancers are among the most common forms of occupational malignancies that are potentially expected globally. This systematic review is registered in PROSPERO (CRD42021295221) and aims to assess the risk of cutaneous squamous cell carcinoma (cSCC) associated to occupational solar UVR exposure. Systematic searches will be performed in three electronic literature databases (PubMed/Medline, EMBASE, and Scopus). Further references will be retrieved by a manual search (e.g., in grey literature databases, internet search engines, and organizational websites). We will include cohort studies and case-control studies. Risk of Bias assessment will be conducted separately for case-control and cohort studies. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) will be used for the certainty of assessment. In case quantitative pooling is not feasible, a narrative synthesis of results will be performed.

Solar Ultraviolet Radiation, Skin Cancer and Photoprotective Strategies in South Africa†

The most recent data relating to the incidence of, and mortality from, the three commonest forms of skin cancer, namely basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and cutaneous melanoma (CM), in the Black African, Colored, Asian/Indian and White population groups in South Africa are reviewed. While exposure to solar ultraviolet radiation is the major environmental risk factor for BCC in all four groups, for SSC in the White and Asian/Indian groups and for CM in the White group, this is unlikely to be the case for most SCCs in the Black African group and for most CMs in the Black African and Asian/Indian groups. Strategies for practical personal photoprotection in South Africa are discussed with particular emphasis on people at heightened risk of skin cancer including the White population group, those with HIV or oculocutaneous albinism and outdoor workers.

Occupational skin cancer: measurements of ultraviolet radiation exposure bring knowledge for prevention

Outdoor workers are at higher risk for keratinocyte cancer. Data-base of UV-exposure generated in the Genesis-UV study will facilitate specific prevention measures and workers’ health surveillance in outdoor occupations.

Sun protection and occupation: Current developments and perspectives for prevention of occupational skin cancer

A substantial proportion of all reported occupational illnesses are constituted by skin cancer, making this disease a serious public health issue. Solar ultra-violet radiation (UVR) exposure is the most significant external factor in the development of skin cancer, for which the broad occupational category of outdoor workers has already been identified as high-risk group. Sun protection by deploying adequate technical, organizational, and person-related measures has to be understood as a functional aspect of workplace safety. To prevent skin cancers brought on by-typically cumulative-solar UVR exposure, outdoor workers must considerably lower their occupationally acquired solar UVR doses. Estimating cumulative sun exposure in outdoor workers requires consideration of the level of solar UVR exposure, the tasks to be done in the sun, and the employees' solar UVR preventive measures. Recent studies have highlighted the necessity for measures to enhance outdoor workers' sun protection behavior. In the coming decades, occupational dermatology is expected to pay increasing attention to sun protection at work. Also, the field of dermato-oncology will likely be concerned with sky-rocketing incidences of occupational skin cancers. The complete range of available alternatives should be utilized in terms of preventive actions, which seems pivotal to handle the present and future challenges in a purposeful manner. This will almost definitely only be possible if politicians' support is effectively combined with communal and individual preventive actions in order to spur long-term transformation.

[Assessment of an e‑learning platform for dermatosurgery]

BACKGROUND

Dermatosurgical (DS) teaching is based on a combination of reading/understanding textbooks and applying surgical procedures (± supervision). Most textbooks are primarily text-centered. The text is visually supported by photos/sketches (S) and possibly videos (V). A learning goal of this teaching should be that the learner is confident to perform a procedure independently.

METHODS

We have developed an online-based platform, the FlapFinder (FF; www.skin-surgery.org ), which teaches the user DS in the facial region primarily in the form of S + V. These are supported by a short text (T) and bonus material (B). B contains personal recommendations from the FF authors. A SurveyMonkey® (Survey Monkey, San Mateo, CA, USA) analysis should clarify how this is assessed by the user.

RESULTS

In all, 62 participants completed the questionnaire in full. This was a heterogeneous group (27 dermatologists vs. 35 non-dermatologists; 32 × clinic vs. 30 × non-clinic) with different prior experience. The majority of users found that the combination of T + S + V helped them to understand (55/62; 88.7%), remember (53/62, 85.5%), and perform the procedures independently (43/62; 69.3%). While S + V were most frequently used (22/62; 35.5% and 27/62; 43.6%), users reported having benefited most from this (20/62; 32.3% and 24/62; 38.7%), T + B were used less (0/62, 0.0% and 2/62; 3.2%). Nevertheless, the majority would not want to do without either S, V, T, or B (49/62; 79%).

CONCLUSION

The combination of S + V + T + B is rated positively by DS learners. S + V are rated as particularly helpful. Future studies must clarify whether the learning objective of the concrete practical performance of DS is changed by e‑media.

Hydrochlorothiazide use, sun exposure, and risk of keratinocyte cancer

Background

Keratinocyte cancer (KC) rates are increasing in the U.S., particularly in older age groups. Use of hydrochlorothiazide (HCTZ), due to its photosensitizing properties, and high sun exposure are two known NMSC risk factors, but their synergistic effects are undetermined. The purpose of this study was to examine the development of NMSC between adults who did and did not use HCTZ, as well as those with high and low sun exposure.

Methods

A retrospective case–control sample was assembled from adult patients in north-central Wisconsin (USA). Duration of HCTZ use and occupational sun exposure were extracted from electronic health records, along with a linked survey of lifetime sun exposure.

