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

Guidelines for the diagnosis and treatment of basal cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology

Basal cell carcinoma (BCC) is the most common form of cancer, with a high impact on the public health burden and social costs. Despite the overall prognosis for patients with BCC being excellent, if lesions are allowed to progress, or in a small subset of cases harboring an intrinsically aggressive biological behavior, it can result in local spread and significant morbidity, and conventional treatments (surgery and radiotherapy) may be challenging. When a BCC is not amenable to either surgery or radiotherapy with a reasonable curative intent, or when metastatic spread occurs, systemic treatments with Hedgehog inhibitors are available. These guidelines were developed, applying the GRADE approach, on behalf of the Italian Association of Medical Oncologists (AIOM) to assist clinicians in treating patients with BCC. They contain recommendations with regard to the diagnosis, treatment and follow-up, from primitive tumors to those locally advanced or metastatic, addressing the aspects of BCC management considered as priorities by a panel of experts selected by AIOM and other national scientific societies. The use of these guidelines in everyday clinical practice should improve patient care.

European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023

Basal cell carcinoma (BCC) is the most common malignant tumour in white populations. Multidisciplinary experts from European Association of Dermato-Oncology (EADO), European Dermatology Forum, European Society for Radiotherapy and Oncology (ESTRO), Union Européenne des Médecins Spécialistes, and the European Academy of Dermatology and Venereology developed updated recommendations on diagnosis and treatment of BCC. BCCs were categorised into 'easy-to-treat' (common) and 'difficult-to-treat' according to the new EADO clinical classification. Diagnosis is based on clinico-dermatoscopic features, although histopathological confirmation is mandatory in equivocal lesions. The first-line treatment of BCC is complete surgery. Micrographically controlled surgery shall be offered in high-risk and recurrent BCC, and BCC located on critical anatomical sites. Topical therapies and destructive approaches can be considered in patients with low-risk superficial BCC. Photodynamic therapy is an effective treatment for superficial and low-risk nodular BCCs. Management of 'difficult-to-treat' BCCs should be discussed by a multidisciplinary tumour board. Hedgehog inhibitors (HHIs), vismodegib or sonidegib, should be offered to patients with locally advanced and metastatic BCC. Immunotherapy with anti-PD1 antibodies (cemiplimab) is a second-line treatment in patients with a progression of disease, contraindication, or intolerance to HHI therapy. Radiotherapy represents a valid alternative in patients who are not candidates for or decline surgery, especially elderly patients. Electrochemotherapy may be offered when surgery or radiotherapy is contraindicated. In Gorlin patients, regular skin examinations are required to diagnose and treat BCCs at an early stage. Long-term follow-up is recommended in patients with high-risk BCC, multiple BCCs, and Gorlin syndrome.

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.

[S3 guideline on skin cancer prevention: evaluation and updating procedure]

BACKGROUND

Originally published in 2014, the S3 guideline "Prevention of skin cancer" is the first evidence-based guideline available exclusively for primary and secondary prevention, which summarizes interprofessional consented recommendations for skin cancer risk reduction and early detection. Due to the large number of new publications and expanding focus, an update was deemed necessary.

METHODS

After a structured needs assessment, key questions were prioritized. The resulting systematic literature search resulted in a three-stage screening process. Recommendations formulated in working groups were approved in a formal consensus process, taking into account conflicts of interest, and finalized after a 6‑week public consultation process.

RESULTS

The needs assessment identified "skin cancer screening" (60.1%), "individual risk avoidance behaviors" (44.20%), and "risk factors" (43.48%) as topics of greatest interest. The prioritization phase resulted in 41 new key questions. A total of 22 key issues were re-evaluated in an evidence-based manner using 93 publications. As part of comprehensive guideline restructuring, 61 recommendations were newly developed and 43 were modified. The consultation phase resulted in no changes to recommendations and 33 changes to background material.

