Pion IA; Kopf AW; Hughes BR; Wetton NM; Collins M; Newton Bishop JA
Ronald O. Perelman Department of Dermatology, New York University (NYU) School of Medicine, New York, New York, USA.
Pediatr Dermatol (United States) Jan-Feb 1997, 14 (1) p6-12

Childhood exposure to sunlight is a risk factor for melanoma . To formulate a meaningful program to educate children about the ill effects of the sun, their extant knowledge base must be determined. We have used the "draw-and-write" technique to assess children's perceptions about the sun, suntans, and skin cancer. A total of 693 school children aged 4 to 13 years were asked to draw pictures and label them in response to a series of carefully worded questions. Awareness of the need to apply sunscreen increased from 44% in children aged 4 to 6 years to 95% in children aged 9 to 10 years. Ten percent of children aged 4 to 6 years already perceived a suntan as attractive. While almost all children were aware of the negative immediate effects of sun exposure, namely sunburn, just 30% of American children aged 11 to 13 were aware that sun exposure is a risk for skin cancer. No differences between boys and girls were seen. The "draw-and-write" technique allows assessment of the attitudes and perceptions of children regarding the sun and skin cancer. It also provides valuable information on which to base health education and evaluate its cost-effectiveness.

Castillero Pinilla C.; Saldivar Moreno C.; Lopez Graniel C.
Dr. C. Castillero Pinilla, Instituto Nacional de Cancerologia, Division de Ensenanza, Av. San Fernando num. 22, Col. Tlalpan, 14000 Mexico D.F. Mexico
Revista del Instituto Nacional de Cancerologia (Mexico) 1998, 44/4 (205-209)

Malignant melanoma is currently the tumor with the most accelerated incidence increase. The incidence of malignant melanoma of the trunk is increasing in well-developed countries and represents the third most common location, just after head and neck and limbs. Risk factors associated with this location are hereditary syndromes and sun-burns during childhood and adolescence; however, there is a strong association with preexisting nevuses. The prevention of malignant melanoma of the trunk is the same than for other site malignant melanomas, being necessary the use of sunblockers during childhood and adolescence. Treatment is directed toward the use of vital blue dye sentinel-node mapping for managing regional nodes, with preoperative lymphoscintigraphy. Primary tumor must be managed according to established surgical margins for any other malignant melanomas, 1 cm for less than 1 mm- depth lesions, 2 cm for more than 1.1 mm-depth lesions. Prognosis is determined mainly by the clinical stage.

Carter R.; Marks R.; Hill D.
R. Carter, Health Economics Unit, Centre for Health Program Evaluation, PO Box 477, West Heidelberg, Vic. 3081 Australia
Health Promotion International (United Kingdom) 1999, 14/1 (73-82)

This study aimed to determine the potential cost-effectiveness of initiating a co-ordinated and comprehensive national skin cancer primary prevention campaign in Australia. The study is undertaken from the perspective of the Federal government as potential funder of a national initiative, but other perspectives are analysed. Using the SunSmart Campaign in the Stat of Victoria, Australia, as a model for the national program, estimates were made of the reduction in the incidence and associated premature mortality for skin cancer that would accompany reduction in sunlight exposure. Cost offsets to government flowing from the reduction in management costs for skin cancer were estimated and deducted from the cost of the health promotion campaign. Costs affecting individuals, such as the cost of sunscreen, were included in the sensitivity analysis. On the basis of the asumptions used (with a 'do nothing' comparator), a national campaign involving a 20-year commitment of $AUD 5 million annually (i.e. 28c per person) would avoid 4300 premature deaths and cost $AUD 1360 per life-year saved, or $AUD 14,360 per death deferred. If the cost offsets are included, the program should not only prevent premature deaths but also yield a net saving to government of $AUD 103 million (PV). In the sensitivity analysis the results were robust to a variety of cost and outcome variations. Increasing the lag between decreases in UVR exposure and falls in the incidence of melanoma from 5 to 15 years, and inclusion of costs affecting individuals and their families had the largest effects on cost-effectiveness. The cost per life-year saved (excluding cost effects) increased from $AUD 1360 to $AUD 5103 and $AUD 25,134 respectively. A survey of current expenditure by State/Territory government departments and anticancer bodies on skin cancer primary prevention was carried out as part of the analysis and an annual commitment of $AUD 5 million by the Federal government represents a doubling of current expenditures (of approximately 14c per person). The cost-effectiveness (using a 'current practice' comparator) yields a cost of $AUD 2715 per life-year saved (ignoring the cost offsets and using a conservative estimate of improved health outcomes attributed to the new national program). The study results, although indicative only, strongly suggest that a comprehensive national skin cancer primary prevention program would be excellent 'value for money' from a variety of perspectives, using both 'do nothing' and 'current practice' comparators.

