Time to get serious about skin cancer prevention

Clinicopathological Profile of a Cohort of Patients With Malignant Melanoma in the United Kingdom

Introduction Malignant melanoma (MM) is potentially a fatal type of skin cancer and a major health concern for the Caucasian population. It is a heterogeneous disease with a wide spectrum of manifestations. Therefore, in this study, we evaluated the clinicopathological characteristics of MM. Methods We retrospectively studied the clinicopathological characteristics of MM in 167 biopsy-proven cases of MM reported between January 2020 and December 2021 at Kings Mill Hospital, Sutton-in-Ashfield, United Kingdom. Clinical data such as the age, sex, and anatomical site of the lesion were obtained from the clinical referral forms. Biopsies of the lesions were performed, and the specimens collected were sent to the laboratory for histopathological study and v-raf murine sarcoma viral oncogene homolog B1 (BRAF) mutation evaluation. Formalin-fixed paraffin-embedded blocks (FFPE) were prepared, sectioned, and stained with hematoxylin and eosin for histological examination. Results A total of 167 cases of MM were included in the study. The age range was 23-96 years, with the median age at diagnosis found to be 66 years; males were more commonly affected (52.1%). The median Breslow thickness was 1.20 mm. The median mitotic activity was 1.0/mm². The lower limb was the most common site of involvement (27.5%), followed by the thorax (25.1%). The most common histological subtype was superficial spreading melanoma (SSM) (77.8%), followed by nodular melanoma (14.4%). The in situ component was present in 95.8% of cases; a majority (92.2%) of the cases showed vertical growth phase, 71.9% of cases were at Clark's level IV of invasion, regression was noted in 70.7% of cases, ulceration was present in 21.6% of cases, and microsatellites were present in 3% of cases. Perineural invasion was present in 3% of cases, and lymphovascular invasion (LVI) was present in 4.2% of cases. BRAF mutation testing was performed on 36 cases, out of which 20 cases (55.6%) showed BRAF mutation. Acral lentiginous melanoma and nodular melanoma were most likely to show ulceration (66.7% and 37.5%, respectively). SSM and lentigo maligna melanoma were more likely to be associated with regression. Conclusion The study demonstrated that MM is prevalent among the elderly population with male predominance; SSM was found to be the most common subtype. The study further demonstrated various clinicopathological features of MM and its association with histological subtypes.

Incidence of in Situ vs Invasive Melanoma: Testing the "Obligate Precursor" Hypothesis

Background

Melanoma incidence has been rising in populations with predominantly European ancestry (White), speculated to be partly driven by heightened detection of indolent tumors. If in situ melanomas are destined to evolve to invasive cancers, detecting and removing them should deplete the pool of invasive lesions, and people with in situ melanoma should, on average, be younger than those with invasive melanoma.

Methods

We analyzed long-term incidence trends (1982-2018) for in situ and invasive melanomas in 3 predominantly White populations with high, medium, and low melanoma rates: Queensland (Australia), United States White, and Scotland. We calculated the incidence rate ratio (IRR) of in situ to invasive melanomas and estimated the contributions of age, period, and cohort effects. We compared age at diagnosis of in situ vs invasive melanomas overall and stratified by sex and anatomic site.

Results

In all 3 populations, the in situ to invasive incidence rate ratio increased statistically significantly from less than 0.3 in 1982 to 1.95 (95% confidence interval [CI] = 1.88 to 2.02) in Queensland, 0.93 (95% CI = 0.90 to 0.96) in the US White population, and 0.58 (95% CI = 0.54 to 0.63) in Scotland in 2018. The mean age at diagnosis of in situ melanomas was the same or higher than invasive melanomas for almost all time periods among men and women and on all body sites except the lower limbs.

Conclusions

The increasing ratio of in situ to invasive melanoma incidence over time, together with the high (and increasing) mean age at diagnosis of in situ melanomas, is consistent with more indolent lesions coming to clinical attention than in previous eras.

An Exploration of the Use and Impact of Preventive Measures on Skin Cancer

Background: Skin cancer is the most common form of cancer, and both clinical and epidemiological data link cumulative solar dosages and the number of sunburns to skin cancer. Each year, more than 5.4 million new cases of skin cancer are diagnosed, incurring a significant health and financial burden. Recommended preventive measures for skin cancer include the use of sunscreen, sun avoidance, and protective clothing. This study used a national database to examine the association of preventive measures with the prevalence of skin cancer, specifically analyzing the preventive measures of sunscreen use, staying in the shade, and wearing long-sleeved shirts. The second aim was to determine which characteristics, if any, correlated with using prevention measures. Methods: This study analyzed data from the National Health and Nutritional Examination Survey 2015−2016 cycle to examine the association of three preventive measures (using sunscreen, staying in the shade, and wearing long-sleeved shirts) with skin cancer. Logistic regression and chi-square tests were utilized to examine the relationship between skin cancer and these prevention methods. Results: Sunscreen use (OR = 3.752; p < 0.05) was statistically associated with a lower prevalence of skin cancer, while wearing long-sleeved shirts (OR = 6.911; p = 0.064) and staying in the shade (OR = 0.646; p = 0.481) did not emerge as factors significantly associated with a lower prevalence after controlling for gender, race/ethnicity, marital status, income, health insurance, and general health. Additionally, men and individuals of color were less likely to use sunscreen. Conclusion: Sunscreen use was associated with a lower prevalence of skin cancer, while wearing long-sleeved shirts and staying in the shade was not significantly linked to lower rates of skin cancer, suggesting that these measures may not be as effective as sunscreen for preventing skin cancer. Men and individuals of color were significantly less likely to use sunscreen. These findings can help guide future education efforts and research regarding skin cancer prevention and suggest the need to develop male-oriented programs to mitigate the gender disparity in employing sun-protection measures.