CONCLUSION

The identified need for change resulted in extensive modification and redrafting of recommendations. As the target group "nononcology patients" cannot be identified via cancer registries or certification systems, no quality indicators can be derived from the guideline. To transfer the guideline to health care, innovative, addressee-specific concepts are required, which will be discussed and implemented during the preparation of the patient guideline.

Skin Cancer Management: Current Scenario And Future Perspectives

Skin cancer is a life-threatening disease and has caused significant loss to human health across the globe. Its prevalence has been increasing every year and is one of the common malignancies in the case of organ transplant recipients, of which 95% constitute basal cell and squamous cell carcinomas. The prime factor causing skin cancer is UV radiation. Around the 20th century, sunlight was the primary cause of skin cancer. A novel hypothesis by US scientists stated that cutaneous melanoma was mainly due to recurrent exposure to the sun, whereas keratinocyte cancer occurred due to progressive accumulation of sun exposure. Management of skin cancer is done via various approaches, including cryotherapy, radiotherapy, and photodynamic therapy. Post-discovery of X-rays, radiotherapy has proven to treat skin cancers to some extent, but the indications are uncertain since it depends upon the type of tumour and surgical treatment required for the patient. Due to various limitations of skin cancer treatment and increased severity, there is a requirement for cost-effective, novel, and efficient treatment. Various nanocarriers such as SLNs, magnetic nanoparticles, gold nanoparticles, carbon nanotubes, etc., are the potential carriers in the management and prognosis of both non-melanoma and melanoma skin cancer. Various research and review databases and patent reports have been studied, and information compiled to extract the results. The review also discusses the role of various nanocarriers in treating and diagnosing skin cancer.

Indoor Tanning and the Risk of Overall and Early-Onset Melanoma and Non-Melanoma Skin Cancer: Systematic Review and Meta-Analysis

Simple Summary

Motivated by the increasing incidences of skin cancer, in 2015, Australian states banned indoor tanning to prevent exposure to artificial ultraviolet light. However, there has been no study investigating the association between indoor tanning and early-onset melanoma and non-melanoma skin cancer. In this study, we reviewed a total of 54 studies to examine the association between indoor tanning device use and overall and early-onset skin cancer. We found that indoor tanning is associated with increased risk for early-onset melanoma and NMSC, and has a dose–response relationship with first exposure at an early age and the frequency of exposure. Therefore, this study emphasizes the importance of avoiding indoor tanning risk in younger adults. Our findings provide evidence that supports policies regulating the excessive use of tanning devices, especially in the vulnerable younger population, to reduce the additional risk of skin cancer.

Abstract

The aim of this study was to examine the association between indoor tanning use and the risk of overall and early-onset (age < 50) melanoma and non-melanoma skin cancer (NMSC). To evaluate the association between indoor tanning and skin cancer, a systematic review of the literature published until July 2021 was performed using PubMed, EMBASE, and MEDLINE. Summary relative risk (RR) from 18 studies with 10,406 NMSC cases and 36 studies with 14,583 melanoma cases showed significant association between skin cancer and indoor tanning (melanoma, RR= 1.27, 95% CI 1.16–1.39; NMSC, RR = 1.40, 95% CI 1.18–1.65; squamous cell carcinoma (SCC), RR = 1.58, 95% CI 1.38–1.81; basal cell carcinoma (BCC), RR = 1.24, 95% CI 1.00–1.55). The risk was more pronounced in early-onset skin cancer (melanoma, RR = 1.75, 95% CI 1.14–2.69; NMSC, RR = 1.99, 95% CI 1.48–2.68; SCC, RR = 1.81, 95% CI 1.38–2.37; BCC, RR = 1.75, 95% CI 1.15–2.77). Moreover, first exposure at an early age (age ≤ 20 years) and higher exposure (annual frequency ≥ 10 times) to indoor tanning showed increasing risk for melanoma (RR = 1.47, 95% CI 1.16–1.85; RR = 1.52, 1.22–1.89) and NMSC (RR = 2.02, 95% CI 1.44–2.83; RR = 1.56, 95% CI 1.31–1.86). These findings provide evidence supporting primary prevention policies regulating modifiable behaviors to reduce the additional risk of skin cancer among younger adults.

