Long-term ultraviolet flux, other potential risk factors, and skin cancer risk: a cohort study

Combinatorial approach of cannabidiol and active-targeted-mediated photodynamic therapy in malignant melanoma treatment

Malignant melanoma (MM) continues to claim millions of lives around the world due to its limited therapeutic alternatives. Photodynamic therapy (PDT) has gained popularity in cancer treatment due it increased potency and low off-target toxicity. Studies have pointed out that the heterogeneity of MM tumours reduces the efficacy of current therapeutic approaches, including PDT, leading to high chances of recurrences post-treatment. Accumulating evidence suggests that cannabidiol (CBD), a non-psychoactive derivative of cannabis, can synergise with various anticancer agents to increase their efficacy. However, CBD demonstrates low bioavailability, which is attributed to factors relating to poor water compatibility, poor absorption and rapid metabolism. Nanotechnology offers tools that address these issues and enhance the biological efficiency and targeted specificity of anticancer agents. Herein, we highlighted the standard therapeutic modalities of MM and their pitfalls, as well as pointed out the need for further investigation into PDT combination therapy with CBD.

Long-Term Patient-Reported Outcomes following Oncological Facial Reconstructive Surgery using the FACE-Q Skin Cancer Module

Background

Long-term patient-reported outcomes (PROs) of oncological facial reconstructive surgery are unknown.

Objective

The present study aimed to assess long-term PROs and to identify possible correlations between patient and treatment characteristics and long-term PROs.

Methods & Materials

Between 2006 and 2011, 202 patients underwent facial reconstruction after Mohs micrographic surgery for non-melanoma skin cancer at our institution. After 10 years of follow-up, 96 out of the remaining 122 patients completed the FACE-Q Skin Cancer Module.

Results

Patients who were surgically treated for squamous cell carcinoma reported poorer scores on the satisfaction with facial appearance (p=0.038), appraisal of scars (p=0.039) and appearance-related psychosocial distress scales (p=0.036) compared to patients with basal cell carcinoma and lentigo maligna. Finally, female patients reported significantly higher scores on the Cancer Worry Scale than male patients (p=0.047).

Conclusion

Long-term patient satisfaction with respect to their facial appearance and scars after reconstructive surgery for skin cancer was comparable to short-term patient satisfaction, whereas Cancer Worry Scale and psychosocial distress appeared to be slightly higher. Our results can be used to better inform patients on the long-term effects of facial reconstructive surgery on patient satisfaction and quality of life, which are important to improve patient counselling, patient expectation management and shared decision-making.

Association of sun-seeking behaviors with indoor tanning behavior in US white females during high school/college in Nurses' Health Study II

BACKGROUND

Frequent exposure to ultraviolet light has more detrimental and longer-term effects on the skin in early life than in adulthood. Teenagers with strong sun-seeking behaviors may be more likely to use an indoor tanning bed than those who seek less sun. We aimed to examine associations between sun-seeking behaviors and indoor tanning behavior during high school/college in US females.

METHODS

In this cross-sectional study, we used data from The Nurses' Health Study II, a large prospective cohort of US female nurses. We included a total of 81,746 white females who provided responses on the average annual frequency of indoor tanning during high school/college. Our study exposures were number of times/week spent outdoors in a swimsuit and percentage of time wearing sunscreen at the pool/beach as a teenager, weekly hours spent outdoors in direct sunlight during the daytime during high school/college, and number of severe sunburns that blistered between ages 15-20 years. The main outcome was annual frequency of indoor tanning bed usage during high school/college.

RESULTS

In multivariable-adjusted logistic regression, we demonstrated positive associations between sun-seeking behaviors and indoor tanning use. Specifically, teenagers who spent 7 times/week outdoors in a swimsuit (adjusted odds ratio [aOR], 95% confidence interval [CI] for daily vs. <1/week: 2.68, 1.76-4.09) were more likely to use indoor tanning beds ≥ 12 times/year. Teenagers with ≥ 10 sunburns (aOR, 95% CI for ≥ 10 vs. never: 2.18, 1.53-3.10) were more likely to use indoor tanning beds ≥ 12 times/year. Also, teenagers/undergraduates who spent ≥ 5 h/week outdoors in direct sunlight (aOR, 95% CI for ≥ 5 h/week vs. <1 h/week: 2.18, 1.39-3.44) were more likely to use indoor tanning ≥ 12 times/year. However, there was not a significant association between average usage of sunscreen at the pool/beach and average usage of indoor tanning beds. Multivariable-adjusted linear regression models also showed similar results.

CONCLUSIONS

Teenagers who spent more time outdoors in a swimsuit/direct sunlight or got more sunburns tended to use indoor tanning more frequently. These findings provide evidence that teenagers with stronger sun-seeking behaviors may have more exposure to artificial ultraviolet radiation as well.

Furocoumarins potentiate UVA-induced DNA damage in skin melanocytes

Epidemiological studies have found that high citrus fruit consumption was associated with higher risk of skin cancer. Citrus fruits and some vegetables contain furocoumarins, which may interact with ultraviolet radiation to induce skin cancer. We aimed to determine the effects of two furocoumarins, including 8-methoxypsoralen (8-MOP) and 6',7'-dihydroxybergamottin (DHB), on UVA-induced DNA damage in human epidermal melanocytes, the origin of melanoma. Our hypothesis was that these dietary furocoumarins increase UVA-induced DNA damage in melanocytes, compared to cells exposed to UV alone. We incubated melanocytes with 8-MOP or DHB, followed by exposure to physiological doses of UVA radiation. We used Western blots to quantify the UVA-induced DNA damage measured by the fraction of phosphorylated histone variant H2AX (γH2AX), which is a marker of DNA damage, relative to total H2AX (γH2AX/H2AX) in the presence or absence of furocoumarins. To quantify the UVA-induced change in γH2AX/H2AX, we calculated the UVA:Control ratio as the ratio of γH2AX/H2AX in UVA-exposed cells to that in cells without UVA (control). The mean UVA:Control ratios were borderline significantly higher for cells treated with 8-MOP and significantly higher for cells treated with DHB, compared to that of untreated cells. This study suggests that furocoumarins (particularly 8-MOP and DHB) enhance UVA-induced DNA damage in melanocytes, which is a potential novel mechanism for citrus and furocoumarins to elevate the risk of skin cancer.

Partially Alternative Feeding with Fermented Distillers' Grains Modulates Gastrointestinal Flora and Metabolic Profile in Guanling Cattle

Fermented distillers' grains (FDG) are commonly used to enhance the health and metabolic processes of livestock and poultry by regulating the composition and activity of the intestinal microbiota. Nevertheless, there is a scarcity of research on the effects of the FDG diet on the gastrointestinal microbiota and its metabolites in cattle. This study examines the impact of FDG dietary supplements on the gastrointestinal flora and metabolic profile of Guanling cattle. Eighteen cattle were randomly assigned to three treatment groups with six replicates per group. The treatments included a basal diet (BD), a 15% concentrate replaced by FDG (15% FDG) in the basal diet, and a 30% concentrate replaced by FDG (30% FDG) in the basal diet. Each group was fed for a duration of 60 days. At the conclusion of the experimental period, three cattle were randomly chosen from each group for slaughter and the microbial community structure and metabolic mapping of their abomasal and cecal contents were analyzed, utilizing 16S rDNA sequencing and LC-MS technology, respectively. At the phylum level, there was a significant increase in Bacteroidetes in both the abomasum and cecum for the 30%FDG group (p < 0.05). Additionally, there was a significant reduction in potential pathogenic bacteria such as Spirochetes and Proteobacteria for both the 15%FDG and 30%FDG groups (p < 0.05). At the genus level, there was a significant increase (p < 0.05) in Ruminococcaceae_UCG-010, Prevotellaceae_UCG-001, and Ruminococcaceae_UCG-005 fiber degradation bacteria. Non-target metabolomics analysis indicated that the FDG diet significantly impacted primary bile acid biosynthesis, bile secretion, choline metabolism in cancer, and other metabolic pathways (p < 0.05). There is a noteworthy correlation between the diverse bacterial genera and metabolites found in the abomasal and cecal contents of Guanling cattle, as demonstrated by correlation analysis. In conclusion, our findings suggest that partially substituting FDG for conventional feed leads to beneficial effects on both the structure of the gastrointestinal microbial community and the metabolism of its contents in Guanling cattle. These findings offer a scientific point of reference for the further use of FDG as a cattle feed resource.

Application habits and practices of regular sunscreen users in the United States: Results of an online survey

A nationwide online survey assessed claimed usage of sunscreen products in 2283 self-identified regular sun protection factor (SPF) consumers (RSPFC) in the United States. Subjects applied sunscreen most frequently when spending more than 3 h in the sun. Sunscreen usage peaks during the summer, with sunny weather prompting 99% usage of beach/recreational SPF products but drops to approximately 50% and 30% on partly cloudy and cloudy days, respectively, regardless of SPF product category. About half of RSPFC augment sunscreen product usage by limiting time in the sun and wearing a hat. SPF products are not reapplied by approximately 20-60% of RSPFC, depending upon product category, and reapplication was less than 33% on cloudy and partly cloudy days. Primary reasons for reapplication were water exposure, number of hours in the sun, and being active/sweating, most notably for beach/recreational SPF products. Importantly, in children, 45% of parents reported "redness" as a signal for reapplying sunscreen product. Only 10% of respondents correctly identified sunscreen products as drugs. Based on these results, while sunscreens may share common ingredients and efficacy measures, their usage by consumers varies widely depending on product type, season, weather, gender, age, and geographical location.