Generating political priority for skin cancer primary prevention: A case study from Aotearoa New Zealand

ISSUES ADDRESSED

Skin cancer is highly prevalent but preventable, yet little research has been done on the challenges in generating political priority for skin cancer prevention. This qualitative study aimed to identify the political challenges to, facilitators of, and strategies to strengthen skin cancer prevention. The focus was on the case of Aotearoa New Zealand (NZ): a country with high skin cancer rates, but limited investment in primary prevention.

METHODS

Data sources included 18 national key informant interviews and documentary analysis. Data were analysed inductively for emerging themes and framed using a conceptual framework of political priority.

RESULTS

Challenges to advocates for skin cancer primary prevention include limited resources and competing priorities. Political-level challenges include a lack of quick results compared with other initiatives vying for political attention, lack of negative externalities and, in NZ, misalignment with health system priorities. Challenges in the evidence base include the perceived conflict of sun protection with Vitamin D and physical activity, the lack of data on the financial burden of skin cancer and relatively low temperatures in NZ. Facilitators include strong policy community cohesion and issue framing, and weak opposition. Promising strategies to strengthen skin cancer prevention in NZ could include network building, using framing that resonates with policy makers and addressing key knowledge gaps in NZ, such as the financial burden of skin cancer.

CONCLUSION

Advocacy for skin cancer prevention faces challenges due to advocates' limited resources, political challenges such as lack of quick results and gaps in evidence. Nonetheless, the initiative encounters little opposition and can be framed in ways that resonate with policy makers. SO WHAT?: Skin cancer is highly preventable, but advocates for prevention initiatives have struggled to gain political traction. This study identifies several strategies that could help raise the political profile for skin cancer prevention.

Cancer incidence trends in the Czech Republic

BACKGROUND

Evaluation of time trends is an integral part of a comprehensive analysis of cancer data. Our study aimed to assess trends in cancer incidence in the period 1977-2018 in the Czech Republic.

METHODS

Cancer data were obtained from the Czech National Cancer Registry. Incidence trends were evaluated using the joinpoint regression. The overall trend for the entire analysed period and the current trend for the last 10 years were determined using the average annual percentage change.

RESULTS

In the period 1977-2018, the age-standardised incidence (European standard) of malignant neoplasms excluding non-melanoma skin cancers increased from 518.2 to 681.9 cases per 100,000 population in men, and from 320.9 to 467.2 in women. The largest increase in trend in the analysed period was observed for melanoma, which showed an average annual increase of 4.0 % in men and 3.3 % in women. Over the last decade, a significant increase has been observed for head and neck cancer and oesophageal cancer, mainly in women. On the contrary, the largest decrease in trend in the analysed period was observed for stomach cancer, with an average decrease of 2.9 % in men and 2.8 % in women. Over the last 10 years, a highly significant decrease has also been observed for colorectal cancer: 3.2 % in men and 2.8 % in women. The largest difference in trend between the sexes was recorded in lung cancer: a steady decline of 1.3 % per year was observed for men, but an increase of 3.1 % per year was demonstrated for women. After the introduction of colorectal and cervical cancer screening programmes, a significant decrease of incidence rates for these diagnoses was observed.

CONCLUSIONS

Knowledge of the current cancer burden in the population and its time trends will help to prioritise targets and future resource allocation to cancer control.

Trend Shifts in Age-Specific Incidence for In Situ and Invasive Cutaneous Melanoma in Sweden

BACKGROUND

The incidence of invasive cutaneous melanoma (CM) is increasing in Sweden. The aim was to present age- and sex-specific trends of the age-standardised incidence and the average annual percentage change (AAPC) for in situ and invasive CM.

METHODS

Joinpoint regression models were used to analyse data from the Swedish Cancer Register and the Swedish Melanoma Registry 1997-2018 (N = 35,350 in situ CM; 59,932 CM).

