Strategically reversing the rising incidence of melanoma in younger patients

Skin cancer is the most common malignancy in the U.S., with more than 2 million new cases reported each year.1 While squamous cell and basal cell cancers are relatively indolent, with treatment largely confined to the local setting, malignant melanoma has a higher potential to metastasize to regional and distant locations. The incidence of melanoma has been increasing annually for the last 30 years in the U.S. The American Cancer Society estimates that there were 87,110 new cases of melanoma in the U.S. last year, with approximately 9,730 deaths in 2017.¹

Men account for most of the cases of melanoma in the U.S.—from 2006 to 2015, 57.6 percent of cases of melanoma reported in the National Cancer Database were in men. When stratified by age, however, most melanoma cases in younger patients were in women, with 58.6 percent of new cases of melanoma in individuals younger than 50 years old occurring in women. The gender disparity was even more pronounced in individuals younger than 40 years of age, with 63.8 percent of new melanomas being reported in women in that demographic (see Table 1).

Table 1. Age group by gender of melanoma of the skin diagnosed 2006–2015

Patient risk factors

The U.S. Preventive Services Task Force, consistent with the guidelines of most cancer organizations, does not recommend routine skin screening in average-risk individuals.² The American Cancer Society, however, does suggest complete skin examinations as part of a regular annual physician visit for all individuals older than 20 years of age.³ None of these recommendations, however, apply to individuals who might be at higher risk, though what makes an individual higher risk is loosely defined.

Most of the risk factors for the development of melanoma are well known to physicians. Several risk factors that indicate a need for routine screening include an increased number of moles, light skin color, and a family history of melanoma. While those risk factors are not modifiable, the most likely cause of cutaneous melanoma in most patients is ultraviolet exposure.

The effect of ultraviolet radiation exposure on an individual is largely influenced by skin color. Skin color has long been symbolic of social status in many cultures and remains so in most parts of the world. Before the industrial revolution, pale skin was preferred in European countries, as it suggested that a person was of a class that could avoid outdoor work.⁴ After the industrial revolution, however, the working classes tended to spend large portions of their lives in factories or other places of employment. These groups were unable to afford vacations to the countryside, but spent their leisure times indoors in an attempt to avoid the urban pollution that was pervasive at the time.⁴ Hence, a shift developed from a preference for pale skin to more tanned skin. The popularization of a tanned complexion is often attributed to images distributed of Coco Chanel in 1923 after a severe sunburn that she developed during a long cruise.⁴ A tanned appearance became a common aspiration among younger women in the 1950s and 1960s, and in 1978, the first commercial tanning bed was marketed as a means to obtain that ideal tan.⁴

Tanning bed use

Exposure to ultraviolet light is associated with an increased risk of skin cancer, including malignant melanoma. Ultraviolet light exposure can be from both natural and artificial sources, particularly tanning beds. In 2009, the World Health Organization’s International Agency for Research on Cancer listed ultraviolet radiation and indoor tanning beds as Class I carcinogens (in the same class as cigarettes, benzene, and asbestos).⁵ The U.S. Centers for Disease Control and Prevention report that more than 30 million Americans use tanning beds annually.⁶ Furthermore, the Youth Risk Behavior Surveillance System, a program that regularly surveys high school students to identify risk factors that might adversely affect their health, reported in 2011 that 13 percent of high school students used indoor tanning. More specifically, 29 percent of Caucasian high school girls used indoor tanning.⁷

Exposure to ultraviolet radiation is associated with an increased risk of skin malignancy at all ages. Exposure at earlier ages, however, is associated with a higher risk of skin malignancy. The latency period for developing skin malignancy is usually more than a decade. Using a tanning bed increases the risk for squamous cell carcinoma by 67 percent and basal cell carcinoma by 29 percent. This risk is higher when the tanning bed use begins before 25 years of age.8 Exposure to tanning beds before the age of 30 is associated with a 43–76 percent increased risk of malignant melanoma.⁹ For this reason, limiting tanning bed use by minors can have profound implications in reducing their risk of skin malignancy.