Ultraviolet Radiation and Basal Cell Carcinoma: An Environmental Perspective

Ultraviolet radiation (UVR) is a known carcinogen participated for the development of skin cancers. Solar UVR exposure, particularly ultraviolet B (UVB), is the mostly significant environmental risk factor for the occurrence and progress of basal cell carcinoma(BCC). Both cumulative and intermittent high-grade UVR exposure could promote the uncontrolled replication of skin cells. There are also exsiting other contributing environmental factors that combine with the UVR exposure to promote the development of BCC. DNA damage in formation of skin cancers is considered to be a result of UVR toxicity. It is UVR that could activate a series of oncogenes simultaneously inactivating tumor suppressor genes and aberrant proliferation and survival of keratinocytes that repair these damages. Furthermore, mounting evidence demonstrates that inflammatory responses of immune cells in the tumor microenvironment plays crucial role in the skin tumorigenesis as well. In this chapter, we will follow the function of UVR in the onset and development of BCC. We describe the factors that influence BCC induced by UVR, and also review the recent advances of pathogenesis of BCC induced by UVR from the genetic and inflammatory aspects.

Sex disparity in skin carcinogenesis and potential influence of sex hormones

Background

Sex or gender disparity in skin cancer has been documented for a long time at the population level. UV radiation (UVR) is a common environmental risk for all three major types of skin cancer: cutaneous melanoma (CM), basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). The underlying mechanism for sex disparity has been largely attributed to sex‐differentiated behaviour patterns related to UVR. Non‐UVR factors such as intrinsic physiological differences have been suggested but remain understudied.

Aims, Materials and Methods

This review summarizes and compares the known sex differences in three skin cancer types with regard to body site distribution and age influence.

Results

We found a similar age‐dependent sex difference pattern in CM and BCC. Specifically, CM and BCC tend to show higher incidence in young women and old men, with a switching age around menopause. The switching age suggests involvement of sex hormones, which has shown controversial influence on skin cancers at epidemiological level. Literatures regarding sex hormone receptors for oestrogen, androgen and progesterone are summarized for potential explanations at molecular level.

Discussion

Overall, more and more evidence suggests non‐UVR factors such as sex hormones play critical roles in skin cancer (especially CM and BCC), yet solid population and molecular evidence are required. Incidences of skin cancer are increasing which suggests limited effect for the current UVR‐avoidance prevention methods.

Conclusion

Fully understanding the causes of sex disparities in incidence is necessary for developing a comprehensive prevention strategy.

Risk factors for early-onset basal cell carcinomas and the trend towards their female predominance

BACKGROUND

A dramatic rise in the incidence rates of basal cell carcinoma (BCC) in young women has been reported.

OBJECTIVES

We investigate potential risk factors (RF) for sporadic BCC in young patients and the current distribution of such RF in the general population of Catalonia, comparing the differences among men and women.

PATIENTS AND METHODS

A case-control study was performed, 69 BCCs diagnosed in patients ≤ 45 years of age vs. 69 healthy controls. Afterward, 1,078 participants from the general population completed an RF questionnaire.

RESULTS

Repeated sunburns were more frequent in instances of early-onset BCC in covered skin than in sun-exposed skin (P  =  0.029). In the general population, 39.1 % of participants reported sunbed use (50.1 % in women, 10.9 % in men). Sunbed use was the only relevant RF more predominant in women than men, favoring the trend to female predominance of BCCs above other RF. Additionally, we found a significant trend in young participants for reduced sunbed use (P < 0.001), although they had the same percentage of repeated sunburns. Repeated sunburns are the most relevant RF for early-onset BCCs that can be targeted in prevention campaigns.