RESULTS

The AAPC of CM for women was 4.5 (4.1-5.0; p < 0.001) for the period 1997-2018. For men, the APCC was 4.2 (3.0-5.4; p < 0.001), with a significantly higher annual percentage change (APC) for the period 2000-2018 (5.0; 4.6-5.4; p < 0.001) compared to 1997-1999. An increasing annual incidence of CM ≤ 0.6 mm and 0.7 mm Breslow tumour thickness was found for men with a significant incidence shift for the period 2006-2015, respectively. Similarly for women, with a significantly higher APC for CM ≤ 0.6 mm from 2005. The incidence of intermediate thick CM (2.1-4.0 mm) has not increased since 2011. The incidence of CM > 4.0 mm has been increasing among both sexes, with a significantly lower APC among women from 2005.

CONCLUSIONS

The incidence of in situ and low-risk CM ≤ 1.0 mm in tumour thickness has been rising among both sexes since the 2000s.

Melanoma Incidence Among Non-Hispanic Whites in All 50 US States From 2001 Through 2015

BACKGROUND

The United States has large regional variation in primary prevention campaigns for skin cancer. We collected data from all 50 states to examine changes in melanoma incidence and performed age-period-cohort analyses to describe the simultaneous effects of age, period, and cohort on incidence rates.

METHODS

Annual melanoma incidence rates for non-Hispanic whites from 2001 to 2015 were extracted from the US Cancer Statistics registry. Secular trends were examined overall and by sex and state. We used joinpoint regression to compute annual percent change and average annual percent change and corresponding 95% confidence intervals (CIs). We also analyzed incidence trends by 5-year age group and birth cohort using incidence rate ratios and age-period-cohort modeling.

RESULTS

Melanoma incidence increased from 20.7 per 100 000 (95% CI = 20.5 to 20.9) in 2001 to 28.2 per 100 000 (95% CI = 28.0 to 28.5) in 2015, increasing by 3.90% (95% CI = 2.36% to 5.48%) annually between 2001 and 2005 and 1.68% (95% CI = 1.37% to 1.99%) annually from 2005 through 2015. The average annual percent change in melanoma incidence rates were similar for men (2.34%, 95% CI = 1.91 to 2.78) and women (2.25%, 95% CI = 1.60 to 2.91). Age-specific relative risk by birth cohort increased from circa 1921 to 1981 before decreasing. Compared with adults born circa 1956, those born circa 1991 had lower melanoma risk (incidence rate ratio  = 0.85; 95% CI = 0.77 to 0.94). Geographic variation was observed; some states still have melanoma rates trending upwards in all birth cohorts.

CONCLUSIONS

The continued increase in melanoma incidence among non-Hispanic whites, particularly in states where rates continue to rise among recent and current birth cohorts, underscores the need for increased public health campaigns aimed at reducing sun exposure.

Decision Tree Model vs Traditional Measures to Identify Patterns of Sun-Protective Behaviors and Sun Sensitivity Associated With Sunburn

Importance

Understanding patterns of sun-protective behaviors and their association with sunburn can provide important insight into measurement approaches and intervention targets.

Objective

To assess whether decision-based modeling can be used to identify patterns of sun-protective behaviors associated with the likelihood of sunburn and to compare the predictive value of this method with traditional (ie, composite score) measurement approaches.

Design, Setting, and Participants

This cross-sectional study used a nationally representative sample of 31 162 US adults from the 2015 National Health Interview Survey, consisting of household interviews conducted in person and completed by telephone when necessary. Participants included civilian noninstitutionalized US adults. Data were collected from January 1 through December 31, 2015.

Main Outcomes and Measures

The associations among sun sensitivity, multiple sun-protective behaviors (ie, using sunscreen, seeking shade, wearing a hat, and wearing protective clothing), and sunburn were examined using a χ2 automatic interaction detection method for decision tree analysis. Results were compared with a composite score approach.

Results

In our study population of 28 558 respondents with complete data (54.1% women; mean [SD] age, 49.0 [18.0] years), 20 patterns of sun protection were identified. Among 15 992 sun-sensitive individuals, those who used only sunscreen had the highest likelihood of sunburn (62.4%). The group with the lowest likelihood of sunburn did not report using sunscreen but engaged in the other 3 protective behaviors (24.3% likelihood of sunburn). Among 12 566 non-sun-sensitive individuals, those who engaged in all 4 protective behaviors had the lowest likelihood of sunburn (6.6%). The highest likelihood of sunburn was among those who only reported sunscreen use (26.2%). The decision tree model and the composite score approach correctly classified a similar number of cases; however, the decision tree model was superior in classifying cases with sunburn (44.3% correctly classified in the decision tree vs 25.9% with the composite score).

Conclusions and Relevance

This innovative application of a decision tree analytic approach demonstrates the interactive and sometimes counterintuitive effects of multiple sun-protective behaviors on likelihood of sunburn. These data show where traditional measurement approaches of behavior may fall short and highlight the importance of linking behavior to a clinically relevant outcome. Given the scope of those affected and enormous associated health care costs, improving efforts in skin cancer prevention has the potential for a significant effect on public health.