Results

There were 333 cases and 666 controls in the analytical sample. A significant main effect was observed for HCTZ duration in the full sample. Under low sun exposure, the odds of NMSC was 14% greater for each additional year of HCTZ use (aOR = 1.14 [1.11, 1.18], p < 0.001). In a sensitivity analysis of participants age 70 years and over, there was a borderline significant (p = 0.086) HCTZ use by high sun exposure interaction, suggesting modestly increased HCTZ risk in older, high sun exposure adults.

Conclusions

Consistent with prior studies, longer duration of HCTZ use was a predictor of NMSC in north-central Wisconsin adults. NMSC may be accelerated in HCTZ users with outdoor lifestyles, but future studies should attempt to further disaggregate specific effects of sun exposure time, HCTZ duration, and age on NMSC development.

Sun Protection Behavior in Danish Outdoor Workers Following a Multicomponent Intervention

Background

Outdoor workers can be exposed to relatively high levels of ultraviolet radiation and are at risk of developing occupational skin cancer. Implementing the use of sun protection in outdoor workers at work is therefore important. The objective of this follow-up study was to evaluate the effect of a multicomponent intervention to improve the use of sun protection in Danish outdoor workers.

Method

A total of 237 Danish outdoor workers were asked to complete surveys in 2016/17 and in 2020. Multicomponent interventions, between surveys, included information on skin cancer risk and use of sun protection, personal dosimetry and skin examination for signs of photodamage and skin cancer. Survey items on awareness of occupational skin cancer risk and perceived importance of sun protection as well as availability and use of sun protection at work were compared and analyzed in relation to the multicomponent intervention.

Results

Overall, the use of sun protection at work increased significantly (composite score [95% CI] 4.0 [3.7, 4.3] in 2016/17 and 4.6 [4.3, 4.9] in 2020, p < 0.001). Sunscreen was by far the biggest contributor, and the only type of sun protection used at work, which changed significantly (often/always use 37% in 2016/17 and 52% in 2020, p < 0.001). The biggest influence on the increased use of sun protection at work seemed to be a significant increase in the awareness of occupational skin cancer risk (moderate/high 43% in 2016/17 and 63% in 2020, p < 0.001) and perceived importance of sun protection at work (moderate/high 69% in 2016/17 and 83% in 2020, p < 0.001).

Conclusion

The results of this study indicate that awareness of occupational skin cancer risk as well as the perceived importance and use of sun protection at work in Danish outdoor workers may be improved by means of multicomponent intervention.

Covering of large scalp defects prior to postoperative irradiation

BACKGROUND AND OBJECTIVE

After R0 resection of extensive cutaneous squamous cell carcinoma of the scalp with indication for postoperative radiotherapy, closure techniques should be chosen that allow rapid initiation of radiotherapy. The aim of this retrospective analysis is to evaluate defect coverage by transverse transposition flap and split skin grafting of the donor site in such a scenario with regard to oncologic safety (recurrence rate) and permanence of wound closure.

PATIENTS AND METHODS

Eleven patients were identified who had histologic cutaneous squamous cell carcinoma treated by microscopically controlled excision and defect coverage using a transverse transposition flap and split skin grafting of the donor site and who received postoperative radiotherapy. Patients were evaluated for recurrence, wound healing disorders and side effects of radiotherapy.

RESULTS

The mean age was 81 years. Follow-up time averaged 1.4 years after the last radiotherapy session. Wound healing disorders of the transposition flap or graft necrosis were not detected. All therapy-associated side effects had resolved at follow-up. Local recurrence or metastasis did not occur.

CONCLUSIONS

Combined transverse transposition flap plasty with split-skin grafting of the donor site is a safe treatment concept with few side effects for large scalp defects with exposed calvaria requiring postoperative radiotherapy.

Nonparametric bounds in two-sample summary-data Mendelian randomization: Some cautionary tales for practice

Recently, in genetic epidemiology, Mendelian randomization (MR) has become a popular approach to estimate causal exposure effects by using single nucleotide polymorphisms from genome-wide association studies (GWAS) as instruments. The most popular type of MR study, a two-sample summary-data MR study, relies on having summary statistics from two independent GWAS and using parametric methods for estimation. However, little is understood about using a nonparametric bound-based analysis, a popular approach in traditional instrumental variables frameworks, to study causal effects in two-sample MR. In this article, we explore using a nonparametric, bound-based analysis in two-sample MR studies, focusing primarily on implications for practice. We also propose a framework to assess how likely one can obtain more informative bounds if we used a different MR design, notably a one-sample MR design. We conclude by demonstrating our findings through two real data analyses concerning the causal effect of smoking on lung cancer and the causal effect of high cholesterol on heart attacks. Overall, our results suggest that while a bound-based analysis may be appealing due to its nonparametric nature, it is far more conservative in two-sample settings than in one-sample settings to get informative bounds on the causal exposure effect.

Sunburns and Sun Protection Behaviors among Male Hispanic Outdoor Day Laborers

Individuals who work outside are at increased risk for skin cancer due to excessive exposure to ultraviolet (UV) radiation. Little is known about UV exposures and sun safety practices of outdoor day laborers, who are disproportionately Hispanic. This study identified the correlates of sunburn and sun protection behaviors in a sample of male, Hispanic day laborers (n = 175). More than half of the participants (54.9%) experienced one or more sunburns when working during the past summer, and 62.9% reported having one or more symptoms of heat illness. The frequency of engaging in sun protection behaviors was suboptimal, including sunglasses use (M = 2.68, SD = 1.71), staying in the shade (M = 2.30, SD = 0.94), wearing sunscreen (M = 2.10, SD = 1.39), and wearing a wide-brimmed hat (M = 1.75, SD = 1.32), based on a 5-point scale (1 = never; 5 = always). Lower education level, higher levels of skin sensitivity to the sun, any symptom of heat illness, fewer barriers to wearing a wide-brimmed hat, and not wearing a wide-brimmed hat were associated with a greater number of sunburns. Factors associated with each sun protection behavior varied. Implications and directions for future research are discussed.