CONCLUSIONS

We should be aware of the more relevant RF for early-onset BCCs and their distribution among the general population to address preventive campaigns.

Cosmetic Tattooing and Early Onset Basal Cell Carcinoma: A Population-based Case-Control Study from New Hampshire

BACKGROUND

Cosmetic tattoos use dyes with carcinogenic potential. Skin cancers arising in tattoos have been reported.

METHODS

We investigated whether risk of early onset basal cell carcinoma was related to the site and colors of cosmetic tattoos as part of a population-based case-control study of cases (ages 25-50 years), identified from a state-wide surveillance system, and age- and gender-matched controls, selected from driver's license records, randomly assigned an anatomic site of the cases.

RESULTS

One hundred fifty-six cases (17%) with early onset basal cell carcinoma and 213 controls (26%) reported cosmetic tattoos. Among those with tattoos, the adjusted odds ratio of basal cell carcinoma at the tattoo site compared to another site was 1.8 (95% confidence interval = 1.0, 3.2). We observed the strongest associations for yellow and green tattoo colors.

CONCLUSION

Our preliminary findings support the possibility of an enhanced risk of early onset basal cell carcinomas at the site of cosmetic tattoos.

Photodynamic therapy in superficial basal cell carcinoma treatment

Basal cell cancer (BCC) is an epithelial neoplasm that arises from basal cells, which constitute the lower layer of the epidermis. Global statistics have shown the progressive increase in the incidence of skin cancer in several countries. The cumulative exposure to solar radiation (ultraviolet B) in the first two decades of life represents the critical risk for the disease. Preclinical and clinical trials have shown photodynamic therapy (PDT) as a promising innovation for treatment of skin cancers, especially to the non-melanoma group. The authors reviewed trials with photodynamic therapy in superficial basal cell carcinoma with different photosensitizers to better evaluate how PDT modifies the natural history of sBCC. We conclude trials should not assess only the immediate efficacy but the main goal of long-term effectiveness of the protocols in order to generate best evidence for clinical practice.

Small Molecule Inhibitors of the Hedgehog Pathway in the Treatment of Basal Cell Carcinoma of the Skin

Basal cell carcinoma (BCC) is the most common type of skin cancer, with rising incidence rates primarily attributed to an aging population and ultraviolet radiation exposure. While the majority of BCCs are localized and respond to standard therapies, a very small minority of these tumors become locally destructive or metastasize. These advanced BCCs may not be amenable to localized treatment with surgery and/or radiation therapy. Most BCCs result from mutations in key receptors in the Hedgehog (HH) signaling pathway. As a result, identification of drugs that inhibit the receptor Smoothened (SMO) in the HH pathway has resulted in novel therapeutic approaches to treating patients with advanced BCC. These HH-pathway inhibiting medications have shown efficacy in clinical trials, and two medications, vismodegib and sonidegib, have received FDA approval. However, several limitations of these drugs have been identified, including treatment-limiting adverse events, drug resistance, and the formation of additional malignancies. This paper aims to summarize the clinical trials leading to the approval of SMO inhibitors, as well as reviewing potential mechanisms driving tumor resistance and the formation of cutaneous squamous cell carcinomas. Strategies to overcome some of these challenges, including the development of drugs that inhibit other downstream targets in the HH pathway, are the subject of ongoing clinical trials.

Psychometric Testing of the Turkish Version of the Skin Cancer and Sun Knowledge Scale in Nursing Students

The present study aimed assesses the nursing students' knowledge of skin cancer and sun and their sun protection behaviors. This descriptive cross-sectional study was performed from May to June 2014 with a convenience sample of 376 undergraduate nursing students from one nursing faculty located in Izmir. Mean age of the students was 21.56 ± 1.96 years. The mean score that the females obtained from the level of knowledge and protection behaviors scales was significantly higher than that of the males. Older age group (≥22 years) obtained higher scores on the knowledge and protection behaviors scales than younger group (≤21 years). Nursing students' knowledge of, and behavior regarding, skin cancer and sun health were insufficient. Equipping them with the necessary knowledge and behaviors related to skin cancer and sun health by developing training programs and strategies on the issue is of utmost importance.