The Family Lifestyles, Actions and Risk Education (FLARE) study: Protocol for a randomized controlled trial of a sun protection intervention for children of melanoma survivors

BACKGROUND

Children of parents who had melanoma are more likely to develop skin cancer themselves owing to shared familial risks. The prevention of sunburns and promotion of sun-protective behaviors are essential to control cancer among these children. The Family Lifestyles, Actions and Risk Education (FLARE) intervention will be delivered as part of a randomized controlled trial to support parent-child collaboration to improve sun safety outcomes among children of melanoma survivors.

METHODS

FLARE is a two-arm randomized controlled trial design that will recruit dyads comprised of a parent who is a melanoma survivor and their child (aged 8-17 years). Dyads will be randomized to receive FLARE or standard skin cancer prevention education, which both entail 3 telehealth sessions with an interventionist. FLARE is guided by Social-Cognitive and Protection Motivation theories to target child sun protection behaviors through parent and child perceived risk for melanoma, problem-solving skills, and development of a family skin protection action plan to promote positive modeling of sun protection behaviors. At multiple assessments through one-year post-baseline, parents and children complete surveys to assess frequency of reported child sunburns, child sun protection behaviors and melanin-induced surface skin color change, and potential mediators of intervention effects (e.g., parent-child modeling).

CONCLUSION

The FLARE trial addresses the need for melanoma preventive interventions for children with familial risk for the disease. If efficacious, FLARE could help to mitigate familial risk for melanoma among these children by teaching practices which, if enacted, decrease sunburn occurrence and improve children's use of well-established sun protection strategies.

Association of sun-seeking behaviors with indoor tanning habit in US females

Background

Frequent exposure to ultraviolet light in early life has more detrimental and long-term effects on skin than in adulthood. Teenagers with strong sun-seeking behaviors may be more likely to use an indoor tanning bed than those who seek less sun, probably due to addictiveness of ultraviolet exposure. We aimed to examine associations between sun exposure behaviors and average annual indoor tanning usage frequency during high school/college in US females.

Methods

In this cross-sectional study, we used data from The Nurses' Health Study II, a large prospective cohort of US female nurses. We included a total of 81,746 white females who answered the average annual frequency of indoor tanning during high school/college. Our study exposures were average weekly time spent outdoors in a swimsuit and average percentage of time of wearing sunscreen at the pool or beach during their teenage years, average weekly hours spent outdoors in direct sunlight in daytime during high school/college, and the number of severe sunburns which blistered between ages 15-20. Main outcomes was average annual frequency of indoor tanning bed usage during high school/college.

Results

In multivariable-adjusted logistic regression, we demonstrated positive associations between the sun exposure behaviors and the indoor tanning habit. Specifically, teenagers who spent daily outdoors in a swimsuit (adjusted odds ratio [aOR], 95% confidence interval [CI] for daily vs. <1/week: 2.68, 1.76-4.09) or who had ≥ 10 sunburns that blistered (aOR, 95% CI for ≥ 10 vs. never: 2.18, 1.53-3.10) were more likely to use indoor tanning beds ≥ 12 times/year. Also, teenagers/undergraduates who spent ≥ 5hours/week outdoors in direct sunlight during daytime used indoor tanning ≥ 12 times/year (aOR, 95% CI: 2.18, 1.39-3.44) than those who spent < 1/week. However, there was not a significant association between average uses of sunscreen at the pool/beach and indoor tanning bed. Multivariable-adjusted linear regression models also showed similar results.

Conclusions

Teenagers who spent more time outdoors or got more sunburns tended to use indoor tanning more frequently. These findings provide evidence that teenagers with strong sun-seeking behaviors may have excessive exposure to artificial ultraviolet radiation as well.

A meta-analysis of sunburn and basal cell carcinoma risk

Basal cell carcinoma (BCC) is the most common cancer in the United States. Sunburn is a modifiable risk factor for BCC. The objective of this project was to synthesize research on BCC and sunburn to quantify the impact and severity of sunburn at different life stages on BCC risk in the general population. A systematic literature search of four electronic databases was conducted and data were extracted by two independent reviewers using standardized forms. Data from 38 studies were pooled using both dichotomous and dose-response meta-analytic methods. BCC risk increased with ever experiencing a sunburn in childhood (OR=1.43, 95% CI: 1.19, 1.72) and with ever experiencing a sunburn in life (OR= 1.40, 95% CI: 1.02, 1.45). Every five sunburns experienced per decade in childhood increased BCC risk by 1.86 (95% CI: 1.73, 2.00) times. Every five sunburns experienced per decade in adulthood increased BCC risk by 2.12 (95% CI: 1.75, 2.57) times and every five sunburns per decade of life increased BCC risk by 1.91 (95% CI: 1.42, 2.58) times. The data on sunburn exposure and BCC show that an increase in number of sunburns at any age increased the risk of BCC. This may inform future prevention efforts.

Factors associated with suspected nonmelanoma skin cancers, dysplastic nevus, and cutaneous melanoma among first-time SpotMe screening program participants during 2009-2010

BACKGROUND

There have been no studies of the American Academy of Dermatology's SpotMe skin cancer screening program to collectively analyze and determine the factors associated with suspected basal cell carcinoma (BCC), squamous cell carcinoma (SCC), dysplastic nevus (DN), and cutaneous melanoma (CM) diagnoses.

OBJECTIVE

Describe the demographics, risk factors, and access to care profiles associated with suspected diagnoses of BCC, SCC, DN, and CM among first-time SpotMe screenees during 2009-2010.

METHODS

We conducted a cross-sectional analysis of data from the SpotMe skin cancer screenings conducted in 2009 and 2010. We performed multivariable logistic regression analysis for each diagnosis, incorporating standard demographic, access to care, and risk factor variables in the models.

RESULTS

Men, those without a regular dermatologist, persons reporting recently changing moles, and those with a personal history of melanoma were at increased risk for each of the suspected diagnoses analyzed. Uninsured persons were at increased risk for suspected malignancies (BCC, SCC, and CM).

LIMITATIONS

Lack of histologic confirmation for diagnoses and cross-sectional design.

CONCLUSION

Among first-time SpotMe participants, suspected diagnoses of BCC, SCC, DN, and CM shared several associated factors, which may be considered when planning outreach and screening for populations at risk for skin cancer.

Head and Neck Region Dermatological Ultraviolet-Related Cancers are Associated with Exfoliation Syndrome in a Clinic-Based Population

OBJECTIVE

We assessed the relationship between ultraviolet (UV)-associated dermatological carcinomas (basal cell carcinoma [BCC] and squamous cell carcinoma [SCC]) and exfoliation syndrome (XFS) or exfoliation glaucoma (XFG).

DESIGN

Case-control study.

PARTICIPANTS

Between 2019 and 2021, 321 participants and control subjects (XFS or XFG = 98; primary open-angle glaucoma [POAG] = 117; controls = 106; ages 50-90 years) were recruited.

METHODS

A cross-sectional survey assessing medical history, maximum known intraocular pressure, cup-to-disc ratio, Humphrey visual field 24-2, the propensity to tan or burn in early life, history of BCC or SCC, and XFS or XFG diagnosis. The multivariable models adjusted for age, sex, medical history, eye color, hair color, and likeliness of tanning versus burning at a young age.

MAIN OUTCOME MEASURES

History of diagnosed XFS or XFG.

RESULTS

Any history of BCC or SCC in the head and neck region was associated with a 2-fold higher risk of having XFS or XFG versus having POAG or being a control subject (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.04-3.89) in a multivariable-adjusted analysis. We observed a dose-response association in which the chance of having XFS or XFG increased by 67% per head and neck BCC or SCC occurrence (OR, 1.67; 95% CI, 1.09-2.56). When we excluded POAG participants, head and neck BCC or SCC was associated with a 2.8-fold higher risk of XFS or XFG (OR, 2.80; 95% CI, 1.12-7.02), and each additional occurrence had a 2-fold higher risk of XFS or XFG (OR, 1.97; 95% CI, 1.09-3.58). The association between head and neck region BCC or SCC and POAG compared with the control subjects was null (OR, 1.42; 95% CI, 0.58-3.48). With BCC or SCC located anywhere on the body, there was a nonsignificantly higher risk of having XFS or XFG compared with having POAG or being a control subject (OR, 1.65; 95% CI, 0.88-3.09).

CONCLUSIONS

Head and neck region BCCs or SCCs are associated with a higher risk of having XFS or XFG. These findings support prior evidence that head and neck UV exposure may be a risk factor for XFS.

EVALUATION OF PLANT-BASED UV FILTERS POTENTIAL IN MODERN CONCEPT VIEW OF SKIN PHOTOPROTECTION

A therapeutic plants potential is based on the pharmacological effects due to their phytochemical profile. Today, scientific interest in botanicals is increasing as a result of recent research that looks at the prospect of using these raw materials for the cosmetic industry as a means to protect the skin from the harmful effects of UV rays.

The aim of the study was to evaluate a potential of plant-based UV-filters in modern concept view of skin photoprotection.

Materials and methods. A systematic literature search was carried out using the electronic information arrays PubMed, Scopus, Google Scholar, eLibrary. The search depth was 10 years (the period from 2010 to 2021). The search was carried out by the following keywords: antioxidants, cosmetics, photoprotection, chemical composition, pharmacological action.

Results. In the paper, modern principles of skin photoprotection based on the use of chemical or physical UV-filters are considered and scientifically substantiated A trend for the use of plant-based materials and their components in the formulation of photoprotectors was notified. That is associated with a wide activity spectrum, the absence of a xenobiotic effect, and a high bioavailability of organic plant compounds.

Conclusion. The data analysis from scientific publications demonstrated a potential photoprotective activity of plant-based biologically active substances due to antioxidant, anti-inflammatory and anti-radical effects. The results of the study are a theoretical basis for a further comprehensive experimental study of plant objects in order to obtain a pool of evidence in the field of photoprotection in in vivo experiments.

Comparison of phenotypic features in patients with single vs multiple primary cutaneous melanomas: a prospective single-center study

BACKGROUND

There is sparse data regarding total body nevus count (TBNC), nevus count in specific locations, phenotypic factors, anthropometric indices, sunburn, and the relation to multiple primary cutaneous melanomas (MPCM) development. We aim to compare these variables in a cohort of patients diagnosed with single primary melanoma (SPM) and MPCM with histologic diagnoses of melanoma in situ, superficial spreading, and nodular melanoma in our clinic.

METHODS

Prospective observational studies for the evaluation of nevus counts in biopsy-proven melanoma patients from 2017 to 2020 at Ankara University were conducted. Age, gender, family history of melanoma, increased sun exposure, nonmelanoma skin cancers (NMSC), height, sunburn history, TBNC, and nevi count in specific anatomical locations were evaluated by multivariate logistic regression analysis.

RESULTS

A total number of 156 patients consisting of 22 MPCM and 134 SPM were included. Mean TBNC for SPM vs MPCM patients were 96.87 (SD ± 124.71) vs 247.00 (SD ± 261.58), respectively (P < 0.0001). TBNC was correlated to the left arm, trunk, lower extremity, and head and neck nevus counts but not with the right arm nevus count. Multiple regression analysis showed that having more than 10 nevi on the head and neck area is associated with MPCM (OR, 3.882 [95% CI, 1.084-13.899]). TBNC and nevus count in specific locations were found to be significantly higher in MPCM.

CONCLUSION

The risk of MPCM was associated with having ≥10 nevi on the head and neck.

Outdoor activities and sunburn among urban and rural families in a Western region of the US: Implications for skin cancer prevention

Prevention of skin cancer involves decreasing exposure to ultraviolet radiation (UVR) and avoiding sunburn, especially early in life. Individuals living in urban versus rural areas, as defined by the Rural Urban Commuting Area (RUCA) code classification, have different risks for skin cancer, likely due to differing patterns of outdoor activities and preventive behaviors employed when outdoors. However, few studies have examined differences in outdoor activities between rural and urban individuals and examined this among both adults and children. This study compared the outdoor activities, sun protection strategies, tanning behaviors, and sunburn occurrence of adults and children (n = 97 dyads) in rural versus urban settings in a Western region of the United States. The relationships between outdoor activities and sunburn occurrence were examined in both groups. Analyses employed Barnard's Exact Test and logistic generalized estimating equations models. Individuals in rural and urban areas reported differences in sun protection strategies used, tanning behaviors, and outdoor activities. Individuals in urban areas more commonly reported use of certain forms of sun protection, such as sunscreen and shade, whereas long pants and skirt wearing were more common for children in rural areas. Individuals in rural areas were more likely than those in urban areas to engage in farm work, yard work, and youth sports. Gender differences in these outcomes were also identified. Skin cancer preventive interventions could be tailored for rural and urban families to target sun protection strategies to outdoor activities and to situations in which sunburns are likely to occur.

Encouraging sun protection early in life: from a successful prevention programme in children to the identification of psychological barriers in adolescents

Children and adolescents have high rates of sunburn and high levels of ultraviolet radiation (UVR) exposure and are therefore at risk of developing skin cancer in later life. Minimizing UVR exposure in childhood and adolescence may be the most important component of skin cancer prevention efforts. Thus, age-adapted prevention campaigns, targeting children, adolescents and caregivers, are needed to change sun protection behaviour among individuals in these age groups. In the first part of this review, we describe the 'SunPass' programme, which was initiated in Germany in 2010 as the first nationwide educational intervention for sun safety designed to teach kindergarten children and their caregivers how to protect themselves from overexposure to the sun. Implemented in 55 kindergartens, this programme has been shown to be effective at improving sun protection behaviour (P < 0.001) and hat use (P = 0.029) among kindergarten children, as well as at improving shade practices and increasing demand for protective clothing (P < 0.001). Up to 40 000 children, 50 000 parents/grandparents and 2500 kindergarten caregivers took part in the SunPass programme in Germany from 2019 to June 2021. The programme has also been adapted and implemented in several other European countries and could be readily adapted for use elsewhere. In the second part of this review, we discuss the specific challenges faced by adolescents and consider how these issues may impact their sun protection behaviour. Adolescents have difficulties suppressing responses to reward-related cues and projecting themselves into the future. They also place a lot of importance on social acceptance and cosmetic appearance, and their higher risk of depression, addiction and impulsivity make them vulnerable to tanning addiction. These specificities need to be acknowledged by dermatologists, so they can adapt their therapeutic relationship and develop effective sun protection interventions for this generation.

Reproductive factors, hormone use, and incidence of melanoma in a cohort of US Radiologic Technologists

STUDY QUESTION

Are reproductive factors and exogenous hormone use associated with incidence of cutaneous melanoma while accounting for ultraviolet radiation (UVR) exposure across different life periods and sun sensitivity factors?

SUMMARY ANSWER

Earlier age at menarche and late age at first birth, but not other estrogen-related factors were associated with an increased incidence rate of melanoma, with higher risks observed for earlier age at menarche and light hair color at age 15 years.

WHAT IS KNOWN ALREADY

Although estrogens have been recognized as photosensitizing, previous studies have reported inconsistent findings for the association of melanoma with estrogen-related factors. Most have not collected detailed skin cancer risk factors and have not thoroughly investigated effect modification by ambient UVR and sun sensitivity.

STUDY DESIGN, SIZE, DURATION

Participants in the US Radiologic Technologists study, an occupational cohort of 146 022 radiologic technologists (73% women), were included and followed during the four time periods (1983-1989, 1994-1998, 2003-2005 and 2012-2014).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Non-Hispanic white female participants who completed both the second (baseline) and third questionnaires, and did not report having cancer (except keratinocyte carcinoma) at baseline, were included and followed from their age at completion of the second (baseline) questionnaire until the earlier of first primary cancer diagnosis, including invasive melanoma of the skin, or completion of either the third or fourth questionnaire. Reproductive and exogenous hormonal factors were ascertained from the second (baseline) questionnaire, which also collected information on demographic, lifestyle factors and sun sensitivity factors. Ambient UVR was assigned by linking geocoded residential locations, based on self-reported residential history information collected from the third questionnaire to satellite-based ambient UVR data from the National Aeronautics and Space Administration's Total Ozone Mapping Spectrometer database. To examine the association of reproductive factors, exogenous hormone use, and first primary invasive melanoma of the skin, we used Poisson regression to calculate rate ratios (RRs) and 95% likelihood-based CIs, adjusting for attained age, birth cohort, lifetime average annual ambient UVR, contraceptives and menopausal hormone therapy use. To address the effect modification of ambient UVR exposure and sun sensitivities on melanoma risk, we conducted likelihood-ratio tests for multiplicative interaction.

MAIN RESULTS AND THE ROLE OF CHANCE

Over a median follow-up time of 17.1 years, 0.95% of eligible participants had an incident first primary melanoma (n = 444). Higher melanoma incidence rates were observed in participants with older attained age, blue/green/gray eye color, blonde/red/auburn natural hair color at age 15, fair skin complexion, and higher UVR. We found an increased incidence rate of melanoma in women who experienced menarche at an earlier age (13, 12 and <12 years vs ≥14 years: RR = 1.48, 95% CI = 1.11-1.98; 1.19, 0.89-1.61; 1.26, 0.93-1.73), and in women with older age at first birth (25-29 and ≥30 years vs <25 years; 1.09, 0.86-1.39; 1.48, 1.12-1.95; P-value for trend = 0.006). However, no significant association was observed for other reproductive factors, and for all exogenous hormone use. The associations of melanoma incidence for most reproductive factors and exogenous hormone use were not modified by ambient UVR, eye color, natural hair color at age 15 and skin complexion. The exception was that natural hair color at age 15 modified the associations of melanoma for age at menarche (P-value for interaction = 0.004) and age at first birth among parous women (0.005). In participants with blonde/red/auburn natural hair color at age 15, we found increased risk of melanoma among women who experienced menarche at age 13, 12 and <12 years (vs ≥14 years: RR = 3.54, 95% CI = 1.98-6.90; 2.51, 1.37-4.98; 2.66, 1.41-5.36, respectively; P-value for trend = 0.10). However, the association between age at menarche and melanoma was null in participants with brown/black natural hair color at age 15.

LIMITATIONS, REASONS FOR CAUTION

Information on reproductive history and exogenous hormone use was self-reported. We did not have information on specific doses or formulations of exogenous hormone medications or breastfeeding.

WIDER IMPLICATIONS OF THE FINDINGS

Women residing in areas of high ambient UVR and those with blonde/red/auburn natural hair color may constitute an additional high-risk group in need of more frequent skin cancer screening. Identifying susceptible periods of exposure or factors that modify UVR susceptibility may aid in guiding more targeted guidelines for melanoma prevention.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by the Intramural Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, US Department of Health and Human Services. Authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Cutaneous beta HPVs, sun exposure and risk of squamous and basal cell skin cancers in Australia

BACKGROUND

Sun exposure causes cutaneous squamous (SCC) and basal cell (BCC) carcinomas. Human papillomavirus (HPV) infection might cause SCC.

METHODS

We examined associations of beta and gamma HPV infection in skin-swab DNA and serum antibodies with skin cancer risk, and modification of the carcinogenic effects of sun exposure by them, in case-control studies of 385 SCC cases, 832 BCC cases and 1100 controls nested in an Australian prospective cohort study (enrolled 2006-2009).

RESULTS

Presence of beta-1 and beta-3 HPV DNA appeared to increase risks for SCC and BCC by 30%-40% (P adjusted <0.01). BCC was also associated with genus beta DNA, OR=1.48; 95%CI 1.10-2.00 (P adjusted <0.01). Associations were strengthened with each additional positive beta HPV DNA type: SCC (OR=1.07; 95%CI 1.02-1.12) and BCC (OR=1.06; 95%CI 1.03-1.10), P trend <0.01. Positivity to genus beta or gamma in serology, and genus gamma in DNA, was not associated with either cancer. There was little evidence that any beta HPV type was more strongly associated than others with either cancer. A weaker association of sun-exposure with SCC and BCC in the presence of beta-3 HPVs than in their absence suggests that beta-3 HPVs modify sun exposure's effect.

CONCLUSIONS

Our substantive findings are at the level of genus beta HPV. Like SCC, BCC risk may increase with increasing numbers of beta HPV types on skin.

IMPACT

The consistency in our findings that HPV infection may moderate the effects of sun exposure, the main environmental cause of SCC and BCC, merits further investigation.

Polygenic Risk Scores Stratify Keratinocyte Cancer Risk among Solid Organ Transplant Recipients with Chronic Immunosuppression in a High Ultraviolet Radiation Environment

Solid organ transplant recipients (SOTRs) have elevated risks for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), especially in high UVR environments. We assessed whether polygenic risk scores can improve the prediction of BCC and SCC risks and multiplicity over and above the traditional risk factors in SOTRs in a high UV setting. We built polygenic risk scores for BCC (n = 594,881) and SCC (n = 581,431) using UK Biobank and 23andMe datasets, validated them in the Australian QSkin Sun and Health Study cohort (n > 6,300), and applied them in SOTRs in the skin tumor in allograft recipients cohort from Queensland, Australia, a high UV environment. About half of the SOTRs with a high genetic risk developed BCC (absolute risk = 45.45%, 95% confidence interval = 33.14-58.19%) and SCC (absolute risk = 44.12%, 95% confidence interval = 32.08-56.68%). For both cancers, SOTRs in the top quintile were at >3-fold increased risk relative to those in the bottom quintile. The respective polygenic risk scores improved risk predictions by 2% for BCC (area under the curve = 0.77 vs. 0.75, P = 0.0691) and SCC (area under the curve = 0.84 vs. 0.82, P = 0.0260), over and above the established risk factors, and 19.03% (for BCC) and 18.10% (for SCC) of the SOTRs were reclassified in a high/medium/low risk scenario. The polygenic risk scores also added predictive accuracy for tumor multiplicity (BCC R2 = 0.21 vs. 0.19, P = 3.2 × 10-3; SCC R2 = 0.30 vs. 0.27, P = 4.6 × 10-4).

Behavioral Research in Cancer Prevention and Control: Emerging Challenges and Opportunities

It is estimated that behaviors such as poor diet, alcohol consumption, tobacco use, sedentary behavior, and excessive ultraviolet exposure account for nearly one-half of all cancer morbidity and mortality. Accordingly, the behavioral, social, and communication sciences have been important contributors to cancer prevention and control research, with methodological advances and implementation science helping to produce optimally effective interventions. To sustain these contributions, it is vital to adapt to the contemporary context. Efforts must consider ancillary effects of the 2019 coronavirus disease pandemic, profound changes in the information environment and public understanding of and trust in science, renewed attention to structural racism and social determinants of health, and the rapidly increasing population of cancer survivors. Within this context, it is essential to accelerate reductions in tobacco use across all population subgroups; consider new models of energy balance (diet, physical activity, sedentary behavior); increase awareness of alcohol as a risk factor for cancer; and identify better communication practices in the context of cancer-related decisions such as screening and genetic testing. Successful integration of behavioral research and cancer prevention depends on working globally and seamlessly across disciplines, taking a multilevel approach where possible. Methodological and analytic approaches should be emphasized in research training programs and should use new and underused data sources and technologies. As the leadership core of the National Cancer Institute’s Behavioral Research Program, we reflect on these challenges and opportunities and consider implications for the next phase of behavioral research in cancer prevention and control.

Use of hydrochlorothiazide and risk of skin cancer in a large nested case-control study in Spain

PURPOSE

Hydrochlorothiazide (HCTZ) use has been linked to skin cancer in northern European countries. We assessed the association between HCTZ exposure and risk of malignant melanoma (MM) and keratinocyte carcinoma (KC) in a European Mediterranean population.

METHODS

Two parallel nested case-control studies were conducted in Spain using two electronic primary healthcare databases, each one providing data on both exposure and outcomes: SIDIAP and BIFAP. Cancer cases were matched to 10 controls by age and gender through risk-set sampling. The ORs and 95% CI for MM and KC associated with previous HCTZ use were estimated using conditional logistic regression. In BIFAP, KC cases were further identified as basal cell carcinoma (BCC) or squamous cell carcinoma (SCC).

RESULTS

In adjusted analyses, both ever and cumulative high (≥50,000 mg) use of HCTZ were associated with an increased risk of KC. The risk estimates for high use were 1.30 (1.26-1.34) in SIDIAP and 1.20 (1.12-1.30) in BIFAP, with a lower risk for BCC (1.11 [1.02-1.21]) than for SCC (1.71 [1.45-2.02]). A dose-response relationship was observed between cumulative doses of HCTZ and KC risk. Inconsistent results were found for high use of HCTZ and risk of MM: 1.25 (1.09-1.43) in SIDIAP and 0.85 (0.64-1.13) in BIFAP.

CONCLUSIONS

In this European Mediterranean population, a high cumulative use of HCTZ was related to an increased risk of KC with a clear dose-response pattern.

Association of Lifetime Indoor Tanning and Subsequent Risk of Cutaneous Squamous Cell Carcinoma

Importance

No study, to our knowledge, has prospectively investigated a dose-response association between lifetime indoor tanning and risk of cutaneous squamous cell carcinoma (SCC).

Objective

To investigate the dose-response association between lifetime indoor tanning and SCC risk, the association between duration of use and age at initiation with SCC risk, and the association between age at initiation and age at diagnosis.

Design, Setting, and Participants

This cohort study included data from women born from 1927 to 1963 from the Norwegian Women and Cancer study, established in 1991 with follow-up through December 31, 2015. Baseline questionnaires were issued to participants from 1991 to 2007, with follow-up questionnaires given every 5 to 7 years. Data analysis was performed from January 2, 2018, to March 2, 2019.

Exposures

Participants reported pigmentation factors. Sunburns, sunbathing vacations, and indoor tanning were reported for childhood, adolescence, and adulthood.

Main Outcomes and Measures

Information on all cancer diagnoses and dates of emigration or death were obtained through linkage to the Cancer Registry of Norway, using the unique personal identification number of Norwegian citizens.

Results

A total of 159 419 women (mean [SD] age at inclusion, 49.9 [8.3] years) were included in the study. During follow-up (mean [SD], 16.5 [6.4] years), 597 women were diagnosed with SCC. Risk of SCC increased with increasing cumulative number of indoor tanning sessions. The adjusted hazard ratio (HR) for highest use vs never use was 1.83 (95% CI, 1.38-2.42; P < .001 for trend). A significantly higher risk of SCC was found among women with 10 years or less of use (HR, 1.41; 95% CI, 1.08-1.85) and more than 10 years of use (HR, 1.43; 95% CI, 1.16-1.76) and among women with age at initiation of 30 years or older (HR, 1.36; 95% CI, 1.11-1.67) and younger than 30 years (HR, 1.51; 95% CI, 1.18-1.92) vs never users. No significant association was found between age at initiation and age at diagnosis (estimated regression coefficient, -0.09 [95% CI, -1.11 to 0.94] for age at initiation of ≥30 years and -0.02 [95% CI, -1.27 to 1.22] for <30 years vs never use).

Conclusion and Relevance

The findings provide supporting evidence that there is a dose-response association between indoor tanning and SCC risk among women. The association between cumulative exposure to indoor tanning and SCC risk was the same regardless of duration of use and age at initiation. These results support development of policies that regulate indoor tanning.

Effect of a Face-Aging Mobile App-Based Intervention on Skin Cancer Protection Behavior in Secondary Schools in Brazil: A Cluster-Randomized Clinical Trial

Question

Can a face-aging mobile app improve the skin cancer protection behavior of secondary school students?

Findings

In this cluster-randomized clinical trial of 52 school classes with 1573 Brazilian pupils, meaningful improvements were observed in sunscreen use, tanning behavior, and skin self-examinations 3 to 6 months after an intervention using a face-aging app compared with the nonintervention group.

Meaning

Face-aging apps may be useful tools to increase skin cancer protection in adolescents and thereby decrease skin cancer risk.

Importance

Because exposure to UV radiation early in life is an important risk factor for melanoma development, reducing UV exposure in children and adolescents is of paramount importance. New interventions are urgently required.

Objective

To determine the effect of the free face-aging mobile app Sunface on the skin cancer protection behavior of adolescents.

Design, Setting, and Participants

This cluster-randomized clinical trial included a single intervention and a 6-month follow-up from February 1 to November 30, 2018. Randomization was performed on the class level in 52 school classes within 8 public secondary schools (grades 9-12) in Itauna, Southeast Brazil. Data were analyzed from May 1 to October 10, 2019.

Interventions

In a classroom seminar delivered by medical students, adolescents’ selfies were altered by the app to show UV effects on their future faces and were shown in front of their class, accompanied by information about UV protection. Information about relevant parameters was collected via anonymous questionnaires before and 3 and 6 months after the intervention.

Main Outcomes and Measures

The primary end point of the study was the difference in daily sunscreen use at 6 months of follow-up. Secondary end points included the difference in daily sunscreen use at 3 months of follow-up, at least 1 skin self-examination within 6 months, and at least 1 tanning session in the preceding 30 days. All analyses were predefined and based on intention to treat. Cluster effects were taken into account.

Results

Participants included 1573 pupils (812 girls [51.6%] and 761 boys [48.4%]; mean [SD] age, 15.9 [1.3] years) from 52 school classes. Daily sunscreen use increased from 110 of 734 pupils (15.0%) to 139 of 607 (22.9%; P < .001) at the 6-month follow-up in the intervention group. The proportion of pupils performing at least 1 skin self-examination in the intervention group rose from 184 of 734 (25.1%) to 300 of 607 (49.4%; P < .001). Use of tanning decreased from 138 of 734 pupils (18.8%) to 92 of 607 (15.2%; P = .04). No significant changes were observed in the control group. The intervention was more effective for female students (number needed to treat for the primary end point: 8 for girls and 31 for boys).

Conclusions and Relevance

These findings suggest that interventions based on face-aging apps may increase skin cancer protection behavior in Brazilian adolescents. Further studies are required to maximize the effect and to investigate the generalizability of the effects.

Trial Registration

ClinicalTrials.gov Identifier: NCT03178240

Involvement of adenylate cyclase/cAMP/CREB and SOX9/MITF in melanogenesis to prevent vitiligo

Vitiligo is autoimmune, acquired, idiopathic, chronic, and progressive de/hypopigmentary cutaneous condition that targets the cell-producing pigment called melanin. It binds to a thread of great disappointment and emotional stress in societies. Combining multiple stress-related theories like toxic compound accumulation, autoimmunity, mutations, altered cellular environment, infection, impaired migration/proliferation, and immunological mismatch of anti-melanocyte and self-reactive T-cells that cause melanocytes damage is formulated resulting in vitiligo. Vitiligo has an orphan status for drug synthesis. Still, different therapies are available, with topical steroids and narrow-band ultraviolet-B monotherapy being the most common treatments, others including medical, physical, or surgical, but not effective. Each modality has its baggage of disadvantages and side effects. Stimulation of the transcriptional process for melanogenesis is mainly achieved by the cAMP-dependent activation of several melanogenic genes by MITF. In this review, we summarized that cAMP encourages the expression of the enzyme tyrosinase, TYRP1, TYRP2, and most other biological effects of cAMP are mediated through the cAMP-dependent PKA pathway resulting in CREB phosphorylation. It has been shown that TYRP1 and 2 do not have cAMP response elements (CREs) in promoting regions; the regulation of these genes by cAMP occurs through the direct participation of MITF during melanogenesis. The available medicines, therefore, only provide symptomatic relief, but do not stop the disease progression. In addition, the treatment process needs to be changed; existing approaches need to be overlooked for patients who are suffering and therefore analyze its efficacy and safety to achieve a favorable risk-benefit ratio.

Cohort Study of Nonmelanoma Skin Cancer and the Risk of Exfoliation Glaucoma

PRECIS

In a cohort study of 120,307 participants with 25+ years of follow-up, a history of nonmelanoma skin cancer (NMSC) was associated with a 40% higher exfoliation glaucoma (XFG) risk.

PURPOSE

The purpose of this study was to evaluate the relationship between NMSC (a marker of ultraviolet radiation exposure) and XFG.

METHODS

We performed a cohort study of US women (n=79,102; 1980-2014) and men (n=41,205; 1986-2014), aged 40+ years and at risk for glaucoma who reported eye examinations. From 1984 (women)/1988 (men), we asked about basal cell carcinoma or squamous cell carcinoma history separately; in prior years, we asked about any NMSC history in a single question. Squamous cell carcinoma was confirmed with histopathology reports while basal cell carcinoma and any early (<1984/<1988) NMSC history was self-reported. Incident XFG cases (362 women and 83 men) were confirmed with medical records. Using pooled data, we estimated multivariable-adjusted relative risks [MVRRs; 95% confidence intervals (CIs)] with Cox proportional hazards models that were stratified by age (in mo), 2-year time period at risk and average lifetime residential latitude.

RESULTS

In multivariable-adjusted analyses, we observed a 40% higher XFG risk with any NMSC history (MVRR=1.40; 95% CI=1.08-1.82); the association was observed even with 4 and 8-year lags in NMSC history. Also, the NMSC association was stronger in younger (below 65 y; MVRR=2.56; 95% CI=1.62-4.05) versus older participants (65 y and above; MVRR=1.25; 95% CI=0.94-1.66; P for interaction=0.01) and those living in the northern latitudes (≥42°N; MVRR=1.92; 95% CI=1.28-2.88) versus more southern latitudes (<42°N; MVRR=1.19; 95% CI=0.86-1.66; P for interaction=0.04).

CONCLUSION

NMSC was associated with higher XFG risk, particularly among younger participants and those living in the Northern US.

Age-Specific Incidence of Melanoma in the United States

Importance

Melanoma is epidemiologically linked to UV exposure, particularly childhood sunburn. Public health campaigns are increasing sun-protective behavior in the United States, but the effect on melanoma incidence is unknown.

Objective

To examine the incidence of melanoma in the United States and whether any age-specific differences are present.

Design, Setting, and Participants

Observational, population-based registry data were extracted on July 3, 2018, from the combined National Program of Cancer Registries-Surveillance Epidemiology and End Results United States Cancer Statistics database for 2001-2015. Deidentified data for 988 103 cases of invasive melanoma, with International Classification of Diseases for Oncology histologic categorization codes 8720 to 8790, were used for analysis. Data analysis was performed from July 1, 2018, to March 1, 2019.

Main Outcomes and Measures

The annual rates of melanoma in pediatric, adolescent, young adult, and adult age groups were determined. Analyses were stratified by sex, and incidence rates were age-adjusted to the 2000 US standard population. Annual percentage change (APC) in incidence rate was calculated over the most recent decade for which data were available (2006-2015) using the weighted least squares method.

Results

In 2015, 83 362 cases of invasive melanoma were reported in the United States, including 67 in children younger than 10 years, 251 in adolescents (10-19 years), and 1973 in young adults (20-29 years). Between 2006 and 2015, the overall incidence rate increased from 200.1 to 229.1 cases per million person-years. In adults aged 40 years or older, melanoma rates increased by an APC of 1.8% in both men (95% CI, 1.4%-2.1%) and women (95% CI, 1.4%-2.2%). In contrast, clinically and statistically significant decreases were seen in melanoma incidence for adolescents and young adults. Specifically, incidence rates decreased by an APC of -4.4% for male adolescents (95% CI, -1.7% to -7.0%), -5.4% for female adolescents (95% CI, -3.3% to -7.4%), -3.7% for male young adults (95% CI, -2.5% to -4.8%), and -3.6% for female young adults (95% CI, -2.8% to -4.5%). Data on skin pigmentation and sun protection history were unavailable; similar trends were observed with data limited to non-Hispanic whites. Young adult women appeared to have twice the risk of melanoma as young adult men.

Conclusions and Relevance

The incidence of invasive melanoma in the United States appeared to decrease in adolescents and young adults from 2006 to 2015, and this finding contrasted with increases in older populations. These incidence trends suggest that public health efforts may be favorably influencing melanoma incidence in the United States.

UV-type specific alteration of miRNA expression and its association with tumor progression and metastasis in SCC cell lines

PURPOSE

UV exposure is the main risk factor for development of cutaneous squamous cell carcinoma (cSCC). While early detection greatly improves cSCC prognosis, locally advanced or metastatic cSCC has a severely impaired prognosis. Notably, the mechanisms of progression to metastatic cSCC are not well understood. We hypothesized that UV exposure of already transformed epithelial cSCC cells further induces changes which might be involved in the progression to metastatic cSCCs and that UV-inducible microRNAs (miRNAs) might play an important role.

METHODS

Thus, we analyzed the impact of UV radiation of different quality (UVA, UVB, UVA + UVB) on the miRNA expression pattern in established cell lines generated from primary and metastatic cSCCs (Met-1, Met-4) using the NanoString nCounter platform.

RESULTS

This analysis revealed that the expression pattern of miRNAs depends on both the cell line used per se and on the quality of UV radiation. Comparison of UV-induced miRNAs in cSCC cell lines established from a primary tumor (Met-1) and the respective (un-irradiated) metastasis (Met-4) suggest that miR-7-5p, miR-29a-3p and miR-183-5p are involved in a UV-driven pathway of progression to metastasis. This notion is supported by the fact that these three miRNAs build up a network of 81 potential target genes involved e.g. in UVA/UVB-induced MAPK signaling and regulation of the epithelial-mesenchymal transition. As an example, PTEN, a target of UV-upregulated miRNAs (miR-29a-3p, miR-183-5p), could be shown to be down-regulated in response to UV radiation. We further identified CNOT8, the transcription complex subunit 8 of the CCR4-NOT complex, a deadenylase removing the poly(A) tail from miRNA-destabilized mRNAs, in the center of this network, targeted by all three miRNAs.

CONCLUSION

In summary, our results demonstrate that UV radiation induces an miRNA expression pattern in primary SCC cell line partly resembling those of metastatic cell line, thus suggesting that UV radiation impacts SCC progression beyond initiation.

Concomitant DNA methylation and transcriptome signatures define epidermal responses to acute solar UV radiation

The simultaneous analysis of different regulatory levels of biological phenomena by means of multi-omics data integration has proven an invaluable tool in modern precision medicine, yet many processes ultimately paving the way towards disease manifestation remain elusive and have not been studied in this regard. Here we investigated the early molecular events following repetitive UV irradiation of in vivo healthy human skin in depth on transcriptomic and epigenetic level. Our results provide first hints towards an immediate acquisition of epigenetic memories related to aging and cancer and demonstrate significantly correlated epigenetic and transcriptomic responses to irradiation stress. The data allowed the precise prediction of inter-individual UV sensitivity, and molecular subtyping on the integrated post-irradiation multi-omics data established the existence of three latent molecular phototypes. Importantly, further analysis suggested a form of melanin-independent DNA damage protection in subjects with higher innate UV resilience. This work establishes a high-resolution molecular landscape of the acute epidermal UV response and demonstrates the potential of integrative analyses to untangle complex and heterogeneous biological responses.

Intake of Furocoumarins and Risk of Skin Cancer in 2 Prospective US Cohort Studies

BACKGROUND

In prior studies, higher citrus consumption was associated with higher risk of cutaneous malignant melanoma, squamous cell carcinoma (SCC), and basal cell carcinoma (BCC). Furocoumarins, compounds with phototoxicity and photocarcinogenicity in citrus, may be responsible for the association.

OBJECTIVES

The objective of the study was to investigate the association between furocoumarin intake and skin cancer risk.

METHODS

A total of 47,453 men from the Health Professionals Follow-Up Study (HPFS) and 75,291 women from the Nurses' Health Study (NHS) with diet data collected every 2-4 y in the 2 prospective cohort studies were included. A furocoumarin food composition database for 7 common furocoumarins [bergaptol, psoralen, 8-methoxypsoralen, bergapten, 6',7'-dihydroxybergamottin (6'7'-DHB), epoxybergamottin, and bergamottin] was developed and used to calculate participants' cumulative average and energy-adjusted furocoumarin intake. Multivariate HRs and 95% CIs of the associations between furocoumarin intake and skin cancer risk were estimated using Cox proportional hazards models. Analyses were performed separately in each cohort as well as pooled using a fixed-effects model.

RESULTS

Throughout follow-up (1984-2012 in the NHS and 1986-2012 in the HPFS), we identified 1593 melanoma, 4066 SCC, and 28,630 BCC cases. Higher intake of total furocoumarins was associated with an increased risk of BCC; the pooled HR comparing the top with the bottom quintile was 1.16 (95% CI: 1.11, 1.21; P-trend = 0.002). Higher intakes of bergaptol, bergapten, 6'7'-DHB, and bergamottin were also significantly associated with increased BCC risk. No significant associations were found between intake of total furocoumarins and the risks of SCC or melanoma.

CONCLUSIONS

Intakes of total furocoumarins as well as some individual furocoumarins were associated with an increased risk of skin cancer, especially BCC, in 2 cohorts of US health professionals.

Awareness about proper use of sunscreen in people of color: A Jordanian-based survey

INTRODUCTION

The use of sunscreen is an important preventive measure against skin cancer and treatment for other skin conditions. There is evidence pointing to lack awareness and misconceptions regarding use of Sunscreen. This is especially evident in populations with skin of color (POC).

METHODS

This is a cross-sectional study of 2000 individuals. A structured questionnaire was designed to collect data on general knowledge and use of sunscreen as well as reasons for stopping use of sunscreen.

RESULTS

The results of this study indicate a clear deficiency in the use and knowledge about sunscreen among Jordanians. Females are using sunscreen more than males. However, the use of sunscreen is inadequate in many aspects including timing of application, frequency of use, and amount used among other things. There is an obvious lack of knowledge about sunscreen as shown by lack of awareness about benefits of use in various times of the year, use in children, use for all skin types, and several misconceptions among other knowledge gaps. Main reasons for stopping sunscreen include side effects, cost, and being not suitable for skin. Awareness about sunscreen can be improved by proper counseling by healthcare professionals and utilization of various media platforms.

CONCLUSIONS

The use of sunscreen is inadequate in this population of color (POC). Lack of proper counseling, failure to read use instructions can contibute to inadequate use of sunscreen. Risks and benefits of sunscreen should be explained by medical professionals. The media should be more utilized to disseminate such knowledge.

Trends in emergency department visits due to sunburn and factors associated with severe sunburns in the United States

Little is known regarding the burden of sunburns leading to emergency department (ED) visits in the United States (US). The objectives of this research were to characterize the burden of sunburn ED visits, investigate predictors of severe sunburns, and evaluate risk factors for increased cost of care in patients presenting to the ED for sunburn. In this nationally representative cross-sectional study of the National Emergency Department Sample (NEDS, 2013-2015), multivariable models were created to evaluate adjusted odds for sunburn ED visits, seasonal/regional variation in sunburn ED visits, adjusted odds for second and third degree sunburns, and risk factors for increased ED expenditure. 82,048 sunburn ED visits were included in this study. On average, the cost of care for a sunburn ED visit was $1132.25 (± $28.69). The prevalence and cost of ED visits due to sunburn increased during the summer months. Controlling for sociodemographic factors, comorbidities, and hospital characteristics, patients presenting to the ED for all sunburns (and for severe sunburns) were most likely to be lower income young adult men. Older, higher income patients in metropolitan hospitals had more expensive ED visits. This research provides nationally representative estimates of visits to the ED due to sunburn in the US, as well as evaluates determinants for severe sunburns and more expensive sunburn ED visits. Ultimately, characterizing the national burden of ED visits due to sunburn is critical in the development of interventions to reduce the impact of sunburn ED visits on the US healthcare system.

Ultraviolet Radiation Exposure and the Risk of Herpes Zoster in Three Prospective Cohort Studies

OBJECTIVE

To examine the association between ultraviolet radiation (UVR) exposure and the risk of herpes zoster (HZ) in 3 prospective cohorts.

PATIENTS AND METHODS

We included 205,756 participants from the Health Professionals Follow-up Study (HPFS; 1986-2008), Nurses' Health Study (NHS; 1996-2012), and Nurses' Health Study II (NHS II; 1991-2013). Ambient UVR exposure was based on updated geocoded address histories linked with a high-resolution spatiotemporal ultraviolet model. Incident HZ cases were identified by self-reported clinician diagnosis. Sunburn history and medical, lifestyle, and dietary factors were assessed using biennial questionnaires. Multivariable Cox proportional hazards models were used.

RESULTS

A total of 24,201 cases of HZ occurred during 3,626,131 person-years. Ambient UVR exposure was associated with a higher risk of HZ in men (HPFS: multivariable-adjusted hazard ratio [MVHR] comparing highest vs lowest quintiles, 1.14; 95% CI, 1.02-1.29; P=.03 for trend) but not in women (NHS: MVHR, 0.99; 95% CI, 0.93-1.05; NHS II: MVHR, 0.96; 95% CI, 0.90-1.03). A higher lifetime number of severe sunburns was associated with a higher risk of HZ in all cohorts (HPFS: MVHR for ≥10 sunburns vs none, 1.08; 95% CI, 0.96-1.20; P=.02 for trend; NHS: MVHR, 1.14; 95% CI, 1.05-1.22; P=.01 for trend; NHS II: MVHR, 1.13; 95% CI, 1.00-1.28; P<.001 for trend).

CONCLUSION

Ambient UVR exposure was associated with a higher risk of HZ in men but not in women. A history of severe sunburn was associated with a modest increased risk of HZ in men and women, possibly because of immunosuppression from overexposure to the sun.

Assessment of climate change impact on the malaria vector Anopheles hyrcanus, West Nile disease, and incidence of melanoma in the Vojvodina Province (Serbia) using data from a regional climate model

Motivated by the One Health paradigm, we found the expected changes in temperature and UV radiation (UVR) to be a common trigger for enhancing the risk that viruses, vectors, and diseases pose to human and animal health. We compared data from the mosquito field collections and medical studies with regional climate model projections to examine the impact of climate change on the spreading of one malaria vector, the circulation of West Nile virus (WNV), and the incidence of melanoma. We analysed data obtained from ten selected years of standardised mosquito vector sampling with 219 unique location-year combinations, and 10 years of melanoma incidence. Trends in the observed data were compared to the climatic variables obtained by the coupled regional Eta Belgrade University and Princeton Ocean Model for the period 1961-2015 using the A1B scenario, and the expected changes up to 2030 were presented. Spreading and relative abundance of Anopheles hyrcanus was positively correlated with the trend of the mean annual temperature. We anticipated a nearly twofold increase in the number of invaded sites up to 2030. The frequency of WNV detections in Culex pipiens was significantly correlated to overwintering temperature averages and seasonal relative humidity at the sampling sites. Regression model projects a twofold increase in the incidence of WNV positive Cx. pipiens for a rise of 0.5°C in overwintering TOctober-April temperatures. The projected increase of 56% in the number of days with Tmax ≥ 30°C (Hot Days-HD) and UVR doses (up to 1.2%) corresponds to an increasing trend in melanoma incidence. Simulations of the Pannonian countries climate anticipate warmer and drier conditions with possible dominance of temperature and number of HD over other ecological factors. These signal the importance of monitoring the changes to the preparedness of mitigating the risk of vector-borne diseases and melanoma.

Sun Safe Workplaces: Effect of an Occupational Skin Cancer Prevention Program on Employee Sun Safety Practices

OBJECTIVE

Occupational skin cancer prevention is a priority because outdoor workers are exposed to high levels of ultraviolet radiation, the primary risk factor for skin cancer.

METHODS

A 2-year follow-up assessment of the impact of Sun Safe Workplaces (SSW), a workplace sun safety program that promoted policy adoption and education, on employee sun safety behavior was conducted. Sixty-three of 98 local government organizations from the original study participated.

RESULTS

Outdoor workers (n = 1724) completed surveys on personal sun protection practices. Employees' sun protection improved statistically significantly in the intervention group receiving the SSW program. SSW's effect was mediated by the number of workplace actions to implement elements of the policy, including sun protection messages and equipment and employee reports of sun safety training.

CONCLUSION

Policy promotion is a feasible approach to occupational skin cancer prevention.

Differences in reported sun protection practices, skin cancer knowledge, and perceived risk for skin cancer between rural and urban high school students

PURPOSE

The purpose of the current study was to evaluate differences in reported use of sun protection, tanning behaviors, skin cancer-related knowledge, and perceived risk between rural and urban high school students in a geographic area with high rates of melanoma.

METHODS

A total of 1,570 high school students (56.8% female) from urban (6 schools) and rural (7 schools) geographic areas in Utah completed questionnaires assessing sun protection and tanning behaviors, skin cancer-related knowledge, and perceived risk for skin cancer. Analyses examined potential differences in these outcomes between rural and urban students and by gender.

RESULTS

Compared to students in urban areas, those in rural areas had lower odds of wearing sunscreen (OR 0.71; 95% CI 0.53, 0.95; p = 0.022), re-applying sunscreen (OR 0.61; 95% CI 0.74, 1.02; p = 0.002), wearing long-sleeved shirts (OR 0.63 95% CI 0.46, 0.86; p = 0.004), and seeking shade (OR 0.67; 95% CI 0.50, 0.88; p = 0.005).

CONCLUSIONS

Rural students reported less adequate use of sun protection than urban students. Rural male students reported lower knowledge scores compared to urban males. Future skin cancer prevention efforts targeting rural high schoolers are warranted.

Barriers and Facilitators to Melanoma Prevention and Control Behaviors Among At-Risk Children

Melanoma prevention is essential for children who are at elevated risk for the disease due to family history. However, children who carry a familial risk for the disease do not optimally adhere to recommended melanoma preventive behaviors. The current study sought to identify perceived barriers to and facilitators of children's engagement in melanoma preventive behaviors among children at elevated risk for melanoma due to family history of the disease (i.e., having a parent with a history of melanoma) from both parents' and childrens' perspectives. Qualitative methods were employed and consisted of separate focus group discussions with children (ages 8-17 years, n = 37) and their parents (n = 39). Focus group transcripts were coded using content analysis. Parents and children reported a number of barriers and facilitators, including on the individual (e.g., knowledge and awareness, preferences), social (e.g., peer influences, family modeling and communication), and contextual (e.g., healthcare provider communication) levels. The identified categories of barriers and facilitators both confirm and extend the literature documenting the reasons children who are at elevated risk for melanoma do not engage in melanoma prevention and control behaviors. Programs aiming to decrease melanoma risk among children of melanoma survivors could help families address their barriers to preventive behavior implementation and build on facilitators. Melanoma survivors and their children could benefit from support on their interactions with healthcare providers, schools, peers, and other caregivers about melanoma prevention.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Optimal sunscreen use, during a sun holiday with a very high ultraviolet index, allows vitamin D synthesis without sunburn

Background

Sunlight contains ultraviolet (UV)A and UVB radiation. UVB is essential for vitamin D synthesis but is the main cause of sunburn and skin cancer. Sunscreen use is advocated to reduce the sun's adverse effects but may compromise vitamin D status.

Objectives

To assess the ability of two intervention sunscreens to inhibit vitamin D synthesis during a week‐long sun holiday.

Methods

The impact of sunscreens on vitamin D status was studied during a 1‐week sun holiday in Tenerife (28° N). Comparisons were made between two formulations, each with a sun protection factor (SPF) of 15. The UVA‐protection factor (PF) was low in one case and high in the other. Healthy Polish volunteers (n = 20 per group) were given the sunscreens and advised on the correct application. Comparisons were also made with discretionary sunscreen use (n = 22) and nonholiday groups (51·8° N, n = 17). Sunscreen use in the intervention groups was measured. Behaviour, UV radiation exposure, clothing cover and sunburn were monitored. Serum 25‐hydroxyvitamin D₃ [25(OH)D₃] was assessed by high‐performance liquid chromatography–tandem mass spectrometry.

Results

Use of intervention sunscreens was the same (P = 0·60), and both equally inhibited sunburn, which was present in the discretionary use group. There was an increase (P < 0·001) in mean ± SD 25(OH)D₃ (28·0 ± 16·5 nmol L⁻¹) in the discretionary use group. The high and low UVA‐PF sunscreen groups showed statistically significant increases (P < 0·001) of 19·0 ± 14·2 and 13·0 ± 11·4 nmol L⁻¹ 25(OH)D₃, respectively with P = 0·022 for difference between the intervention sunscreens. The nonholiday group showed a fall (P = 0·08) of 2·5 ± 5·6 nmol L⁻¹ 25(OH)D₃.

Conclusions

Sunscreens may be used to prevent sunburn yet allow vitamin D synthesis. A high UVA‐PF sunscreen enables significantly higher vitamin D synthesis than a low UVA‐PF sunscreen because the former, by default, transmits more UVB than the latter.

What's already known about this topic?

Action spectra (wavelength dependence) for erythema and the cutaneous formation of vitamin D overlap considerably in the ultraviolet (UV)B region.

Theoretically, sunscreens that inhibit erythema should also inhibit vitamin D synthesis.

To date, studies on the inhibitory effects of sunscreens on vitamin D synthesis have given conflicting results, possibly, in part, because people typically apply sunscreen suboptimally.

Many studies have design flaws.

What does this study add?

Sunscreens (sun protection factor, SPF 15) applied at sufficient thickness to inhibit sunburn during a week‐long holiday with a very high UV index still allow a highly significant improvement of serum 25‐hydroxyvitamin D₃ concentration.

An SPF 15 formulation with high UVA protection enables better vitamin D synthesis than a low UVA protection product. The former allows more UVB transmission.

Linked Editorial: https://doi.org/10.1111/bjd.18273.

https://doi.org/10.1111/bjd.18492 available online

https://www.bjdonline.com/article/optimal-sunscreen-use-during-a-sun-holiday-with-a-very-high-ultraviolet-index-allows-vitamin-d-synthesis-without-sunburn/

Cutaneous nevi and risk of melanoma death in women and men: A prospective study

BACKGROUND

It was unclear whether an increased number of common nevi (moles) predicts melanoma death.

OBJECTIVE

We prospectively examined the association between number of common nevi and risk of melanoma death.

METHODS

Our study used data from the Nurses' Health Study (n = 77,288 women) and Health Professionals Follow-up Study (n = 32,455 men). In 1986, participants were asked about the number of moles they had with a ≥3-mm diameter on the upper extremity, and we stratified their answers into 3 categories (none, 1-2, or ≥3) on the basis of data distribution.

RESULTS

During follow-up (1986-2012), 2452 melanoma cases were pathologically confirmed; among these, we identified 196 deaths due to melanoma. Increased number of nevi was associated with melanoma death; the hazard ratio (HR) for ≥3 nevi compared with no nevi was 2.49 (95% confidence interval [CI] 1.50-4.12) for women and 3.97 (95% CI 2.54-6.22) for men. Among melanoma cases, increased number of nevi was associated with melanoma death in men (≥3 nevi, HR 1.89, 95% CI 1.17-3.05) but not in women. Similarly, the number of nevi was positively associated with Breslow thickness in men only (Ptrend = .01).

LIMITATIONS

This is an epidemiologic study without examination into mechanisms.

CONCLUSION

Increased number of cutaneous nevi was significantly associated with melanoma death. High nevus count might serve as an independent prognostic factor to predict the risk of melanoma death particularly among male melanoma patients.

Reproductive factors, exogenous hormone use and incidence of melanoma among women in the United States

Background

Although the photosensitising effects of oestrogens may increase the impact of ultraviolet radiation (UVR) on melanoma risk, few prospective studies have comprehensively assessed the association between oestrogen-related factors and melanoma.

Methods

We examined the associations between reproductive factors, exogenous oestrogen use and first primary invasive melanoma among 167 503 non-Hispanic white, postmenopausal women in the NIH-AARP Diet and Health Study. Satellite-based ambient UVR estimates were linked to geocoded residential locations of participants at study baseline.

Results

Increased risk of melanoma was associated with early age at menarche (≤10 vs ≥15 years: HR = 1.25, 95% CI: 0.92, 1.71; P for trend = 0.04) and late age at menopause (≥50 vs <45 years: HR = 1.34, 95% CI: 1.13, 1.59; P for trend = 0.001). The relationship between ambient UVR and melanoma risk was highest among women with age at menarche ≤10 years (HR per UVR quartile increase = 1.29; 95% CI: 1.05, 1.58; P-interaction = 0.02). Melanoma risk was not associated with parity, age at first birth, use of oral contraceptives or use of menopausal hormone therapy.

Conclusions

Our findings suggest that increased melanoma risk is associated with early age at menarche and late age at menopause. Effect modification findings support the hypothesis that endogenous oestrogen exposure in childhood increases photocarcinogenicity. Future studies should include information on personal UVR exposure and sun sensitivity.

Synthesis and physiological implications of melanic pigments

The process of melanin synthesis and distribution is called melanogenesis, a process that is based on melanocytes present among the basal cells of the epidermis. Pigments formed in melanocyte melanosomes are then stored in the basal layer of epidermal cells, as well as in dermal macrophages, which become melanophores. From the embryological point of view, melanocytes derive from the melanoblasts of the neural crest, from where they migrate during the first months of life into the skin, eye, cochlea, bone, peripheral nervous system, heart and adipose tissue. The melanic pigments, eumelanin and pheomelanin, are the final product of complex biochemical reactions starting from the amino acid L-tyrosine. Melanin has a major role in skin homeostasis through the photoprotection it offers from the harmful effect of ultraviolet radiation. Melanin absorbs and/or reflects ultraviolet radiation but is also involved in the neutralizing process of free radicals and reactive oxygen species. Pigmentogenesis is a dependent oxygen process and is controlled by intrinsic factors (genetic and hormonal) as well as extrinsic factors (ultraviolet radiation). Melanogenesis is stimulated by stimulant melanocytic hormone, adrenocorticotropin hormone, estrogens and progesterone. The present review aimed to provide a summary of recent data about melanogenesis physiology.

Host Characteristics and Risk of Incident Melanoma by Breslow Thickness

BACKGROUND

Several host characteristics, including pigmentary traits (hair color, sunburn susceptibility and tanning ability), number of common nevi (moles), and family history of melanoma, have been associated with risk of melanoma.

METHODS

We prospectively examined the associations between host characteristics and risk of incident melanoma by Breslow thickness (≤1 mm, thin melanoma; or >1 mm, "thicker melanoma") based on the Nurses' Health Study (NHS, n = 86,380 women), NHS II (n = 104,100 women), and Health Professionals Follow-up Study (HPFS, n = 46,934 men).

RESULTS

During 22-30 years' follow-up, a total of 1,813 incident melanoma cases were identified with information on Breslow thickness, 1,392 (76.8%) of which had thin melanoma. No significant differences were observed for thin and thicker melanoma in associations with hair color, sunburn susceptibility, and tanning ability. However, we found significant differences for the association with family history of melanoma, with a higher risk estimate for thicker melanoma [HR = 2.55; 95% confidence interval (CI): 1.91-3.42] than thin melanoma (HR = 1.59; 95% CI: 1.21-2.08; P heterogeneity = 0.02). Interestingly, women and men displayed differential associations between nevi count and risk of melanoma by Breslow thickness, with the association appearing stronger for thicker melanoma than thin melanoma in men (P heterogeneity = 0.01), but not in women.

CONCLUSIONS

Individuals with family history of melanoma may be more likely to develop thicker melanoma. Men with high number of common nevi may tend to develop thicker melanoma, which was not found for women.

IMPACT

The findings further stress the risk of thicker melanoma for individuals with a family history of melanoma and men with a high nevi count.

Sunscreen applied at ≥ 2 mg cm-2 during a sunny holiday prevents erythema, a biomarker of ultraviolet radiation-induced DNA damage and suppression of acquired immunity

BACKGROUND

Sun protection factor (SPF) is assessed with sunscreen applied at 2 mg cm^-2 . People typically apply around 0·8 mg cm^-2 and use sunscreen daily for holidays. Such use results in erythema, which is a risk factor for skin cancer.

OBJECTIVES

To determine (i) whether typical sunscreen use resulted in erythema, epidermal DNA damage and photoimmunosuppression during a sunny holiday, (ii) whether optimal sunscreen use inhibited erythema and (iii) whether erythema is a biomarker for photoimmunosuppression in a laboratory study.

METHODS

Holidaymakers (n = 22) spent a week in Tenerife (very high ultraviolet index) using their own sunscreens without instruction (typical sunscreen use). Others (n = 40) were given SPF 15 sunscreens with instructions on how to achieve the labelled SPF (sunscreen intervention). Personal ultraviolet radiation (UVR) exposure was monitored electronically as the standard erythemal dose (SED) and erythema was quantified. Epidermal cyclobutane pyrimidine dimers (CPDs) were determined by immunostaining, and immunosuppression was assessed by contact hypersensitivity (CHS) response.

RESULTS

There was no difference between personal UVR exposure in the typical sunscreen use and sunscreen intervention groups (P = 0·08). The former had daily erythema on five UVR-exposed body sites, increased CPDs (P < 0·001) and complete CHS suppression (20 of 22). In comparison, erythema was virtually absent (P < 0·001) when sunscreens were used at ≥ 2 mg cm^-2 . A laboratory study showed that 3 SED from three very different spectra suppressed CHS by around ~50%.

CONCLUSIONS

Optimal sunscreen use prevents erythema during a sunny holiday. Erythema predicts suppression of CHS (implying a shared action spectrum). Given that erythema and CPDs share action spectra, the data strongly suggest that optimal sunscreen use will also reduce CPD formation and UVR-induced immunosuppression.

Risk of Kaposi sarcoma after solid organ transplantation in the United States

Due to treatment with immunosuppressive medications, solid organ transplant recipients have elevated risk for Kaposi sarcoma (KS), which is caused by human herpesvirus 8 (HHV8). Other risk factors for KS are poorly understood. We linked the United States solid organ transplant registry with 17 population-based cancer registries to ascertain KS incidence among 244,964 transplant recipients from 1987-2014. To compare incidence rates of KS according to patient and transplant characteristics, we calculated incidence rate ratios (IRRs) using Poisson regression. To compare associations of KS with other skin cancers occurring before or within 12 months of KS diagnosis, we computed odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression. All statistical tests were two-sided. We identified 163 KS cases during follow-up. Among transplant recipients, we found significantly increased risk of KS associated with male sex (IRR = 1.87; 95%CI:1.32,2.71), nonwhite race (IRR = 2.67; 95%CI:1.92,3.72), non-US citizenship (IRR = 2.10; 95%CI:1.19,3.47), lung transplant (IRR = 2.22; 95%CI:1.03,4.24, vs. kidney), and older age at transplant. KS risk decreased significantly with time since transplant and recent calendar year, however, no specific induction or maintenance medication was associated with KS. KS incidence was not significantly associated with ambient ultraviolet radiation (IRR = 1.32 95%CI:0.87,2.02, tertile 3 vs. 1). KS incidence has decreased in recent calendar years. In a cross-sectional sample, we found cutaneous squamous cell carcinoma was associated with KS (OR = 4.83; 95%CI:1.30,14.69). KS risk factors included those potentially associated with HHV8 infection and increased immunosuppression. Our findings suggest that transplant recipients with a non-KS skin cancer may also be at high KS risk.