Educational interventions for primary care providers to improve clinical skin examination for skin cancer

BACKGROUND AND PURPOSE

Skin cancer, the most commonly diagnosed cancer in the United States, is a serious health care concern. Early skin cancer detection improves prognosis; most common early detection approach is a comprehensive clinical skin examination (CSE). A CSE consists of skin cancer risk assessment, head-to-toe skin examination, and skin lesion assessment. Nurse practitioners (NPs) currently lack adequate training and confidence to conduct CSE. The goal of this systematic review was to learn more about published interventions targeting CSE training for primary care NPs and/or other primary care providers. The findings were categorized based on the established procedures for intervention development.

METHODS

The databases PubMed, Google Scholar, CINAHL, and Web of Science were searched. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 10 articles were selected for data extraction.

CONCLUSIONS

There is a paucity of articles that report rigorously developed interventions aimed at educating primary care NPs to conduct CSE. Existing CSE interventions were not tested for efficacy or effectiveness, and the implementation methods were weak or not reported. A synthesis of the review findings revealed inadequately reported sample characteristics, vague intervention goals, unspecified frequency or duration of interventions, and lack of standardized intervention protocols.

IMPLICATIONS FOR PRACTICE

This review builds a foundation for more rigorously developed interventions to improve CSE and provides guidance for NPs to select education on CSE and other clinical foci. Future research will guide the development and evaluate the effectiveness of CSE education, which ultimately could improve skin cancer prognosis interventions and lack of standardized intervention protocols.

Understanding Ultraviolet Radiation Dorsal Foot Injury at the Beach

BACKGROUND

Efforts made to protect the dorsal aspect of the foot are currently unknown. We sought to determine whether beachgoers protect the dorsal aspect of their feet as frequently as other anatomic sites.

METHODS

A convenience sample of Galveston, Texas, beachgoers completed anonymous surveys to assess whether the dorsal foot was at risk for ultraviolet radiation (UV-R) injury. Additional information collected included demographics and general knowledge about skin cancer to determine if these variables were significantly correlated with dorsal foot protection from UV-R injury.

RESULTS

Of 216 respondents, only 103 used a topical UV-R barrier on their dorsal feet, while 183 applied sunscreen to the body and 133 applied sunscreen to the legs. Eighty-seven of 113 nonusers explained, "I did not think about it." The average number of applications of sunscreen per person to the dorsal feet was less than other anatomical body sites (1.19 body applications, 0.86 leg applications, and 0.58 dorsal feet applications per person; P < .001). 58.0% of females applied sunscreen to the dorsal feet compared with only 36.5% of males (P = .001). Self-identifying Fitzpatrick skin type 5 or 6 individuals did not apply sunscreen to the dorsal foot as regularly as individuals with types 1 to 4 (84.6% versus 47.6%; P = .0001).

CONCLUSIONS

Current skin cancer epidemiology pairs the feet and the legs together as "lower extremity." For epidemiologic purposes, however, feet and legs should be considered distinct areas in UV-R research because they may use different photoprotection strategies.

Human health in relation to exposure to solar ultraviolet radiation under changing stratospheric ozone and climate

The Montreal Protocol has limited increases in the UV-B (280-315 nm) radiation reaching the Earth's surface as a result of depletion of stratospheric ozone. Nevertheless, the incidence of skin cancers continues to increase in most light-skinned populations, probably due mainly to risky sun exposure behaviour. In locations with strong sun protection programs of long duration, incidence is now reducing in younger age groups. Changes in the epidemiology of UV-induced eye diseases are less clear, due to a lack of data. Exposure to UV radiation plays a role in the development of cataracts, pterygium and possibly age-related macular degeneration; these are major causes of visual impairment world-wide. Photodermatoses and phototoxic reactions to drugs are not uncommon; management of the latter includes recognition of the risks by the prescribing physician. Exposure to UV radiation has benefits for health through the production of vitamin D in the skin and modulation of immune function. The latter has benefits for skin diseases such as psoriasis and possibly for systemic autoimmune diseases such as multiple sclerosis. The health risks of sun exposure can be mitigated through appropriate sun protection, such as clothing with both good UV-blocking characteristics and adequate skin coverage, sunglasses, shade, and sunscreen. New sunscreen preparations provide protection against a broader spectrum of solar radiation, but it is not clear that this has benefits for health. Gaps in knowledge make it difficult to derive evidence-based sun protection advice that balances the risks and benefits of sun exposure.

Farmers' Preventive Behavior Analysis Against Sunlight Using the Health Belief Model: A Study from Iran

Agriculture is one of the major sources of employment and income in many countries, especially in developing countries. Farmers are exposed to numerous harmful factors such as sunlight and ultraviolet radiation. These factors contribute to multiple diseases including skin cancer. The aim of this study was to analyze the farmer's preventive behavior against sunlight using the Health Belief Model (HBM). This descriptive study was conducted by survey methodology and a questionnaire. The population of the research was composed of farmers in Kermanshah Province (N = 126,900). The sample size was determined as 382 farmers using the Krejcie and Morgan table. The validity of the questionnaire was confirmed by relevant professors and experts, and the reliability was confirmed through a pilot study and the calculation of Cronbach's alpha coefficient, which was estimated at 0.70-0.83. Findings showed that the HBM structures had a significant effect on the farmer's preventive behavior, so that the perceived barriers, susceptibility, severity, benefits, self-efficacy, and cues to action have the strongest impact on the farmer's preventive behavior against sunlight. The results illustrated that components of the HBM were appropriate predictors for farmers' preventive behavior against sunlight.