Epidemiology of skin cancer in the mature patient

Epidermal cancers include keratinocyte cancer, melanocyte cancer, and Merkel cell carcinoma. These cancers account for the vast majority of new cancers diagnosed in Australia, North America, and Europe. Keratinocyte cancer is the most common epidermal cancer and accounts for 7 out of 8 new cancers diagnosed in Australia. Melanoma and Merkel cell carcinoma are less common than keratinocyte carcinoma but are more important causes of mortality in Australia. Keratinocyte cancer has also been demonstrated to be a marker of cancer-prone phenotype. Risk factors for epidermal cancer include intrinsic and environmental factors, in particular exposure to ultraviolet radiation and advanced age. Actinic keratosis has an approximate prevalence of 79% of men and 68% of women between 60 and 69 years of age, and has a low risk of malignant transformation into squamous cell carcinoma. Basal cell carcinoma is the most common malignancy in Caucasians worldwide, with the incidence increasing by 2% per year in Australia. Squamous cell carcinoma is the second most common epidermal cancer, with an incidence of approximately 1035 or 472 per 100,000 person-years in men and women, respectively. Primary risk factors for both basal cell carcinoma and squamous cell carcinoma include light skin color, UV radiation exposure, and chronic immunosuppression. Although the rate of melanoma is increasing, the mortality in Australia is reducing and is currently 9%. The overall incidence of melanoma in Australia is approximately 50 cases per 100,000 persons (62 for men and 40 for women). Keratinocyte carcinoma and melanoma are risk factors for developing further skin cancer and primary malignancy. This contribution reviews the incidence, prevalence, and risk factors associated with the development of epidermal cancer and premalignant epidermal neoplasia.

Epidemiology of Keratinocyte Carcinoma

Purpose of the review

To provide a synopsis of recent research advances in the epidemiology of keratinocyte carcinoma (KC), with a focus on indoor tanning and known risk factors for other forms of cancer such as cigarette smoking and alcohol drinking.

Recent findings

The evidence is strong enough to infer that use of UVR-emitting indoor tanning devices cause KC. Epidemiologic studies of cigarette smoking, alcohol drinking, and menopausal hormone therapy all show some suggestion for increased risk of KC but the evidence is not yet strong enough to determine if there is a true etiologic role. Body mass index is clearly inversely associated with KC risk but this is more likely to be due to lower UVR exposure in overweight and obese individuals than it is due to a true etiologic role.

Summary

The epidemic of KC continues unabated, and the causal role of indoor tanning is contributing to this unfavorable trend in KC incidence rates. Advances in understanding the etiology of KC should not divert attention away from the fact that the primary public health strategy to prevent KC is known: minimize population exposure to UVR from the sun and from UVR-emitting indoor tanning devices, particularly among those with sun-sensitive phenotypes.

A Cross-Sectional Study of Indoor Tanning in Fitness Centres

Background:

Ultraviolet (UV) radiation is a human carcinogen and is associated with the development of skin cancer. The promotion of indoor tanning (IT) at fitness centres is of particular concern as it reinforces the idea that a tan is associated with health and fitness. The purpose of this study was to investigate the prevalence of IT in fitness centres, with an emphasis on determining the financial costs, adherence to regulations, and safety precautions.

Methods:

Ten cities, representing 9 different Canadian provinces, were chosen for the study. From each province, a minimum of 20 and a maximum of 30 fitness centres were randomly selected from the Yellow Pages website. Each fitness centre was contacted by the principal investigator and inquiries were made from a consumer’s perspective.

Results:

Of the 203 gyms surveyed, 43% (88/203) offered tanning facilities. Of these, 10.23% (9/88) were found to be noncompliant with the provincial IT regulations for age and/or time between tanning sessions.

Interpretation:

Despite the known risks of IT, not all fitness centres are compliant with provincial legislations regarding IT, and some continue to promote tanning access to minors.

Nevoid Basal Cell Carcinoma Syndrome (Gorlin Syndrome)

Nevoid basal cell carcinoma syndrome, or basal cell nevus syndrome (Gorlin syndrome), is a rare autosomal dominantly inherited disorder that is characterized by development of basal cell carcinomas from a young age. Other distinguishing clinical features are seen in a majority of patients, and include keratocystic odontogenic tumors (formerly odontogenic keratocysts) as well as dyskeratotic palmar and plantar pitting. A range of skeletal and other developmental abnormalities are also often seen. The disorder is caused by defects in hedgehog signaling which result in constitutive pathway activity and tumor cell proliferation. As sporadic basal cell carcinomas also commonly harbor hedgehog pathway aberrations, therapeutic agents targeting key signaling constituents have been developed and tested against advanced sporadically occurring tumors or syndromic disease, leading in 2013 to FDA approval of the first hedgehog pathway-targeted small molecule, vismodegib. The elucidation of the molecular pathogenesis of nevoid basal cell carcinoma syndrome has resulted in further understanding of the most common human malignancy.

Do tanning salons adhere to new legal regulations? Results of a simulated client trial in Germany

In August 2009 and January 2012, two regulations were passed in Germany to limit UV exposure in the general population. These regulations state that no minors are allowed to use tanning devices. Personnel of tanning salons is mandated to offer counseling regarding individual skin type, to create a dosage plan with the customer and to provide a list describing harmful effects of UV radiation. Furthermore, a poster of warning criteria has to be visible and readable at all times inside the tanning salon. It is unclear whether these regulations are followed by employees of tanning salons in Germany, and we are not aware of any studies examining the implementation of the regulations at individual salons. We performed a simulated client study visiting 20 tanning salons in the city-state of Bremen in the year 2014, using a short checklist of criteria derived from the legal requirements, to evaluate whether legal requirements were followed or not. We found that only 20 % of the tanning salons communicated adverse health effects of UV radiation in visible posters and other materials and that only 60 % of the salons offered the required determination of the skin type to customers. In addition, only 60 % of the salons offered to complete the required dosage plan with their customers. To conclude, our results suggest that the new regulations are insufficiently implemented in Bremen. Additional control mechanisms appear necessary to ensure that consumers are protected from possible carcinogenic effects of excessive UV radiation.

The case for targeting community pharmacy-led health improvement: Findings from a skin cancer campaign in Wales

Objectives

The aims of the study were: to examine the association between high risk behaviour and deprivation and contribute evidence to the case for or against targeting cancer prevention campaigns at specific risky behaviour in areas of high deprivation.

Methods

This study has an ecological design and involved retrospective analysis of data derived from 5739 sun-safety quizzes completed by pharmacy users at 714 community pharmacies in Wales during May 2014.

Results

Levels of participation in the campaign and high risk sun-safety behaviours were higher in more deprived areas. Respondents from deprived areas had significantly lower sun-safety knowledge. 3802 (66.2%) respondents reported ‘excellent’ or ‘good’ knowledge of behaviours which promote sun-safety but this did not necessarily translate into how individuals behaved. 3787 (66.1%) respondents considered community pharmacies an acceptable location for the campaign and for discussing the signs and symptoms of skin cancer.

Key Findings

Results show association between high risk behaviour and geographically defined deprivation adding to the case for targeting cancer prevention campaigns at specific behaviours and geographies.

Conclusions

Community pharmacies appear to be acceptable locations from which to deliver health improvement campaigns in terms of participant recruitment, ease of delivery, and pharmacy user feedback.