Raising Melanoma Awareness

Melanoma is increasing at a faster rate than any other preventable cancer in the United States. Between 1950 and 2007, the incidence rose 17- fold in men (1.9 to 33.5 per 100,000) and more than 9-fold in women (2.6 to 25.3 per 100,000).1 This year, the American Cancer Society projects over 100,000 new cases in the United States and about 8,000 deaths. Melanoma is the leading cause of cancer death in women ages 25 to 30 and is second only to breast cancer in women ages 30 to 34 years.
Some have attributed rising rates to earlier diagnosis, but melanoma incidence is rising among all categories of tumor depth and subtypes, and not merely an artifact of more intensive screening or identification of thin tumors. Why, then, are the rates of other cancers falling while melanoma continues to rise?

UV exposure, both from sunlight and tanning beds, certainly plays a role. Although challenging to quantify lifetime UV exposure, UVB flux (a measure of midrange UV radiation) and time outdoors significantly increases risk of melanoma. Rising UV indices in the setting of a depleting ozone layer also directly correlate with higher rates of melanoma. Contrary to the myth that a tan is “protective,” even among women with the ability to develop a deep tan, a 10% increase in time outdoors was associated with a 5.8% increase in odds of melanoma.

In a landmark study, the International Agency for Research on Cancer (IARC) found that first exposure to tanning beds before the age of 35 increases an individual’s lifetime risk of melanoma by as much as 75%. Since then, other studies have echoed these findings and shown that melanoma risk increases with length and duration of exposure to tanning regardless of device used (UVB or UVA devices). A systematic review on the prevalence of tanning found that 35.7% of adults, 55% of university students and 19.3% of adolescents had ever used tanning beds. The study estimated that tanning beds accounted for more skin cancers in the United States, Europe and Australia than the number of lung cancer cases caused by smoking in these areas. Yet despite this data, up to 1 million Americans visit tanning salons each day; 70% of these are Caucasian females ages 16-29 years. Amongst the top 125 universities, 48% have indoor tanning facilities either on campus or in off-campus housing and up to 14% allow campus cash cards to be used to pay for tanning, including some local universities.

Whereas the anti-tobacco campaign has been gaining momentum for years, public health has just recently turned its attention to this issue. On May 29, 2014, the Food and Drug Administration (FDA) reclassified sunlamp products as a class II (moderate risk) device requiring a black box warning. Two months later, the Surgeon General issued a “Call to Action to Prevent Skin Cancer.” In Pennsylvania, tanning laws, restricting the use of tanning beds in minors under the age of 17, went into effect in July 2014.

The incidence of melanoma may not stabilize anytime soon, but, if identified early, thin melanomas have an excellent prognosis. However, early detection guidelines have not been clearly defined. The American Cancer Society (ACS) recommends that primary care physicians (PCPs) check for skin cancer “on the occasion of a periodic health examination.” The American Academy of Dermatology (AAD) recommends self-skin exams but does not identify when or how often physician exams should be performed. As of their last review in 2009, the U.S. Preventive Services Task Force (USPSTF), stated there was “insufficient evidence” for a total body skin exam by either a clinician or patient. Nevertheless, studies do show that physician-detected melanomas are thinner. In Germany, a yearlong statewide screening program was associated with a nearly 50% reduction in melanoma mortality.Findings such as these may prompt changes in the USPSTF guidelines.

Access to physicians trained in skin cancer surveillance is another challenge. Dermatology training in medical school is limited, and dermatology training programs graduate few residents each year. Tightened provider networks also risk reducing access to specialists. Fast-track referral systems between primary care and dermatology. Raising melanoma awareness do significantly increase early melanoma diagnosis.

A culture shift is certainly in the works. You are more likely to see kids in sun protective shirts and lathered in sunscreen at the pool these days. Self-tanning creams and spray tans are becoming more popular alternatives. The NFL and MLB are examples of organizations that have partnered with the AAD to support skin cancer screenings in the community. Dermatologists across the country are offering free skin cancer screenings on May 6th in honor of Melanoma Monday and throughout the month. Yet more needs to be done.

The dermatology community must continue to promote education about melanoma, and the importance of screening in high-risk population (i.e., patients with a family history of melanoma, red hair, tanning history, immunosuppression or a high number of nevi). Dermatology also must facilitate access for patients with new or changing skin lesions. Physicians should all feel comfortable asking their patients about risk factors for melanoma. Just as electronic medical systems prompt physicians to counsel patients who smoke, they too should be prompted to counsel patients who sunburn or tan frequently. As community leaders, physicians can help to change the tanning culture and dispel the myth of a “healthy” tan. Patients will also play an important role in spreading the word. The success of the breast and lung cancer campaigns has been in large part due to the patient advocacy groups. Improving prevention and early detection could have a significant impact on melanoma.

Perspective written by Dr. Nicole F. Velez and originally published by the Allegheny County Medical Society (ACMS)