MDA-19 Suppresses Progression of Melanoma Via Inhibiting the PI3K/Akt Pathway

Objective

To investigate the effect of MDA-19 on progression of melanoma, and explore the relevant mechanism.

Methods

The melanoma cell lines, M14 and UACC257, were treated with different concentrations of MDA-19, then CCK8, clone formation assay, Transwell and flow cytometry assays were performed to examine cell proliferation, migration, invasion and apoptosis, respectively. The expression of apoptosis-related proteins (Bcl-2, Bax and caspase 3 P17), EMT and signaling pathway-related proteins were also detected by Western blot.

Results

MDA-19 inhibited melanoma cells in a dose-dependent manner. Compared to the NC group, MDA-19 significantly inhibited cell growth capacity, migration and invasion of M14 and UACC257 cells, and accelerated cell apoptosis in a mitochondrial pathway through regulating Bcl-2/Bax and Caspase 3 in M14 and UACC257 cells. Moreover, MDA-19 was observed to up-regulate the expression of E-cad and down-regulate the expression of N-cad, Vimentin and Slug in melanoma cells in vitro. Furthermore, MDA-19 could inhibit the PI3K/Akt pathway by blocking Akt phosphorylation (p-Akt) and downstream proteins, P70 and Cyclin D1 in M14 and UACC257 cells.

Conclusion

Our data demonstrate that MDA-19 could inhibit progression of melanoma by suppressing the PI3K/Akt pathway, suggesting that MDA-19 is a potential anti-cancer agent for therapy of melanoma.

Skin cancer interventions across the cancer control continuum: A review of experimental evidence (1/1/2000-6/30/2015) and future research directions

While the general efficacy of skin cancer interventions have been reviewed, employing the cancer control continuum would be useful to identify research gaps at specific cancer control points. We characterized the intervention evidence base for specific behavioral targets (e.g., tanning, sun protection, screening) and clinically related targets (e.g., sunburn, skin exams, cancers) at each point in the cancer control continuum. The review included articles published from 1/1/2000-6/30/15 that had an experimental design and targeted behavioral intervention in skin cancer (e.g., specific behaviors or clinically related targets). The search yielded 86 articles, including seven dissemination studies. Of the 79 non-dissemination studies, 57 exclusively targeted primary prevention behaviors, five exclusively targeted screening, 10 targeted both detection and prevention, and eight addressed cancer survivorship. Among prevention studies (n=67), 29 (43%) targeted children and 38 (57%) targeted adults. Of the 15 screening studies, nine targeted high-risk groups (e.g., men aged ≥50 years) and six targeted the general population. Although research has focused on skin cancer prevention, empirically validated interventions are still needed for youth engaged in indoor tanning and for behavioral interventions to pursue change in clinically relevant targets. Research must also address detection among those at highest risk for skin cancer, amelioration of emotional distress attendant to diagnosis and treatment, and survivorship concerns. We discuss essential qualities and opportunities for intervention development and translational research to inform the field.

Systematic review of advanced practice nurses' skin cancer detection knowledge and attitudes, clinical skin examination, lesion detection, and training

BACKGROUND AND PURPOSE

Skin cancer is the most common malignancy in the United States; early detection reduces the public health burden. This systematic review updates the state of advanced practice nurses' skin cancer knowledge and attitudes, performance of and barriers to clinical skin examination (CSE), recognition of skin lesions, and related training activities.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement guided a search of eight literature databases that yielded 12 studies from 2010 to 2016. The United States Preventive Services Task Force's Levels of Certainty guided evidence assessment.

CONCLUSIONS

The studies mainly targeted or included nurse practitioners. Collectively, participants had variable, suboptimal skin cancer knowledge, even after an intervention. A slight majority performed CSE during annual visits but agreed that CSE was important and within their scope of practice. Major CSE barriers were lack of time, training, and confidence. Participants who received training were more proficient in identifying suspicious versus benign lesions. Few skin cancer detection training opportunities for nurses exist.

IMPLICATIONS

The level of certainty of the evidence for skin cancer detection by advanced practice nurses and their impact on the skin cancer problem remain low. These nurses would benefit from accessible and efficacious CSE and lesion training.

Review of the Global Solar UV Index 2015 Workshop Report

The Global Solar UV Index was developed as an easy-to-understand measure of the amount of biologically-effective ambient solar ultraviolet radiation (UVR) at different locations on the earth's surface. Over the past few years, questions have been raised about the global applicability of the UV Index, about the evidence base for exposure risk thresholds and related protective measures, and about whether the overall impact of the UV Index could be improved with modifications. An international workshop was organized by several organizations, including the World Health Organization, to assess if current evidence was sufficiently strong to modify the UV Index and to discuss different ways it might be improved in order to influence sun-protective behavior. While some animal research suggests there may be no threshold effect, the relative importance of sub-erythemal doses of sunlight in causing skin cancer in humans remains unknown. Evidence suggests that regular use of sunscreen can prevent skin cancer and that sunglasses are an effective method of protecting the eyes from solar UVR. The UV Index as a risk communication tool continues to be useful for raising awareness and to support sun-protection behavior. Although there was agreement that guidance on the use of the UV Index could be improved, the workshop participants identified that strong health outcome-based human evidence would be needed as the basis for a revision. For the UV Index to be relevant in as many countries as possible, it should continue to be adapted to suit local conditions.

Tanning and Teens: Is Indoor Exposure the Tip of the Iceberg?

Because of recent state regulations and the reduced availability of free-standing tanning salons, indoor tanning (IT) prevalence is beginning to decline. This may lead to unintended consequences, such as increases in outdoor intentional tanning. We advance a series of research directions to track and intervene to address all forms of intentional tanning. First, we advocate for enforcement of IT regulation and encourage collection of data on tanning salon compliance and alternative IT strategies. Second, we suggest questions about outdoor and IT should be included in national surveys. Third, we need to understand the potentially complex patterns of indoor and outdoor tanning that may exist among those who tan. Fourth, research examining changing motivations for intentional tanning is needed. Finally, IT intervention studies should include outdoor tanning as an outcome to examine the effect of interventions on these related risk behaviors. These advances will ensure the development of novel interventions to address intentional tanning through multiple routes, and to avoid any unintended negative consequence of IT regulation. The promising downward direction of IT use in the United States should now lead the public health field to sharpen its focus on outdoor tanning. Cancer Epidemiol Biomarkers Prev; 26(8); 1170-4. ©2017 AACR.

Noscapinoids bearing silver nanocrystals augmented drug delivery, cytotoxicity, apoptosis and cellular uptake in B16F1, mouse melanoma skin cancer cells

PURPOSE

Noscapine (Nos) and reduced brominated analogue of noscapine (Red-Br-Nos) prevent cellular proliferation and induce apoptosis in cancer cells either alone or in combination with other chemotherapeutic drugs. However, owing to poor physicochemical properties, Nos and Red-Br-Nos have demonstrated their anticancer activity at higher and multiple doses. Therefore, in present investigation, silver nanocrystals of noscapinoids (Nos-Ag2+ nanocrystals and Red-Br-Nos-Ag2+ nanocrystals) were customized to augment drug delivery, cytotoxicity, apoptosis and cellular uptake in B16F1 mouse melanoma cancer cells.

METHODS AND RESULTS

Nos-Ag2+ nanocrystals and Red-Br-Nos-Ag2+ nanocrystals were prepared separately by precipitation method. The mean particle size of Nos-Ag2+ nanocrystals was measured to be 25.33±3.52nm, insignificantly (P>0.05) different from 27.43±4.51nm of Red-Br-Nos-Ag2+ nanocrystals. Furthermore, zeta-potential of Nos-Ag2+ nanocrystals was determined to be -25.3±3.11mV significantly (P<0.05) different from -15.2±3.33mV of Red-Br-Nos-Ag2+ nanocrystals. The shape of tailored nanocrystals was slightly spherical and or irregular in shape. The architecture of Nos-Ag2+ nanocrystals and Red-Br-Nos-Ag2+ nanocrystals was crystalline in nature. FT-IR spectroscopy evinced the successful interaction of Ag2+ nanocrystals with Nos and Red-Br-Nos, respectively. The superior therapeutic efficacy of tailored nanocrystals was measured in terms of enhanced cytotoxicity, apoptosis and cellular uptake. The Nos-Ag2+ nanocrystals and Red-Br-Nos-Ag2+ nanocrystals exhibited an IC50 of 16.6μM and 6.5μM, significantly (P<0.05) lower than 38.5μM of Nos and 10.3μM of Red-Br-Nos, respectively. Finally, cellular morphological alterations in B16F1 cells upon internalization of Nos-Ag2+ nanocrystals and Red-Br-Nos-Ag2+ nanocrystals provided the evidences for accumulation within membrane-bound cytoplasmic vacuoles and in enlarged lysosomes and thus triggered mitochondria mediated apoptosis via caspase activation.

CONCLUSION

Preliminary investigations substantiated that Nos-Ag2+ nanocrystals and Red-Br-Nos-Ag2+ nanocrystals must be further explored and utilized for the delivery of noscapinoids to melanoma cancer cells.

Sun Exposure and Protection Behaviors among Long-term Melanoma Survivors and Population Controls

Introduction: Melanoma is considered a generally preventable cancer, with excessive ultraviolet radiation (UVR) exposure being a strong causal factor. UVR exposure following a melanoma diagnosis can be modified to reduce risk of second primary melanomas. The goal of this study was to compare measures of UVR exposure and protection behaviors between long-term melanoma survivors and controls.Methods: Participants from a previously conducted case-control study were recruited for a cross-sectional survey. Melanoma cases were 25 to 59 years old at diagnosis; controls were age and sex matched. Participants were asked about UVR exposure and protection measures used in the past year, and comparisons between melanoma survivors and controls were conducted using logistic regression models, adjusting for potential confounders.Results: A total of 724 (62.0%) long-term melanoma survivors and 660 (59.9%) controls completed the follow-up survey. Melanoma survivors were significantly less likely to report high sun exposure on a typical weekday [OR, 0.72 (0.55-0.94)], sunburns [OR, 0.40 (0.30-0.53)], or indoor tanning [OR, 0.20 (0.09-0.44)] than controls; however, high sun exposure on a typical weekend day was similar. Report of optimal sun protection behaviors was higher in melanoma survivors compared with controls. However, a few melanoma survivors reported indoor tanning, 10% reported intentionally seeking sun to tan, and 20% reported sunburns.Conclusions: Although long-term melanoma survivors reported healthier UVR exposure and protection behaviors compared with controls, a sizeable proportion still reported elevated sun exposure, sunburns, and suboptimal UVR protection behaviors.Impact: Opportunities remain for improving sun protection to reduce future melanoma risk among melanoma survivors. Cancer Epidemiol Biomarkers Prev; 26(4); 607-13. ©2017 AACR.

Predictors of sun protection behaviours and sunburn among Australian adolescents

BACKGROUND

Excessive sun exposure and sunburn increase individuals' risk of skin cancer. It is especially important to prevent sunburn in childhood due to the higher relative risk of skin cancer across the life span compared to risk associated with sunburn episodes experienced later in life. This study examined demographic and attitudinal factors associated with engagement in a range of sun protection behaviours (wearing a hat, wearing protective clothing, staying in the shade, and staying indoors during the middle of the day) and the frequency of sunburn among Western Australian adolescents to provide insights of relevance for future sun protection campaigns.

METHODS

Cross-sectional telephone surveys were conducted annually with Western Australians between 2005/06 and 2014/15. The results from 4150 adolescents aged 14-17 years were used to conduct a path analysis of factors predicting various sun protection behaviours and sunburn.

RESULTS

Significant primary predictors of the sun protection behaviours included in the study were skin type (sun sensitivity), gender, tanning-related attitudes and behaviours, and perceived relevance of public service advertisements that advocate sun protection. Of the four sun protection behaviours investigated, staying in the shade and staying indoors during the middle of the day were associated with a lower frequency of sunburn.

CONCLUSION

There is a particular need to target sun protection messages at adolescent males who are less likely to engage in the most effective sun protection behaviours and demonstrate an increased propensity to experience sunburn. The results suggest that such future sun protection messages should include a focus on the importance of staying in the shade or indoors during periods of high UV radiation to increase awareness of the efficacy of these methods of avoiding skin cancer.

The Growing Burden of Invasive Melanoma: Projections of Incidence Rates and Numbers of New Cases in Six Susceptible Populations through 2031

New melanoma therapies are being developed rapidly, complementing prevention and detection strategies for disease control. Estimating the future burden of melanoma is necessary for deciding how best to deploy limited resources to achieve effective melanoma control. Using three decades of cancer registry data (1982-2011) from six populations with moderate to high melanoma incidence (US whites and the populations of the United Kingdom, Sweden, Norway, Australia, New Zealand), we applied age-period-cohort models to describe current trends and project future incidence rates and numbers of melanomas out to 2031. Between 1982 and 2011, melanoma rates in US whites, and the populations of the United Kingdom, Sweden, and Norway increased at more than 3% annually and are projected to continue rising until at least 2022. Melanoma incidence in Australia has been declining since 2005 (-0.7% per year), and melanoma incidence in New Zealand is increasing but is projected to decline soon. The numbers of new melanoma cases will rise in all six populations because of aging populations and high age-specific rates in the elderly. In US whites, annual new cases will rise from around 70,000 in 2007-2011 to 116,000 in 2026-2031, with 79% of the increase attributable to rising age-specific rates and 21% to population growth and aging. The continued increases in case numbers in all six populations through 2031 will increase the challenges of melanoma control.

Ubiquitin ligase UBE3C promotes melanoma progression by increasing epithelial-mesenchymal transition in melanoma cells

Melanoma is the most aggressive type of skin cancer, exhibiting extensive local invasion and early distant metastasis. Aberrant expression of ubiquitin-protein ligase E3C (UBE3C) plays a key role in tumor development and progression. In the present study, we analyzed UBE3C expression in samples of cancerous and normal skin tissue. Levels of UBE3C expression were much higher in primary and metastatic melanoma tissues than in normal skin, cutaneous squamous cell carcinoma or basal cell carcinoma. Melanoma cells overexpressing UBE3C frequently exhibited a mesenchymal phenotype, including reduced expression of the epithelial marker E-cadherin and expression of the mesenchymal marker vimentin. Knockdown of UBE3C expression in melanoma cells significantly suppressed melanoma growth and progression. Furthermore, silencing UBE3C led to increased E-cadherin expression and decreased vimentin and Snail1 expression. Thus UBE3C promotes melanoma progression, possibly by inducing epithelial-mesenchymal transition in melanoma cells. Inhibiting UBE3C activity may suppress melanoma invasion and metastasis and may represent a targeted therapeutic approach.

Trends in sun-protection behaviour in Australian adults 2007-2012

BACKGROUND

Almost all skin cancers are the result of overexposure to UV radiation and could be prevented by adhering to a number of simple behavioural guidelines to minimise exposure to the sun. The present study examined trends in sun-protection behaviour among adults living in Western Australia, a region with high levels of UV radiation.

METHODS

During five summers from 2008 to 2012, 2076 Western Australian adults participated in annual, cross-sectional telephone surveys that assessed how often they engaged in a range of sun-protection behaviour (seeking shade, staying inside and wearing a hat, protective clothing, sunscreen or sunglasses).

RESULTS

Apart from an increase in sunscreen use and a consistently high use of sunglasses, most sun-protection behaviour remained stable at moderate levels during the 5-year period. Seeking shade, staying inside and wearing a hat were all practised at levels ranging between 'sometimes' and 'usually' on sunny days in summer during peak UV hours, with little to no variability across the survey years. Wearing protective clothing was the least frequent behaviour across all survey years and was significantly lower in the most recent survey year relative to baseline.

CONCLUSIONS

Further efforts are required to encourage greater enactment of sun-protection behaviour, especially on the use of protective clothing and seeking shade during periods of high UV radiation.

Framing Indoor Tanning Warning Messages to Reduce Skin Cancer Risks Among Young Women: Implications for Research and Policy

OBJECTIVES

We investigated the impact of indoor tanning device warnings that communicate the risks associated with indoor tanning (i.e., loss framed) or the benefits of avoiding indoor tanning (i.e., gain framed).

METHODS

A convenience sample of non-Hispanic White women aged 18 to 30 years who tanned indoors at least once in the past year (n = 682) participated in a within-subjects experiment. Participants completed baseline measures and reported indoor tanning intentions and intentions to quit indoor tanning in response to 5 warning messages in random order. A text-only control warning was based on Food and Drug Administration-required warnings for indoor tanning devices. Experimental warnings included graphic content and were either gain or loss framed.

RESULTS

In multivariable analyses, gain-framed warnings did not differ from the control warning on women's intentions to tan indoors, but they prompted stronger intentions to quit than the control message. Loss-framed warnings significantly reduced intentions to tan indoors and increased intentions to quit indoor tanning compared with control and gain-framed warnings.

CONCLUSIONS

The public health impact of indoor tanning device warnings can be enhanced by incorporating graphic content and leveraging gain- and loss-framed messaging.

Silver nanoparticles protect human keratinocytes against UVB radiation-induced DNA damage and apoptosis: potential for prevention of skin carcinogenesis

Ultraviolet (UV)-B radiation from the sun is an established etiological cause of skin cancer, which afflicts more than a million lives each year in the United States alone. Here, we tested the chemopreventive efficacy of silver-nanoparticles (AgNPs) against UVB-irradiation-induced DNA damage and apoptosis in human immortalized keratinocytes (HaCaT). AgNPs were synthesized by reduction-chemistry and characterized for their physicochemical properties. AgNPs were well tolerated by HaCaT cells and their pretreatment protected them from UVB-irradiation-induced apoptosis along with significant reduction in cyclobutane-pyrimidine-dimer formation. Moreover, AgNPs pre-treatment led to G1-phase cell-cycle arrest in UVB-irradiated HaCaT cells. AgNPs were efficiently internalized in UVB-irradiated cells and localized into cytoplasmic and nuclear compartments. Furthermore, we observed an altered expression of various genes involved in cell-cycle, apoptosis and nucleotide-excision repair in HaCaT cells treated with AgNPs prior to UVB-irradiation. Together, these findings provide support for potential utility of AgNPs as novel chemopreventive agents against UVB-irradiation-induced skin carcinogenesis.

FROM THE CLINICAL EDITOR

Excessive exposure to the sun is known to increase the risk of skin cancer due to DNA damage. In this work, the authors tested the use of silver nanoparticles as protective agents against ultraviolet radiation. The positive results may open a door for the use of silver nanoparticle as novel agents in the future.

Promotion of Sun-Protective Behaviors

Promoting sun-protective behaviors is important because decreased exposure to ultraviolet radiation (UVR) reduces the risk of skin cancer. However, many individuals deliberately engage in overexposure to UVR for cosmetic purposes. Due to this and other factors, the need for prevention programs is clear. Several efficacious prevention strategies have been developed for the health care setting.