Exposição ocupacional e câncer: uma revisão guarda-chuva

Resumo Objetivo: fornecer uma visão geral das associações entre exposição ocupacional e risco da ocorrência ou morte por câncer. Métodos: esta revisão guarda-chuva da literatura utilizou as bases Medline e Web of Science. A partir de protocolo de busca, foram incluídas metanálises para diversas circunstâncias ocupacionais e cânceres selecionados que possuíssem algum nível de evidência para associação com ocupação. Resultados: foram incluídas 37 metanálises, abrangendo 18 localizações de câncer. Considerando a avaliação da heterogeneidade dos estudos, da qualidade da evidência e da força de associação, obteve-se evidências altamente sugestivas de associações entre exposição a solvente e mieloma múltiplo; amianto e câncer de pulmão; hidrocarbonetos e câncer de trato aerodigestivo superior; e estresse ocupacional e câncer colorretal. Conclusão: há evidências robustas para associar exposições ocupacionais e tipos de câncer não previstos, inicialmente, nas orientações de vigilância do câncer relacionado ao trabalho no Brasil. Permanecem lacunas sobre exposições de grande relevância, que carecem de metanálises mais consistentes, por exemplo, exposição a poeiras inorgânicas e câncer de pulmão e mesotelioma; exposição a solventes e tumores hematológicos. Evidências de câncer em outras regiões anatômicas foram menos robustas, apresentando indícios de incerteza ou viés.

Occupational exposure and cancer: an umbrella review

Abstract Objective: to provide an overview of the associations between occupational exposure and risk of occurrence or death from cancer. Methods: this umbrella review used the Medline and Web of Science databases. Based on the search protocol, meta-analysis was included for several occupational circumstances and selected cancers that had some level of evidence associated with the occupation. Results: 37 meta-analysis were included, covering 18 cancer locations. By assessing the heterogeneity of studies, quality of evidence, and strength of association, results highly indicated associations between solvent exposure and multiple myeloma, asbestos and lung cancer, hydrocarbons and upper aerodigestive tract cancer, occupational stress and colorectal cancer. Conclusion: robust evidence shows an association between occupational exposures and types of cancer not initially foreseen in the guidelines for work-related cancer surveillance in Brazil. Gaps in relevant exposures require further research and more consistent meta-analysis, including: exposure to inorganic dust and lung cancer and mesothelioma; solvents and hematological tumors. Evidence of cancer in other anatomical regions was less robust, showing signs of uncertainty or bias.

Tendências na Mortalidade por Câncer de Pele não Melanoma no Brasil e suas Macrorregiões

Introdução: O câncer de pele não melanoma (CPNM) e o mais comum entre todas as malignidades. Objetivo: Descrever as tendências da mortalidade por CPNM no Brasil e nas suas Macrorregiões, de 2001 a 2018. Método: As taxas de mortalidade ajustadas por idade e estratificadas por sexo foram apresentadas por 100 mil pessoas-ano. Uma análise autorregressiva foi implementada para avaliar tendências, Mudança Percentual Anual (MPA) e intervalos de confiança de 95% (IC 95%). Resultados: Houve 27.550 óbitos por CPNM no Brasil com maior frequência em homens (58,1%) e entre pessoas de 70 anos e mais (64,3%). As taxas globais foram de 2,25 (homens) e 1,22 (mulheres) por 100 mil pessoas-ano. As tendências seguiram em elevação no Brasil, em homens (MPA: 2,91%; IC95%: 1,96%; 3,86%) e em mulheres (MPA: 3,51%; IC95%: 2,68%; 4,34%). O mesmo ocorreu na Região Norte, em homens (MPA: 9,75%; IC95%: 7,68%; 11,86%) e em mulheres (MPA: 10,38%; IC95%: 5,77%; 15,21%), bem como na Região Nordeste, em homens (MPA: 9,98%; IC95%: 5,59%; 14,57%) e em mulheres (MPA: 8,34%; IC95%: 3,29%; 13,64%). Conclusão: Os óbitos por CPNM não são raridade no Brasil. O país e as Regiões Norte e Nordeste experimentaram taxas com tendência em elevação. Norte e Nordeste são as Regiões mais próximas da Linha do Equador e as menos desenvolvidas socioeconomicamente. Nessas Macrorregiões, um sinergismo entre diferentes tipos de desigualdades e exposições ambientais pode estar promovendo um aumento dos óbitos por esse tipo de câncer considerado totalmente evitável.

Protocol for a Systematic Review on the Effectiveness of Interventions to Reduce Exposure to Occupational Solar UltraViolet Radiation (UVR) Among Outdoor Workers

Background: Solar UltraViolet Radiation (UVR) is considered the most relevant occupational carcinogenic exposure in terms of the number of workers exposed (i.e., outdoor workers) and UVR-induced skin cancers are among the most frequent types of occupational cancers worldwide. This review aims to collect and evaluate all the available preventive interventions conducted on outdoor workers to reduce their solar UVR related risk, with the final purpose of reducing the burden of occupational skin cancers for outdoor workers.