Hochman M.; Lang P.
Dr. P. Lang, Department of Dermatology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425 United States
Medical Clinics of North America (United States) 1999, 83/1 (261-282)

The incidence of skin cancers is increasing at a rate greater than any other cancer occurring in humans. In this era of managed care, patients with a suspicious skin lesion may first present to their primary care physician for evaluation. Therefore, it is important for the primary care physician to be able to distinguish between benign and malignant pigmented lesions, to know how to evaluate such a patient, and to appreciate the importance of appropriate interdisciplinary management of these patients.

Wille L.; Kolmel K.F.; Gefeller O.
Dr. O. Gefeller, Abteilung Medizinische Statistik, Georg-August-Universitat Gottingen, Humboldt-allee 32, 37073 Gottingen Germany
Zeitschrift fur Dermatologie (Germany) 1998, 184/2 (82-85)

The importance of sunscreens for primary prevention of malignant melanoma is controversial. An overview of all published case-control studies about this topic shows that due to very heterogeneous scientific results neither quantitative nor qualitative statements are possible at the moment whether the use of sunscreens has a protective, a neutral, or an increasing risk effect for the development of melanoma . The responsible factors leading to the observed discrepancies between the studies are discussed in the article. In the current state of knowledge, the necessary reduction of UV- radiation should be preferably ensured by wearing textile sun protection.

Brash D.E.; Ponten J.
D.E. Brash, Department of Therapeutic Radiology, Yale Comprehensive Cancer Center, Yale School of Medicine, New Haven, CT 06520 United States
Cancer Surveys (United States) 1998, 32/- (69-113)

Squamous cell carcinoma of the skin and melanoma are the rare progeny of precancerous lesions that usually remain stable or regress. For SCC the sequence appears to include TP53 mutant clones in normal skin; dysplasia; carcinoma in situ; and SCC. When such lesions are contiguous, their TP53 mutations are consistent with a single clonal lineage. The set of TP53 mutations in tumours is more restricted than in precancers, suggesting additional selection. Melanoma lies at the end of a continuum including mole, dysplastic naevus, radial growth melanoma and vertical growth. The genetics of melanoma is less clear. Basal cell carcinomas seem to arise without a precancer and contain mutations in TP53 and PTCH. Childhood sunlight exposure directs the location and frequency of precancers. For melanoma, its effects on intermittently exposed body sites are super-imposed on the effect at sites chronically exposed. SCC precancers and tumours, BCC tumours and melanoma cell lines contain UV induced mutations. Sun exposed skin of normal individuals contains thousands of small clones of TP53 mutated cells. Predisposition to sunlight induced precancer is a multigenic trait involving factors such as hair and skin color, DNA repair proficiency and mole type and number. These each contribute a relative risk on the order of two to four. Familial predisposition to dysplastic naevi carries a larger risk. The cell of origin for melanoma is uncontroversial, and the proposed hair follicle origin of BCC is consistent with the presence of stem cells in the bulge region. The origin of SCCs and the arrangement of interfollicular stem cell compartments are less clear. Clonal expansion of the initial mutated cell may also be driven by sunlight. When a mutation confers apoptosis resistance, as TP53 mutations do, subsequent UV exposure will be more likely to kill normal cells than mutants. The latter can expand into a clone, only one cell of which need be mutated again. