Risk of Basal and Squamous Cell Carcinomas of the Skin in Sion, Switzerland: A Case-control Study

Clinico-epidemiological characteristics and long-term surgical outcome of basal cell carcinoma treated with standard excision in patients of skin of colour: A retrospective study from Northern India

Background There is scant data on basal cell carcinoma (BCC) in Indian patients. This retrospective study was conducted to explore epidemiology, risk factors, clinical and pathological aspects, and long-term treatment outcomes of BCC in a cohort of North Indian patients. Methods Data about patients registered in the dermatosurgery clinic between 01 January 2017 and 31 December 2022 with a confirmed diagnosis of BCC was collected. Results Among the 83 patients, 56.6% were females, and the median age was 62 years (6-85 years). Most patients (81.9%) had a single BCC lesion, resulting in a total of 126 assessed lesions. The median size of BCC at presentation was 1.90 cm, with nodular BCC being the most common histopathological subtype (39.7%). Head and neck region involvement was observed in 82.5% of patients, with the malar region, nose, and periorbital region being the most commonly affected sites. Pigmentation was clinically evident in 45.2% of cases. Surgical excision was the primary treatment modality (71.1% of patients). The median follow-up duration was 40 months (6-57 months). Recurrence occurred in five patients, with a longer disease-free survival period observed in the surgically treated group (55.58 ± 0.98 months) compared to patients treated with medical or destructive therapies (43.6 ± 3.482 months) (p = 0.003). Conclusion The data from this hospital-based study indicated a slight predilection for females among North Indian patients with BCC, with most cases occurring during their seventh decade of life. The condition commonly occurred on sun-exposed areas such as the malar region and nose, with a high percentage of pigmented lesions. Recurrence following surgical excision was rare, and overall treatment outcomes were favourable.

Occupational solar exposure and basal cell carcinoma. A review of the epidemiologic literature with meta-analysis focusing on particular methodological aspects

BACKGROUND

Numerous epidemiologic studies and a few systematic reviews have investigated the association between occupational solar exposure and basal cell carcinoma (BCC). However, previous reviews have several deficits with regard to included and excluded studies/risk estimates and the assessment of risk of selection bias (RoSB). Our aim was to review epidemiologic studies with a focus on these deficits and to use meta-(regression) analyses to summarize risk estimates.

METHODS

We systematically searched PubMed (including MEDLINE) and Embase for epidemiologic studies. Study evaluation considered four main aspects of risk of bias assessments, i.e. Selection of subjects (selection bias); Exposure variables; Outcome variables; Data analysis.

RESULTS

Of 56 identified references, 32 were used for meta-(regression) analyses. The overall pooled risk estimate for BCC comparing high/present vs. low/absent occupational solar exposure was 1.20 (95% CI 1.02-1.43); among studies without major deficits regarding data analysis, it was 1.10 (95% CI 0.91-1.33). Studies with low and high RoSB had pooled risk estimates of 0.83 (95% CI 0.73-0.93) and 1.95 (95% CI 1.42-2.67), respectively. The definitions of exposure and outcome variables were not correlated with study risk estimates. Studies with low RoSB in populations with the same latitude or lower than Germany had a pooled risk estimate of 1.01 (95% CI 0.88-1.15).

CONCLUSION

Due to the different associations between occupational solar exposure and BCC among studies with low and high RoSB, we reason that the current epidemiologic evidence base does not permit the conclusion that regular outdoor workers have an increased risk of BCC.

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

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

Photoprotection in Outdoor Sports: A Review of the Literature and Recommendations to Reduce Risk Among Athletes

Solar exposure, for long hours and often at peak times with limited shade available, predisposes athletes to episodic sunburn and chronic damage, causing increased risk of precancerous lesions and skin cancer. Environmental factors and training intensity affect risk. Clothing provides good protection, but changing established "uniforms" may not be possible for reasons of practicality, safety, or simply custom. Although physical activity should be encouraged for its physical and mental benefits, risk of skin damage should be minimised. We review existing behaviours, skin cancer risk, and campaigns in the sporting population and highlight key recommendations to help sun protection practices become engrained in sports practice.

Sunscreens With High Versus Low Sun Protection Factor and Cutaneous Squamous Cell Carcinoma Risk: A Population-Based Cohort Study

Evidence on sunscreen use and cutaneous squamous cell carcinoma (cSCC) risk is limited. Most studies have not taken sun protection factor (SPF) into consideration and used nonusers of sunscreen as the reference group. Nonusers are likely a priori at lower cSCC risk than users. No study has investigated the effect of high- versus low-SPF sunscreens on cSCC, appropriately adjusting for time-varying confounding. Using data from the Norwegian Women and Cancer Study (1991–2016), we investigated whether use of SPF ≥15 versus SPF <15 sunscreens reduces cSCC risk. We used a marginal structural Cox proportional hazards model with inverse probability of treatment and censoring weights to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). During follow-up of 148,781 women (mean follow-up, 14.3 years), 653 women were diagnosed with cSCC. The effect on cSCC risk of sunscreens with SPF ≥15 versus SPF <15 was close to the null when used at any latitudes (HR = 1.02, 95% CI: 0.82, 1.27) and when used in lower-latitude settings (HR = 1.05, 95% CI: 0.84, 1.32). In conclusion, we found no indication that sunscreens with SPF ≥15 reduced Norwegian women’s cSCC risk more than sunscreens with SPF <15, suggesting that either there is no difference in their effects long-term or the difference is diluted by incorrect application.

Eye color and the risk of skin cancer

Melanoma, basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common skin cancers. The incidence rates of all three types of skin cancers have increased in the past three decades. Light pigmentary traits have been recognized as one of the host risk factors for skin cancer, but findings on associations between eye colors and risk of skin cancers have been inconsistent.We performed a prospective analysis to examine the association between eye colors and risk of skin cancers using the Health Professionals Follow-up Study (HPFS). Cox proportional hazard models were applied to estimate relative risks (RRs) and their 95% confidence intervals (CIs). Effect modifications due to hair color and skin reaction to sun were also examined.The HPFS included 35,662 males. During a median follow-up of 19 years (1988-2012), 445 melanoma, 1123 SCC, and 7198 BCC cases were documented. Compared to those whose eye colors were dark or brown, participants with hazel/green/medium and blue/light colors had a 24% (RR = 1.24, 95% CI: 1.06-1.45) and a 19% (RR = 1.19, 95% CI: 1.01-1.41) higher risk of SCC, respectively. Similarly, a higher risk of BCC was observed in participants with hazel/green/medium eye colors (RR = 1.16, 95% CI: 1.09-1.23) and blue/light eye colors (RR = 1.17, 95% CI: 1.10-1.25). We did not find significant associations between eye color and risk of melanoma. Lighter eye color was associated with increased risks of SCC and BCC among those with dark hair colors (p for interaction ≤ 0.02).In conclusion, in this large prospective study of men, we found that light eye colors were associated with higher risks of SCC and BCC, but not melanoma. Further studies are needed to confirm this association in other populations.

Basal cell carcinoma risk and solar UV exposure in occupationally relevant anatomic sites: do histological subtype, tumor localization and Fitzpatrick phototype play a role? A population-based case-control study

Background

A two-fold risk increase to develop basal cell carcinoma was seen in outdoor workers exposed to high solar UV radiation compared to controls. However, there is an ongoing discussion whether histopathological subtype, tumor localization and Fitzpatrick phototype may influence the risk estimates.

Objectives

To evaluate the influence of histological subtype, tumor localization and Fitzpatrick phototype on the risk to develop basal cell carcinoma in highly UV-exposed cases and controls compared to those with moderate or low solar UV exposure.

Methods

Six hundred forty-three participants suffering from incident basal cell carcinoma in commonly sun-exposed anatomic sites (capillitium, face, lip, neck, dorsum of the hands, forearms outside, décolleté) of a population-based, case-control, multicenter study performed from 2013 to 2015 in Germany were matched to controls without skin cancer. Multivariate logistic regression analysis was conducted stratified for histological subtype, phototype 1/2 and 3/4. Dose-response curves adjusted for age, age², sex, phototype and non-occupational UV exposure were calculated.

Results

Participants with high versus no (OR 2.08; 95% CI 1.24–3.50; p = 0.006) or versus moderate (OR 2.05; 95% CI 1.15–3.65; p = 0.015) occupational UV exposure showed a more than two-fold significantly increased risk to develop BCC in commonly UV-exposed body sites. Multivariate regression analysis did not show an influence of phototype or histological subtype on risk estimates. The restriction of the analysis to BCC cases in commonly sun-exposed body sites did not influence the risk estimates. The occupational UV dosage leading to a 2-fold increased basal cell carcinoma risk was 6126 standard erythema doses.

Conclusion

The risk to develop basal cell carcinoma in highly occupationally UV-exposed skin was doubled consistently, independent of histological subtype, tumor localization and Fitzpatrick phototype.

Solar Ultraviolet Exposure in Individuals Who Perform Outdoor Sport Activities

BACKGROUND

Skin cancer is the most common cancer in the USA. Therefore, it is important to review the contribution of ultraviolet radiation (UVR) exposure to skin cancer in individuals with the highest risk. Documenting the relationship between outdoor sports solar ultraviolet exposure and their risk of skin cancer along with appropriate risk mitigation strategies can help inform clinicians of practical information for counseling sun protective behaviors in this population.

METHODS

We conducted a review of the current evidence using PubMed to answer the following research questions: (1) How is ultraviolet radiation measured? (2) What is the modern utility of the ultraviolet index in modifying recreational sun protection behaviors? (3) What is the risk of developing skin cancer for outdoor sport participants? (4) What is the prevalence of skin cancer in sport participants? and (5) Is the number of nevi and solar lentigines elevated in outdoor sport participants?

RESULTS

Based on the literature, individuals who practice outdoor sport-related activities receive high ultraviolet radiation exposure, have a high risk for skin cancer, have a high prevalence for pigmented lesions, and may benefit from electronic sun protection educational interventions.

CONCLUSIONS

Individuals who practice outdoor sports experience substantially higher ultraviolet radiation exposure, routinely exceed the recommended exposure limits, and are at a higher risk of developing skin cancer. Therefore, those who are frequently engaged in outdoor leisure activities should be coached about efficient sun protective practices and relevant mobile technologies that may facilitate adherence.

Insufficient Sun Exposure Has Become a Real Public Health Problem

This article aims to alert the medical community and public health authorities to accumulating evidence on health benefits from sun exposure, which suggests that insufficient sun exposure is a significant public health problem. Studies in the past decade indicate that insufficient sun exposure may be responsible for 340,000 deaths in the United States and 480,000 deaths in Europe per year, and an increased incidence of breast cancer, colorectal cancer, hypertension, cardiovascular disease, metabolic syndrome, multiple sclerosis, Alzheimer's disease, autism, asthma, type 1 diabetes and myopia. Vitamin D has long been considered the principal mediator of beneficial effects of sun exposure. However, oral vitamin D supplementation has not been convincingly shown to prevent the above conditions; thus, serum 25(OH)D as an indicator of vitamin D status may be a proxy for and not a mediator of beneficial effects of sun exposure. New candidate mechanisms include the release of nitric oxide from the skin and direct effects of ultraviolet radiation (UVR) on peripheral blood cells. Collectively, this evidence indicates it would be wise for people living outside the tropics to ensure they expose their skin sufficiently to the sun. To minimize the harms of excessive sun exposure, great care must be taken to avoid sunburn, and sun exposure during high ambient UVR seasons should be obtained incrementally at not more than 5-30 min a day (depending on skin type and UV index), in season-appropriate clothing and with eyes closed or protected by sunglasses that filter UVR.

Global evidence on occupational sun exposure and keratinocyte cancers: a systematic review

Individual studies have suggested that the association between occupational exposure to solar ultraviolet radiation (UVR) and the development of keratinocyte cancers (KCs) may only be valid in populations of European ancestry living in certain geographical regions. Comparative global data are scarce and so this review aimed to summarize current evidence on the association between occupational exposure to solar UVR and the development of KCs, with a specific focus on geographical location and skin colour. Ovid MEDLINE, PubMed, Embase and Web of Science were searched for potentially relevant records. Extracted data were summarized by study, country and region. We included one prospective cohort study and 18 case-control studies (n = 15 233) from 12 countries in regions where the majority of the population is white skinned (Americas, Europe and Oceania). Eighteen of the 19 studies reported effect estimates suggesting an increased risk of basal cell carcinoma (BCC) and/or squamous cell carcinoma (SCC) among outdoor workers. Only 11 studies found a significantly increased risk and many had imprecise estimates. There was a significantly increased risk of BCC and SCC in individual studies in North America, Latin America and the Caribbean, Western Europe and Southern Europe, but not across regions or countries. Overall, 95% of studies reported higher risks among outdoor workers, although the increases in risk were statistically significant in just over half of the studies. Well-designed and sufficiently powered occupational case-control and cohort studies with adequate adjustment for confounding factors and other risk factors are required to provide more accurate risk estimates for occupational KC.

Ultraviolet Radiation Exposure, Risk, and Protection in Military and Outdoor Athletes

Overexposure to ultraviolet radiation (UVR) from the sun is associated with deleterious health effects including, but not limited to, increased risk of skin cancers. Military personnel and those who participate in outdoor exercise or sports represent two potential populations at elevated risk of negative health consequences of UVR exposure due to large amounts of time spent outdoors, often in harsh UVR environments. Despite exposure to high and/or frequent doses of UVR in recreational and tactical athletes, adequate sun-protection practices are often disregarded or not well understood by many within these at-risk populations, resulting in heightened risk of negative UVR effects. The focus of this review is to examine the available literature regarding UVR exposure, risk of adverse health effects of UVR exposure, and sun protection practices in outdoor exercisers, athletes, and military personnel.

Sun Exposure Public Health Directives

There have been many public health recommendations for avoiding UV radiation exposures. This is primarily due to concerns about skin cancer and especially melanoma, the most serious type of skin cancer. However, UV radiation is also known as the primary source of vitamin D and other compounds needed for good health. This brief commentary lists several of the many important recent studies of adverse health effects associated with low sun exposure, including some specific cancers, multiple sclerosis, diabetes, cardiovascular disease, autism, Alzheimer's disease, and age-related macular degeneration. Our conclusion is that non-burning UV exposure is a health benefit and-in moderation-should be recommended as such.

Reproducibility of Histopathologic Diagnosis and Classification of Non-Melanocytic Skin Cancer: A Panel Exercise in the Framework of the Multicenter Southern European Study Helios

Aims and background

The reproducibility of histologic diagnoses, and in particular of the distinction between basal and squamous cell forms, has been evaluated in the framework of a multicenter case-control study (in Italy, France, Spain and Switzerland) aimed to assess the causes of non-melanocytic skin cancers.

Methods

A panel composed of 10 pathologists from the collaborating centers was appointed. A total of 1774 slides of routine diagnoses were blindly reviewed by a second panelist; discordant diagnoses underwent a third examination. Controversial and interesting cases were discussed during general sessions.

Results

The results showed a high degree of concordance (99.5%), with a Cohen's kappa of 0.85 (95% CI, 0.77–0.94) in the assessment of malignancy of lesions. The concordance in the distinction between large morphologic groups, basal cell carcinoma and squamous cell carcinoma was also high (Cohen's kappa = 0.85; 95% CI, 0.82–0.89). The assessment of histologic subtypes, degree of invasion and differentiation showed a lower degree of concordance, presumably as a consequence of a weaker consistency in the relevant classifications.

Conclusions

The reproducibility study has therefore validated the epidemiologic study and in particular allowed to correct some misclassifications that could have lessened the analysis of the case-control study. In general, because of its characteristics (number of pathologists and variety of their origins, the large number of cases examined, blind examination of histologic slides), the conclusions of the study may show a certain degree of generalization, at least with regard to the countries represented. Routine histologic diagnoses of cutaneous carcinoma showed a high degree of reliability with reference to the assessment of malignancy and the distinction between basal and squamous cell carcinoma morphotypes.

Extreme UV index and solar exposures at Plateau Rosà (3500 m a.s.l.) in Valle d'Aosta Region, Italy

The purpose of this study is to assess personal exposures of skiers at the Alpine site of Plateau Rosà (45.9°N, 7.7°E, 3500 m a.s.l.), in the Valle d'Aosta region, Italy. The campaign was carried out on July 12th, 2011 during the summer ski season. A peak UVI value of 12.3, among the highest in Europe, was recorded on that day. Personal exposures (PE) were quantified using both polysulphone (PS) and poly-dimethyl phenylene oxide (PPO) dosimeters attached vertically to the cap because it is representative of the vertically oriented face of skiers. Exposure ratio (ER) defined as the ratio between PE and the corresponding ambient dose (i.e. erythemally weighted dose received by a horizontal surface) measured by a broad-band radiometer during the same exposure time of the subjects, was used to compare the results with previous studies. Skin color was also measured on the inner upper arm and on the cheek and differences in ITA (Individual Typology Angle) and a* (redness) values before and after exposure, were statistically analyzed. During the exposure period, the median PE (with PS) was 1.47 kJ m(-2) and that obtained by PPO was 1.15 kJ m(-2). The median of the ERs was 0.65 (min: 0.50, max: 0.83) considering the cumulative PS exposure and 0.46 (min: 0.29, max: 0.95) for PPO. An increase in ITAs on the exposed site (i.e. the skin became lighter) was observed after exposure. These results indicate that: a) for some skiers, the exposures were similar to those received on the horizontal plane; and b) the targeted population showed exposures above the occupational threshold limit value (TLV) defined by ICNIRP; c) the use of physical sunscreens which tend to leave a white cast, might have reduced skin color change. Nevertheless possible visible sun-induced skin-color changes could be observed after longer time intervals after exposure.

A study of Basal cell carcinoma in South asians for risk factor and clinicopathological characterization: a hospital based study

Objectives. Although the incidence of skin cancers in India (part of South Asia) is low, the absolute number of cases may be significant due to large population. The existing literature on BCC in India is scant. So, this study was done focusing on its epidemiology, risk factors, and clinicopathological aspects. Methods. A hospital based cross-sectional study was conducted in Punjab, North India, from 2011 to 2013. History, examination and histopathological confirmation were done in all the patients visiting skin department with suspected lesions. Results. Out of 36 confirmed cases, 63.9% were females with mean ± SD age being 60.9 ± 14.2 years. Mean duration of disease was 4.7 years. Though there was statistically significant higher sun exposure in males compared to females (P value being 0.000), BCC was commoner in females, explainable by intermittent sun exposure (during household work in the open kitchens) in women. Majority of patients (88.9%) had a single lesion. Head and neck region was involved in 97.2% of cases, with nose being the commonest site (50%) with nodular/noduloulcerative morphology in 77.8% of cases. Pigmentation was evident in 22.2% of cases clinically. Nodular variety was the commonest histopathological variant (77.8%). Conclusions. This study highlights a paradoxically increasing trend of BCC with female preponderance, preferential involvement of nose, and higher percentage of pigmentation in Indians.

Early-onset basal cell carcinoma and indoor tanning: a population-based study

OBJECTIVE

Indoor tanning with UV radiation-emitting lamps is common among adolescents and young adults. Rising incidence rates of basal cell carcinoma (BCC) have been reported for the United States and elsewhere, particularly among those diagnosed at younger ages. Recent epidemiologic studies have raised concerns that indoor tanning may be contributing to early occurrence of BCC, and younger people may be especially vulnerable to cancer risk associated with this exposure. Therefore, we sought to address these issues in a population-based case-control study from New Hampshire.

METHODS

Data on indoor tanning were obtained on 657 cases of BCC and 452 controls ≤50 years of age.

RESULTS

Early-onset BCC was related to indoor tanning, with an adjusted odds ratio (OR) of 1.6 (95% confidence interval, 1.3-2.1). The strongest association was observed for first exposure as an adolescent or young adult, with a 10% increase in the OR with each age younger at first exposure (OR per year of age ≤23 = 1.1; 95% confidence interval, 1.0-1.2). Associations were present for each type of device examined (ie, sunlamps, tanning beds, and tanning booths).

CONCLUSIONS

Our findings suggest early exposure to indoor tanning increases the risk of early development of BCC. They also underscore the importance of counseling adolescents and young adults about the risks of indoor tanning and for discouraging parents from consenting minors to this practice.

Ultraviolet radiation and the athlete: risk, sun safety, and barriers to implementation of protective strategies

Ultraviolet (UV) radiation plays a pivotal role in the development of both melanoma and non-melanoma skin cancers. Numerous factors potentially place athletes at high risk for developing these cancers. Various prevention strategies ameliorate this risk, including avoiding sun exposure during peak UV exposure hours, applying sunscreen with a sun protection factor of 30 or above before participating in outdoor sports, wearing hats and sunglasses, and reducing exposure with long pants and long-sleeve shirts. The literature, however, cites several barriers to these prevention approaches, including sports' competition rules, the lack of availability of sunscreen, and the lack of information about sun safety behaviors. Sun safety education programs prove effective in getting athletes to participate in prevention strategies. This article reviews the effect of UV radiation on athletes' skin and provides sports medicine clinicians with suggestions to improve the sun safety behaviors of their athletes.

Indoor tanning and risk of early-onset basal cell carcinoma

BACKGROUND

Despite an increase in incidence of basal cell carcinoma (BCC) among young people and the ubiquity of indoor tanning in this population, few epidemiologic studies have investigated this exposure-disease relationship.

OBJECTIVE

We sought to evaluate the association between indoor tanning and early-onset BCC.

METHODS

Patients with BCC (n = 376) and control subjects with minor benign skin conditions (n = 390) who were younger than 40 years of age were identified through Yale Dermatopathology. Participants provided information on ever indoor tanning, age of initiation, frequency, duration, burns while tanning, and type of tanning device during an in-person interview. We calculated odds ratios (OR) and 95% confidence intervals (CI) using multivariate logistic regression with never indoor tanners as the referent group.

RESULTS

Ever indoor tanning was associated with a 69% increased risk of early-onset BCC (95% CI 1.15-2.48). This association was stronger among females (OR 2.14, 95% CI 1.31-3.47), for multiple BCCs (OR 2.16, 95% CI 1.26-3.70), and for BCCs on the trunk and extremities (OR 2.81, 95% CI 1.57-5.02). Risk increased dose dependently with years using regular indoor tanning devices (P trend = .003), number of overall burns (P trend < .001), and burns to biopsy site (P trend < .001) from indoor tanning. Approximately one quarter (27%) of early-onset BCCs (or 43% among women) could be prevented if individuals never tanned indoors.

LIMITATIONS

Potential recall bias of indoor tanning by patients and generalizability of the control population suggest replication in other studies is warranted.

CONCLUSIONS

Indoor tanning was a strong risk factor for early-onset BCC, particularly among females. Indoor tanning should continue to be targeted by both policy-based and behavioral interventions, as the impact on BCC-associated morbidity may be substantial.

Expanding occupational sun safety to an outdoor recreation industry: a translational study of the Go Sun Smart program

A successful occupational sun-protection program was translated to 67 ski areas where the effectiveness of two dissemination strategies was assessed. An industry professional association distributed materials to the resorts. Half of the resorts received the basic dissemination strategy (BDS) in which the materials were simply distributed to the resorts. In a randomized trial, the BDS was compared with an enhanced dissemination strategy (EDS) that added interpersonal contact with managers. Employees (n=2,228) at worksites that received the EDS had elevated program exposure (74.0% at EDS vs. 57.5% at BDS recalled a message). Exposure increased at two levels of program use: from less than four (55% exposed) to four to eight (68%) and to nine or more (82%) program items in use. More employees exposed to messages engaged in sun-safety behaviors than those unexposed. At worksites using nine or more items (versus 4-8 or <4), employees engaged in additional sun-safety behaviors. Program effects were strongly mediated by increased self-efficacy. Partnerships with industry associations facilitate dissemination of evidence-based programs. Dissemination methods are needed to maximize implementation and exposure to reduce health risk behaviors.

Outdoor sports and skin cancer

Ultraviolet radiation is estimated to be one of the most important risk factors for nonmelanoma and melanoma skin cancers. Athletes practicing outdoor sports receive considerable UV doses because of training and competition schedules with high sun exposure, and in alpine sports, by altitude-related increase of UV radiation and reflection from snow- and ice-covered surfaces. Extreme UV exposure in outdoor sports such as skiing, mountaineering, cycling, or triathlon has been documented in a series of dosimetric studies. Sweating because of physical exercise may contribute to UV-related skin damage as it increases the individual photosensitivity of the skin, facilitating the risk of sunburns. Large epidemiological studies showed that recreational activities such as sun exposure on the beach or during water sports were associated with an increased risk of basal cell carcinoma, whereas skiing has been shown to be at increased risk for squamous cell carcinoma. Risk factors of cutaneous melanoma such as the number of melanocytic nevi and solar lentigines have been found to be more frequent in subjects practicing endurance outdoor sports. An increased risk for cutaneous melanoma may be assumed for these athletes. In addition to the important sun exposure, exercise-induced immunosuppression may increase the risk for nonmelanoma skin cancer and cutaneous melanoma in athletes. Frequently, athletes seem to know little about the risk of sun exposure. Protective means such as avoiding training and competition with considerable sun exposure, choosing adequate clothing, and applying water-resistant sunscreen still need to be propagated in the community of outdoor sportsmen.

Occupation and skin cancer: the results of the HELIOS-I multicenter case-control study

Background

Non-melanoma skin cancer (NMSC) is the most frequent tumour among Caucasian populations worldwide. Among the risk factors associated with this tumour, there are host-related factors and several environmental agents. A greater likelihood of high exposure to physical agents (with the exception of solar radiation) and chemical agents depends on the work setting. Our objective is to evaluate the role of occupational exposures in NMSC, with special emphasis on risk factors other than solar radiation and skin type.

Methods

We analysed 1585 cases (1333 basal cell carcinoma (BCC) and 183 squamous cell carcinoma (SCC)) and 1507 controls drawn from the Helios-I multicenter study. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression mixed models.

Results

For NMSC as a whole (both histological types), miners and quarrymen, secondary education teachers, and masons registered excess risk, regardless of exposure to solar radiation and skin type (OR 7.04, 95% CI 2.44–20.31; OR 1.75, 95% CI 1.05–2.89 and OR 1.54, 95% CI 1.04–2.27, respectively). Frequency of BCC proved higher among railway engine drivers and firemen (OR 4.55; 95% CI 0.96–21.57), specialised farmers (OR 1.65; 95% CI 1.05–2.59) and salesmen (OR 3.02; 95% CI 1.05–2.86), in addition to miners and quarrymen and secondary education teachers (OR 7.96; 95% CI 2.72–23.23 and OR 1.76; 95% CI 1.05–2.94 respectively). The occupations that registered a higher risk of SCC (though not of BCC) were those involving direct contact with livestock, construction workers not elsewhere classified (OR 2.95, 95% CI 1.12–7.74), stationary engine and related equipment operators not elsewhere classified (OR 5.31, 95% CI 1.13–21.04) and masons (OR 2.55, 95% CI 1.36–4.78).

Conclusion

Exposure to hazardous air pollutants, arsenic, ionizing radiations and burns may explain a good part of the associations observed in this study. The Helios study affords an excellent opportunity for further in-depth study of physical and chemical agents and NMSC based on matrices of occupational exposure.

Ultraviolet Carcinogenesis in Nonmelanoma Skin Cancer Part II: Review and Update on Epidemiologic Correlations

The relationship between ultraviolet radiation and nonmelanoma skin cancer (NMSC) is further elucidated by a review of case-control studies relating type of exposure to the development of NMSC. Intermittent sun exposure is important in the pathogenesis of basal cell carcinoma, whereas cumulative exposure is important for both basal cell carcinoma and squamous cell carcinoma. The regional distribution of NMSC is also in areas of sun exposure. Furthermore, there are inherent risk factors for the development of NMSC that include hair and eye colors. Once an individual develops NMSC, he/she has increased risk of developing basal cell carcinoma, squamous cell carcinoma, or melanoma.

Epidemiology of nonmelanoma skin cancer (NMSC) in Europe: accurate and comparable data are needed for effective public health monitoring and interventions

Nonmelanoma skin cancer (NMSC) is the most common malignancy occurring in white populations. It is currently becoming an important challenge in terms of public health management as the increasing incidence rates will probably have a tremendous impact on healthcare costs. Possible factors driving this rise in NMSC numbers are increases in both acute and prolonged UV exposure together with increasing numbers of older people in the population. A better understanding of NMSC epidemiology in Europe is essential if an evidence-based European-wide public health policy is to be developed. It is obvious this can only be achieved by recording and analysing comparative epidemiological data. Finally, by improving the skin examination training for physicians, developing guidelines and exchanging best practices, a high level of healthcare could be provided for NMSC.

Occupational exposure to ultraviolet radiation: the duality dilemma

Human exposure to ultraviolet (UV) radiation is a component of everyday life and a significant hazard for outdoor workers. In addition, a large range of artificial sources also has the potential to provide extreme occupational UV exposure. Even though the human health risks of overexposure to UV are well documented, to date relatively little is known quantitatively about UV exposure. For example, the evidence indicates that workers who are exposed to particular sources (for example, welding arcs) are exposed to extreme UV exposures, despite the use of current control measures. In contrast, increasing evidence points to significant health impacts resulting from underexposure to UV, particularly with the production (or more correctly lack of production) of vitamin D in the skin. The latter poses a serious issue for the work-force, with specific risks for workers lacking adequate sun exposure-underground miners, long-haul flight crews, shift workers, and perhaps indoor workers. Using a risk-management approach, this paper provides a comprehensive review of occupational UV sources, health impact of occupational UV exposure, occupational exposure standards, and levels of exposure in various settings, and discusses the appropriate control measures. In addition, the duality aspect of health impacts from overexposure and underexposure to UV and the associated occupational health implications are specifically explored.

Adverse effects of ultraviolet radiation: a brief review

Solar ultraviolet radiation (UVR) has always been part of the environment of man. UVB is required for the conversion of 7-deoxycholesterol to vitamin D, which is critically important in the maintenance of healthy bones and research is making clear that it has other potential roles in maintenance of human health. Exposure to UVR, whether of solar or artificial origin, also carries potential risks to human health. UVR is a known carcinogen and excessive exposure-at least to solar radiation in sunlight-increases risk of cancer of the lip, basal cell, and squamous cell carcinoma of the skin and cutaneous melanoma, particularly in fair skin populations. There is also evidence that solar UVR increases risk of several diseases of the eye, including cortical cataract, some conjunctival neoplasms, and perhaps ocular melanoma. Solar UVR may also be involved in autoimmune and viral diseases although more research is needed in these areas. Artificial UVR from tanning beds, welding torches, and other sources, may contribute to the burden of disease from UVR. This brief review will assess the human evidence for adverse health effects from solar and artificial UVR and will attempt to assign a degree of certainty to the major disease-exposure relationships based on the weight of available scientific evidence.

Tanning and skin cancer

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

Sunscreen use among collegiate athletes

BACKGROUND

College athletes participating in outdoor sports are a population with extensive exposure to ultraviolet radiation during the peak hours of the day. These relatively young athletes could represent a group with alterable habits.

OBJECTIVE

We sought to assess the level of sunscreen use in college athletes who are at high risk for ultraviolet radiation exposure.

METHODS

An anonymous survey was administered to NCAA soccer and cross-country teams at 4 universities. Answers were analyzed for proportions of sunscreen use and associations among various host variables.

RESULTS

Of the surveyed athletes, 85% reported no sunscreen use in the previous 7 days and only 6% reported sunscreen use at least 3 of the previous 7 days.

LIMITATIONS

The subject population is limited to one geographic area and includes athletes from only two sports.

CONCLUSIONS

These results identify a need for improved primary prevention of ultraviolet damage among the more than 250,000 NCAA athletes participating in outdoor sports. A preventive program involving education, provision of readily available sunscreen, and coach participation is needed to target these individuals.

Ultraviolet Radiation Exposure, Vitamin D, and Cancer

This paper reviews briefly the evidence for an association between various measures of UV radiation (UVR) exposure and the development of cancer. Issues such as data quality, study design, measurement variation, comparability of studies, and quantification of UV exposure in relation to skin cancer are discussed. A range of exposure, based on skin type, might be appropriate: from 5 min a day three times a week for light-skinned individuals and 10 min a day three times a week for darker-skinned individuals. These exposures translate into 13 h per year, for a light-skinned individual, leading to 650 h of exposure from birth to age 50.

Epidemiology of skin tumors: data from the cutaneous cancer registry in Trentino, Italy

BACKGROUND

A Skin Cancer Registry was established in the province of Trento in northeast Italy in 1992 with the aim of collecting data on all cutaneous tumors affecting residents. These neoplasms are responsible for considerable morbidity and utilization of the Health Service because of their high frequency and, therefore, knowledge of the exact incidence is very important in planning health policies. Registry data are also very helpful in performing studies of analytical and descriptive epidemiology.

METHODS

For each patient, we collected personal data, phenotypical characteristics, professional history, concurrent diseases, previous therapy or trauma, and all data regarding the tumors. Patients were interviewed in person or, less frequently, by phone. All data were verified and put in a computerized file, in a protected room. The Statistics Institute of Trento University analyzed the data. Comparison among means was performed using the analysis of variance and differences among proportions were tested by chi-squared analysis. Poisson regression and the likelihood ratio test were used to compare incidence rates. We analyze here the data regarding epiteliomas and melanoma.

RESULTS

During the study period we registered 3435 primary skin tumors in 2868 individuals. Crude incidence rates, calculated using the number of subjects (not the number of tumors), were 87.9 for basal cell carcinoma (BCC), 28.9 for squamous cell carcinoma (SCC), and 14.2 for cutaneous melanoma (CM), per 100,000 per annum. We also calculated the same figures in females and males and specific incidence rates in both sexes and evaluated the distribution of skin cancer according to sex and anatomical site.

CONCLUSION

We report the analysis of the data collected by the Skin Cancer registry in a 6 year period and compare the data with published data in literature and with data of a previously registered melanoma file. Our results confirm the high incidence of nonmelanoma skin cancers and the variation in the histological patterns of CM.

Ultraviolet radiation in alpine skiing: magnitude of exposure and importance of regular protection

BACKGROUND

Participation in outdoor alpine sports has been increasing over the last decade. Ultraviolet exposure levels for these activities can be extreme owing to the venue altitudes. The purpose of this study was to measure the levels of UV-A and UV-B radiation exposure incurred by performance skiers in a typical alpine venue and to determine the need for protection in that environment.

OBSERVATIONS

Total UV-B exposure ranged from 12 to 185 mJ/cm(2) (0.5-7.6 times the minimum erythemal dose [MED] for individuals with type II skin). Ten percent of subjects received more than 1 MED/h at peak exposure times. Daily UV-A exposure ranged from 10.6 to 28 J/cm( 2) (daily average, 0.55 minimum melanogenic dose).

CONCLUSIONS

Alpine skiers with skin types I and II are exposed to measurable erythemal and suberythemal levels of UV radiation repeatedly over the long term at levels that can cause photodamage to their skin and potentially increase their later risk for skin cancer. Programs should be developed to educate skiers regarding the need for UV protection. Given the high levels of exposure noted, skiers should use UV protective measures, including sun-protection factor 30 broad-spectrum sunscreen.

Multiple nonmelanoma skin cancer in an exposed Australian population

BACKGROUND

Patients with nonmelanoma skin cancer (NMSC) frequently develop multiple skin cancers. The study presents incidence rates and rates of excision of NMSC for a population living in a high-risk environment for skin cancer.

METHODS

Between 1997 and 1999 a prospective population-based study collected information on all histologically confirmed NMSCs in Townsville, Australia.

RESULTS

Of the 6708 patients recorded with NMSC, 38.5% had multiple lesions. Yearly age-standardized incidence rates (per 100,000 inhabitants) of basal cell carcinoma (BCC) were 1444.8 for men, 942.7 for women, and of squamous cell carcinoma (SCC) were 805.0 for men, and 423.6 for women. Compared to incidence rates, age-standardized rates of lesions of BCC were 2.1 times higher in men, 1.6 times higher in women, and of SCC were 1.8 times higher in men and 1.4 times higher in women.

CONCLUSIONS

The occurrence of multiple NMSCs compromises results of short-term studies on incidence. Further discussions on the most appropriate strategies to describe the real burden of NMSC are warranted.