Methods: We will search the following databases for peer-reviewed original research published: MEDLINE (through PubMed), Scopus, and EMBASE. We will include only interventional studies, both randomized and non-randomized, with an adequate comparison group, therefore excluding cross-sectional studies, as well as case-reports/series, reviews, and letters/comments. The systematic review will adhere to the “Preferred Reporting Items for Systematic reviews and Meta-Analyses” (PRISMA) guidelines for reporting systematic reviews. After the literature search, studies to be included will be independently reviewed by two Authors, first based on title and abstract, then based on the full text, according to the inclusion criteria. Conflicts will be solved by a third Author. Two authors will independently extract the required data from included studies and perform quality assessment according to the relevant domain for Risk of Bias assessment proposed by the Cochrane collaboration group. In case of sufficient homogeneity of interventions and outcomes evaluated, results from subgroups of studies will be pooled together in a meta-analysis.

Discussion: Following the principles for the evaluation of interventions for cancer prevention established by the International Agency for Research on Cancer, this systematic review will investigate the effectiveness of the interventions, and consequently it will provide reliable indications for the actual reduction of skin cancer incidence in outdoor workers.

Real-world Treatment Patterns and Outcomes with Systemic Therapies in Unresectable Locally Advanced and Metastatic Cutaneous Squamous Cell Carcinoma in Germany

Advanced cutaneous squamous cell carcinoma is a challenge to treat. Conventional systemic treatment options include chemotherapy and epidermal growth factor receptor-inhibitors. The aim of this study was to assess clinical outcomes with systemic treatments in advanced cutaneous squamous cell carcinoma. Patients receiving systemic treatment at the Tübingen Dermato-Oncology centre between 2007 and 2017 were identified (n = 59). Median age was 76 years (interquartile range (IQR) 71-80 years), 83.1% of patients were male, 72.9% had metastatic cutaneous squamous cell carcinoma, and 27.1% had unresectable locally advanced cutaneous squamous cell carcinoma. During median follow-up of 52 weeks (IQR 27-97 weeks), overall response rate was 14.3%, and disease control rate was 53.6%. Median progression-free survival was 15 weeks (IQR 8-42 weeks), and median overall survival was 52 weeks (IQR 27-97 weeks). Patients receiving chemoradiation vs chemo-therapy alone showed better overall survival (hazard ratio 0.41, p = 0.014,) and progression-free survival (hazard ratio 0.42, p = 0.009); no differences were observed for metastatic cutaneous squamous cell carcinoma vs locally advanced cutaneous squamous cell carcinoma patients. Although chemotherapy and/or cetuximab showed limited outcomes in advanced cutaneous squamous cell carcinoma, such therapy may still be an option when anti-PD-1 treatment is contraindicated.

Advanced nanomedicine approaches applied for treatment of skin carcinoma

Skin-cancer is the commonest malignancy affecting huge proportion of the population, reaching heights in terms of morbidity. The treatment strategies are presently focusing on surgery, radiation and chemotherapy, which eventually cause destruction to unaffected cells. To overcome this limitation, wide range of nanoscaled materials have been recognized as potential carriers for delivering selective response to cancerous cells and neoplasms. Nanotechnological approach has been tremendously exploited in several areas, owing to their functional nanometric dimensions. The alarming incidence of skin cancer engenders burdensome effects worldwide, which is further awakening innovational medicinal approaches, accompanying target specific drug delivery tools for coveted benefits to provide reduced toxicity and tackle proliferative episodes of skin cancer. The developed nanosystems for anti-cancer agents include liposomes, ethosomes, nanofibers, solid lipid nanoparticles and metallic nanoparticles, which exhibit pronounced outcomes for skin carcinoma. In this review, skin cancer with its sub-types is explained in nutshell, followed by compendium of specific nanotechnological tools presented, in addition to therapeutic applications of drug-loaded nano systems for skin cancer.

Assessing the compliance of systematic review articles published in leading dermatology journals with the PRISMA statement guidelines: A systematic review

Background

Reporting quality of systematic reviews and meta-analyses is of critical importance in dermatology because of their key role in informing health care decisions.

Objective

To assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines.

Methods

This review was carried out in accordance with PRISMA guidelines. Included studies were reviews published across 6 years in the top 4 highest-impact-factor dermatology journals of 2017. Records and full texts were screened independently. Data analysis was conducted with univariate multivariable linear regression. The primary outcome was to assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the PRISMA statement.

Results

A total of 166 studies were included and mean PRISMA compliance across all articles was 73%. Compliance significantly improved over time (β = .016; P = <.001). The worst reported checklist item was item 5 (reporting on protocol existence), with a compliance of 15% of articles.

Conclusion

PRISMA compliance within leading dermatology journals could be improved; however, it is steadily improving.

Hydrochlorothiazide Use and Risk of Nonmelanoma Skin Cancers: A Biological Plausibility Study

Recent studies reported the association between increased risk of nonmelanoma skin cancers (NMSCs) and the use of hydrochlorothiazide (HCTZ), one of the most commonly prescribed diuretic, antihypertensive drug, over the world. Although HCTZ is known to be photosensitizing, the mechanisms involved in its potential prophotocarcinogenic effects remain unclear. Under acute exposure, therapeutically relevant concentrations of HCTZ (70, 140, and 370 ng/mL) amplified UVA-induced double-strand breaks, oxidative DNA, and protein damage in HaCaT human keratinocytes, and this effect was associated to a defective activity of the DNA repair enzyme, OGG1. Oxidative damage to DNA, but not that to proteins, was reversible within few hours. After chronic, combined exposure to HCTZ (70 ng/mL) and UVA (10 J/cm2), for 9 weeks, keratinocytes acquired a dysplastic-like phenotype characterized by a multilayered morphology and alterations in cell size, shape, and contacts. At the ultrastructural level, several atypical and enlarged nuclei and evident nucleoli were also observed. These transformed keratinocytes were apoptosis resistant, exhibited enhanced clonogenicity capacity, increased DNA damage and inflammation, defective DNA repair ability, and increased expression of the oncogene ΔNp63α and intranuclear β-catenin accumulation (a hallmark of Wnt pathway activation), compared to those treated with UVA alone. None of these molecular, morphological, or functional effects were observed in cells treated with HCTZ alone. All these features resemble in part those of preneoplastic lesions and NMSCs and provide evidence of a biological plausibility for the association among exposure to UVA, use of HCTZ, and increased risk of NMSCs. These results are of translational relevance since we used environmentally relevant UVA doses and tested HCTZ at concentrations that reflect the plasma levels of doses used in clinical practice. This study also highlights that drug safety data should be followed by experimental evaluations to clarify the mechanistic aspects of adverse events.

Stratum corneum biomarkers after in vivo repeated exposure to sub-erythemal dosages of ultraviolet radiation in unprotected and sunscreen (SPF 50+) protected skin

BACKGROUND

There is a need for non-invasive biomarkers to assess in vivo efficacy of protective measures aiming at reducing ultraviolet radiation (UVR) exposure. Stratum corneum (SC) biomarkers showed to be promising markers for internal UVR dose and immune response.

PURPOSE

To establish a dose-response relationship for SC biomarkers and explore their suitability for in vivo assessment of the blocking effect of two sunscreens with a high sun protection factor (SPF) (50+).

METHODS

Twelve volunteers were exposed to a broad-spectrum UVB (280-320 nm), five times a week, during one week. Unprotected back skin was irradiated with 0.24, 0.48, 0.72 and 1.44 standard erythema dose (SED) and sunscreen-protected skin with 3.6 SED. SC samples for determination of the relative amount of cis-urocanic acid (cUCA) and thirteen immunological makers including cytokines and matrix metalloproteinases (MMP) were collected after each irradiation.

RESULTS

cUCA sharply increased after the first irradiation in a dose-dependent fashion. However, it levelled-off after subsequent exposures and reached a plateau for the highest UV-dose after the third irradiation. None of the immunological markers showed dose-dependency. However, MMP-9, IL-1β and CCL27 increased gradually from baseline during repetitive exposures to the highest UV-dose. Assessed from cUCA, both sunscreens blocked >98% of the applied UV-dose.

CONCLUSIONS

cUCA is a sensitive, non-invasive marker of the internal UVR dose enabling in vivo assessment of the blocking effect of high SPF sunscreens in the UVB-region. Immunological SC markers show low sensitivity in detecting immune response at sub-erythemal UVR dosages, suggesting they might be suitable only at higher and/or repetitive UVR exposure.

New methods for assessing secondary performance attributes of sunscreens suitable for professional outdoor work

BACKGROUND

Outdoor workers (OW) are highly exposed to solar ultraviolet radiation (UVR) and thus at increased risk for developing skin cancer. An essential part of an overall strategy to reduce workplace UVR-exposure to OW's skin is the usage of sunscreens. However, compliance with regular sunscreen usage seems to be low, as products are usually designed for recreational sun exposure and thus do not meet the requirements of physically active OW. To date, no standardized test procedures assess the suitability of sunscreens for professional use. The aim of this pilot study was to develop standardized methods of testing secondary performance attributes (PA) to represent real-life working conditions of outdoor work.

METHODS

Ten sunscreen products, carefully selected after a detailed market survey of all relevant producers available on the German market, were evaluated regarding their suitability for professional outdoor work on 24 healthy volunteers in a newly designed test procedure. In addition to three standardized efficacy characteristics, i.e., sun protection factor, water-resistance, and UVA protection, we evaluated each PA involving parameters typically associated with outdoor workplaces.

RESULTS

We developed standardized methods for objectifying the suitability of sunscreen products for professional outdoor work. The test procedures used are well feasible and appropriate for testing the PA because they represent practical working conditions in detail - although the degree of discriminability of single test methods varied. The claimed sun protection factor (SPF) of the products was confirmed; bio-stability of the SPF after physical activity was achieved in most cases. While most products hardly irritate the eyes and are quickly absorbed, the evaluation of the subjective skin feeling and non-slip grip is inconsistent.

CONCLUSIONS

In this pilot study, for the first time secondary PA are defined and examined. Although further objectification of the PA assessment as well as the establishment of minimum standards should be sought, the new methods could already complement the so far mandatory labels and in this way provide a significant impetus for the current scientific and political focus on the improvement of occupational health in highly UVR-exposed OW.

Health Risks Associated With Excessive Exposure to Solar Ultraviolet Radiation Among Outdoor Workers in South Africa: An Overview

Exposure of outdoor workers to high levels of solar ultraviolet radiation (UVR) poses significant, well-known health risks including skin cancer and eye diseases. In South Africa, little is known about how many workers are potentially overexposed to solar UVR and what the associated impacts on their health might be. In this overview, the geography and solar UVR environment in South Africa are considered, as well as the different outdoor occupational groups likely to be affected by excessive solar UVR exposure. Sunburn, pterygium, cataract, keratinocyte cancers, and melanoma are discussed in the context of outdoor workers. Few studies in South Africa have considered these health issues and the most effective ways to reduce solar UVR exposure for those working outside. Several countries have developed policies and guidelines to support sun safety in the workplace which include training and education, in addition to the provision of personal protective equipment and managerial support. Several gaps in occupational sun protection and workplace sun safety for South Africa are identified. Legislation needs to recognize solar UVR exposure as an occupational health hazard, with sun safety guidelines and training provided for employers and employees.

Occupation and cutaneous melanoma: a 45-year historical cohort study of 14·9 million people in five Nordic countries

BACKGROUND

The age-adjusted incidence of cutaneous melanoma (CM) in the Nordic countries has increased during the last 60 years. Few prospective population-based studies have estimated the occupational variation in CM risk over time.

OBJECTIVES

To determine occupational variation in CM risk.

METHODS

A historical prospective cohort study with a 45-year follow-up from 1961 to 2005 (Nordic Occupational Cancer Study, NOCCA) based on record linkages between census and cancer registry data for Nordic residents aged 30-64 years in Denmark, Finland, Iceland, Norway and Sweden. National occupational codes were converted to 53 occupational categories, and stratified into indoor, outdoor and mixed work, and into socioeconomic status. The standardized incidence ratios (SIRs) were estimated as observed number of CM cases divided by the expected number calculated from stratum-specific person-years and national CM incidence rates.

RESULTS

During a follow-up of 385 million person-years, 83 898 incident cases of CM were identified. In all countries combined, men with outdoor work had a low SIR of 0·79 [95% confidence interval (CI) 0·77-0·81] and men with indoor work had a high SIR of 1·09 (95% CI 1·07-1·11). Differences in women pointed in the same direction. High socioeconomic status was associated with an excess risk: SIR 1·34 (95% CI 1·28-1·40) in men and SIR 1·31 (95% CI 1·26-1·36) in women. Technical, transport, military and public safety workers with potential skin exposure to carcinogens had excess risks.

CONCLUSIONS

Occupational variation in CM risk may be partly explained by host, socioeconomic and skin exposure factors. Differences in CM risk across socioeconomic groups attenuated slightly over time.

Protection Against Solar Ultraviolet Radiation in Outdoor Construction Workers: Study Protocol for a Non-randomized Controlled Intervention Study

Introduction: Non-melanoma skin cancer (NMSC) incidence is increasing, and occupational solar exposure contributes greatly to the overall lifetime ultraviolet radiation (UVR) dose. This is reflected in an excess risk of NMSC showing up to three-fold increase in outdoor workers. Risk of NMSC can be reduced if appropriate measures to reduce UVR-exposure are taken. Regular use of sunscreens showed reduced risk of NMSC. However, sun-safety behavior in outdoor workers is poor. The objective of this study is to investigate the effectiveness of an intervention aiming at increasing sunscreen use by construction workers.

Methods: This non-randomized controlled intervention study is comprised of two intervention and two control groups recruited at four different construction sites in the Netherlands. The study population comprises ~200 construction workers, aged 18 years or older, followed during 12 weeks. The intervention consists of providing dispensers with sunscreens (SPF 50+) at construction sites and regular feedback on the application achieved by continuous electronic monitoring. All groups will receive basic information on UV-exposure and skin protection. Stratum corneum (SC) samples will be collected for measurement of biomarkers to assess internal UV-dose. External UV-dose will be assessed by personal UV-sensors worn by the workers during work-shifts in both groups. To detect presence of actinic keratosis (AK) or NMSC, a skin check of body parts exposed to the sun will be performed at the end of the study. The effect of the intervention will be assessed from data on self-reported sunscreen use by means of questionnaires collected on baseline and after 12 weeks of intervention (primary outcome). Levels of SC biomarkers of internal UV-dose, external UV-dose, number of sunburn episodes, and prevalence of NMSC including AK will be assessed as secondary outcomes. The electronically monitored sunscreen consumption will be assessed as process outcome.

Discussion: This study is intended to provide evidence of the effectiveness of a technology-driven intervention to increase sunscreen use in outdoor construction workers. Furthermore, it will increase insight in the UV-protective behavior, external and internal UV-exposure, and the prevalence of NMSC, including AK, in construction workers.

Trial Registration: The Netherlands Trial Register (NTR): NL8462 Registered on March 19, 2020.

Cutaneous Squamous Cell Carcinoma: From Pathophysiology to Novel Therapeutic Approaches

Cutaneous squamous cell carcinoma (cSCC), a non-melanoma skin cancer, is a keratinocyte carcinoma representing one of the most common cancers with an increasing incidence. cSCC could be in situ (e.g., Bowen’s disease) or an invasive form. A significant cSCC risk factor is advanced age, together with cumulative sun exposure, fair skin, prolonged immunosuppression, and previous skin cancer diagnoses. Although most cSCCs can be treated by surgery, a fraction of them recur and metastasize, leading to death. cSCC could arise de novo or be the result of a progression of the actinic keratosis, an in situ carcinoma. The multistage process of cSCC development and progression is characterized by mutations in the genes involved in epidermal homeostasis and by several alterations, such as epigenetic modifications, viral infections, or microenvironmental changes. Thus, cSCC development is a gradual process with several histological- and pathological-defined stages. Dermoscopy and reflectance confocal microscopy enhanced the diagnostic accuracy of cSCC. Surgical excision is the first-line treatment for invasive cSCC. Moreover, radiotherapy may be considered as a primary treatment in patients not candidates for surgery. Extensive studies of cSCC pathogenic mechanisms identified several pharmaceutical targets and allowed the development of new systemic therapies, including immunotherapy with immune checkpoint inhibitors, such as Cemiplimab, and epidermal growth factor receptor inhibitors for metastatic and locally advanced cSCC. Furthermore, the implementation of prevention measures has been useful in patient management.

Comparison between EPA UV index app and UV monitor to assess risk for solar ultraviolet radiation exposure in agricultural settings in Eastern North Carolina

Agricultural workers are exposed to solar ultraviolet (UV) radiation due to the significant amount of time spent working outdoors. Risk information on UV exposure from the EPA SunWise UV Index mobile app is conveniently available for timely advice on risk management, but its reliability is unknown. The purpose of this study was to determine the reliability of the EPA UV Index app in providing accurate risk information to reduce UV exposure and prevent related illnesses among agricultural workers in eastern North Carolina. UV radiation effective irradiance (UV _eff ) indices were datalogged at two agricultural sites using radiometers from April-August 2019 and were assigned to risk levels (low, moderate, high, very high, extreme) based on the ACGIH^® Threshold Limit Values (TLVs^®). The UV index (UV _app ) and its corresponding risk level were obtained using the app. Hourly UV _app -based risk level assignments were time-matched to their corresponding UV _eff /TLV-based risk level assignments (871 pairs) and analyzed using cross tabulation by determining the percentage of hourly UV _eff /TLV-based risk levels ("gold standard") with the same hourly UV _app -based risk levels, with a larger percentage indicating higher app reliability. Results showed that the app correctly identified 100% of low risk conditions, but its reliability decreased as the UV risk condition became more severe. The app correctly identified 0% of moderate, high and very high risk conditions but instead assigned 100% of them to lower risk levels (30-100% as low risk, 5-70% as moderate risk), indicating that the app was less protective in assessing UV risk. The app correctly identified 0.6% of extreme risk conditions but assigned 99.4% of them to lower risk levels (9.4% as low, 29.7% as moderate, 24.6% as high, 35.8% as very high). It is concluded that the performance of the EPA UV Index app in assessing occupational UV risk is not protective of workers particularly for high risk conditions, and that the use of the app for the assessment of risk to UV exposure in agricultural settings is not recommended.

Improved protection of outdoor workers from solar ultraviolet radiation: position statement

The vast majority of non-melanoma skin cancer (NMSC) is attributable to excessive exposure to ultraviolet radiation (UVR). Outdoor workers are exposed to an UVR dose at least 2 to 3 times higher than indoor workers and often to daily UVR doses 5 times above internationally recommended limits. The risk of UVR workplace exposure is vastly neglected, and the evident future challenges presented in this statement are contrasted with the current situation regarding legal recognition, patient care and compensation. While prevention is crucial to reduce cancer risks for outdoor workers, it is as much of relevance to better protect them through legally binding rules and regulations. Specific actions are outlined in five recommendations based on a Call to Action (table 1). The role of health professionals, including dermatologists, in this context is crucial.

Role of occupational and recreational sun exposure as a risk factor for keratinocytic non-melanoma skin cancers: an Italian multicenter case-control study

BACKGROUND

Sun exposure is the main external risk factor for keratinocytic non-melanoma skin cancer (NMSC). Outdoor workers are at increased risk, but the relationship of NMSC with occupational solar exposure is often confounded by concurrent recreational sun exposure. We compared the percentage of outdoor workers in NMSC patients versus controls without history of NMSC and assessed occupational and recreational sun exposure in both groups, evaluating also other risk factors and use of protective measures.

METHODS

Adult NMSC patients and controls without history of NMSC or actinic keratoses, matched for sex and age range, were recruited in the Departments of Dermatology of seven Italian University Hospitals, with a 1:2 patient/control ratio whenever possible. Data were collected using specifically designed questionnaires.

RESULTS

Eight hundred thirty-four patients and 1563 controls were enrolled. History of outdoor work was significantly (P=0.033) more frequent in patients. Patients were more sun exposed from outdoor leisure activities (P=0.012) and sunbathed for longer periods (P=0.13) and between 12 pm and 3.30 pm (P=0.011). Cumulative sun exposure during hobbies was similar between patients and controls in outdoor workers, higher (P<0.05) in patients among indoor workers. Patients and controls with history of outdoor work were more sun exposed at work than during leisure activities (P<0.001). Use of sunscreens by outdoor workers was very low, particularly at work (19.9%). Patients used sunscreens more than controls (P=0.002).

CONCLUSIONS

Occupational and recreational sun exposure are relevant risk factors for outdoor and indoor workers respectively. Sunscreens are alarmingly underused, particularly at work, and are used mainly by patients.

Epidemiology of nonmelanoma skin cancer in Japan: Occupational type, lifestyle, and family history of cancer

Skin cancer is the most frequently diagnosed cancer in the fair-skinned population. In recent years, the incidence of nonmelanoma skin cancer (NMSC) has been increasing worldwide. However, there is no epidemiological study on skin cancer in the Asian population. A prospective cohort study including 140 420 participants was initiated in 1990 for cohort Ⅰ and 1993 for cohort Ⅱ at baseline survey from 11 public health center (PHC) areas. Of these participants, 284 NMSC cases were diagnosed during the follow-up period (through 2012 in the Osaka PHC area and 2013 in the other PHC areas). The Cox proportional hazards model was used to estimate hazard ratios and 95% confidence intervals (CI) for NMSC incidence according to occupational type, lifestyle factors (alcohol consumption, coffee consumption, smoking status, physical activity, and body mass index), and family history of cancer. Among men, compared with indoor workers, outdoor workers were associated with 2.18 (95% CI, 1.17-4.04) higher risk of squamous cell carcinoma (SCC) but not of basal cell carcinoma (BCC). Furthermore, men who have a family history of cancer had 1.99 (95% CI, 1.10-3.62) higher SCC risk. In women, we did not observe any association between occupational type and the risk of SCC (1.26; 95% CI, 0.68-2.32) or BCC (0.74; 95% CI, 0.42-1.28). In conclusion, men who are outdoor workers or have a family history of cancer had an increased risk of SCC.

Design and baseline data of a randomized trial comparing two methods for scaling-up an occupational sun protection intervention

Background

Successful methods for scaling-up evidence-based programs are needed to prevent skin cancer among adults who work outdoors in the sun.

Methods

A randomized trial is being conducted comparing two methods of scaling-up the Sun Safe Workplaces (SSW) intervention. Departments of transportation (DOTs) from 21 U.S. states are participating and their 138 regional districts were randomized following baseline assessment. In districts assigned to the in-person method (n = 46), project staff meets personally with managers, conducts trainings for employees, and provides printed materials. In districts assigned to the digital method (n = 92), project staff conduct these same activities virtually, using conferencing technology, online training, and electronic materials. Delivery of SSW in both groups was tailored to managers' readiness to adopt occupational sun safety. Posttesting will assess manager's support for and use of SSW and employees' sun safety. An economic evaluation will explore whether the method that uses digital technology results in lower implementation of SSW but is more cost-effective relative to the in-person method.

Results

The state DOTs range in size from 997 to 18,415 employees. At baseline, 1113 managers (49.0%) completed the pretest (91.5% male, 91.1% white, 19.77 years on the job, 66.5% worked outdoors; and 24.4% had high-risk skin types). They were generally supportive of occupational sun safety. A minority reported that the employer had a written policy, half reported training, and two-thirds, messaging on sun protection.

Conclusions

Digital methods are available that may make scale-up of SSW cost-effective in a national distribution to nearly half of the state DOTs.

Trial registration: The ClinicalTrials.gov registration number is NCT03278340.

[Cutaneous squamous cell carcinoma]

Cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers of the Caucasian population and accounts for 20% of all skin tumours. An S3 guideline of the German Guideline Program in Oncology has been available since 2019. The diagnosis is based on the clinical examination. Excision and histological confirmation is required for all clinically suspicious lesions to allow prognostic assessment and correct treatment. The therapy of first choice is complete excision with histological control of the surgical margin. In cSCC with risk factors such as tumor thickness >6 mm, sentinel lymph node biopsy may be discussed, but there is currently no clear evidence of its prognostic and therapeutic relevance. Adjuvant radiation therapy may be considered in cases of high risk of recurrence and should be tested in cases of inoperable tumors. The indication for electrochemotherapy should also be considered in the treatment of local or locoregional recurrence. The immune checkpoint inhibitor cemiplimab is approved for the treatment of inoperable or metastasized cSCC. In case of contraindications, chemotherapeutic agents, epidermal growth factor receptor (EGFR) inhibitors or palliative radiotherapy can be used. Since the evidence is low in these cases, a systemic therapy should be used preferentially within clinical studies. Follow-up care should be risk-adapted and includes a dermatological control, supplemented by ultrasound examinations in high-risk patients.

[Actinic keratosis]

Actinic keratoses (AK) are common precancerous cutaneous lesions in fair-skinned individuals as a result of cumulative exposure to ultraviolet radiation. Due to their high prevalence, AK account for a large disease burden, in particular in older persons. As AK may potentially progress into invasive cutaneous squamous cell carcinoma, guidelines recommend early and consequent treatment. Numerous lesion- and field-directed interventions with different efficacy and safety profiles are currently licensed in Germany. The appropriate intervention should be chosen together with the patient based on his or her motivation and expectations towards the treatment.

[Effects of an unconventional skin cancer prevention campaign : Impacts on the sun protection behavior of outdoor workers]

BACKGROUND

The disease burden of actinic keratoses and keratinocyte carcinoma can be reduced by primary and secondary prevention. However, these measures are often poorly received, especially among the high-risk group of outdoor workers.

OBJECTIVES

The aim of this follow-up study was to investigate whether an improvement in sun protection and awareness of skin changes could be observed among the study population, especially outdoor workers, one year after a prevention campaign focusing on this topic.

MATERIALS AND METHODS

In 2017, all participants who initially participated in a study at the Bavarian Central Agricultural Festival 2016 and agreed to participate in the follow-up study were contacted by mail and received the same questionnaire and evaluation questions regarding possible behavioral changes.

RESULTS

A total of 400 people took part in the follow-up study (response rate 52.8%). Of the 240 outdoor workers, 45.0% said they were more conscious of protecting themselves from the sun and 68.8% said they were more aware of skin changes. About 85.0% of outdoor workers indicated that they would consult a dermatologist earlier and 65.8% desired further prevention campaigns regarding skin cancer and sun protection.

CONCLUSION

Overall, the majority of participants reported that they had improved sun protection behavior and awareness of skin changes after the intervention. Based on the participants' self-disclosure, especially outdoor workers tended to use sun protection measure more frequently. These findings underline the importance of target group-oriented awareness and prevention campaigns to reduce the burden of skin cancer.