Policies aimed at preventing ultraviolet exposure

Efforts to minimize ultraviolet exposure via tanning beds have largely occurred at the state level. A total of 42 states and the District of Columbia regulate the use of tanning beds by minors, and 15 states (California, Delaware, Hawaii, Illinois, Kansas, Louisiana, Massachusetts, Minnesota, Nevada, New Hampshire, North Carolina, Oregon, Texas, Vermont, and Washington) and the District of Columbia prohibit commercial tanning bed use by minors. Restricting tanning bed use by minors tends to be a nonpartisan issue, with both red and blue states having regulations in place.¹⁰ In addition, in 2014, the U.S. Food and Drug Administration (FDA) began requiring black box safety warning labels on all tanning beds stating that the products should not be used by individuals younger than 18 years of age. On December 18, 2015, the FDA issued a proposed rule that would prohibit tanning bed use by individuals younger than 18 years old. A second portion of the proposed rule would require adult tanning bed users to sign an acknowledgement of risks every six months. (At press time, this proposed rule has not been acted upon.)¹¹

Another important component of skin cancer prevention is the regular use of sunblock. Regular sunblock usage has long been shown to reduce the incidence of squamous cell cancers and basal cell cancers. Though physicians have long advocated for the use of sunblock to reduce the risk of melanoma, data were lacking to support this assertion. In 2011, researchers in Australia released the first study to show that sunblock also reduces the risk of melanoma. A total of 1,621 individuals were randomized to daily versus ad lib sunblock application for the 10-year study, which showed that daily sunblock use resulted in half the number of melanomas.¹²

A multilayered strategy

A multipronged approach should be considered to address the problem of increasing melanoma rates, particularly among younger women. Advocacy efforts at the state level have been effective in ensuring that children do not use commercial tanning facilities. Expansion of tanning bed restrictions to states without such legislation can help to reduce tanning bed use by teenagers.

Like the efforts taken to address tobacco product use, limiting the use of tanning beds during teenage years may lead to reduced use later in life. In addition to legislative efforts, education about the benefits of regular sunblock use should be a part of preventive health care for all children and adults. This education should be paired with enhanced availability of sunblock, particularly at schools and swimming pools where local policies have sometimes posed challenges. Currently, many school systems prohibit the application of sunblock by students.

Additionally, educational efforts should also be expanded to combat the myth of the “safe tan” or “base tan,” which is the false view that a tan generated early in life will protect from subsequent sun damage.

Finally, and perhaps most notably, the cultural mores that favor tanned skin among individuals with fairer complexions should be challenged. Sun-damaged skin should not be equated with health or beauty in the mass media. With concerted and multiprong efforts, we can turn the tide of the increasing incidence of melanoma in younger Americans.

References

1. American Cancer Society. Cancer Facts & Figures 2016. Available at: www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2016/cancer-facts-and-figures-2016.pdf. Accessed December 5, 2017.
2. U.S. Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;316(4):429-435.
3. Wilkinson S. A short history of tanning. The Guardian. Available at: www.theguardian.com/commentisfree/2012/feb/19/history-of-tanning. Accessed November 30, 2017. Accessed December 5, 2017.
4. American Cancer Society. Guidelines for the early detection of cancer. Available at: www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed November 30, 2017.
5. El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens—part D: Radiation. Lancet Oncol. 2009;10(8):751-752.
6. Centers for Disease Control and Prevention. Indoor tanning is not safe. Available at: www.cdc.gov/cancer/skin/basic_info/indoor_tanning.htm. Accessed November 30, 2017.
7. Guy GP, Berkowitz Z, Watson M, Holman DM, Richardson LC. Indoor tanning among young non-Hispanic white females. JAMA Intern Med. 2013; 173(20):1920-1922.
8. Wehner MR, Shive ML, Chren MM, Han J, Qureshi AA, Linos E. Indoor tanning and non-melanoma skin cancer: Systematic review and meta-analysis. BMJ. 2012;345:e5909. doi: 10.1136/bmj.e5909.
9. Doré JF, Chignol MC. Tanning salons and skin cancer. Photochem Photobiol Sci. 2012;11(1):30-37.
10. National Conference of State Legislators. Indoor tanning restrictions for minors—a state-by-state comparison. Available at: www.ncsl.org/research/health/indoor-tanning-restrictions.aspx. Accessed September 11, 2017.
11. U.S. Food & Drug Administration. FDA proposes tanning bed age restrictions and other important safety measures. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm477434.htm. Accessed November 30, 2017.
12. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: A randomized trial follow-up. J Clin Oncol. 2011;29(3):257-263.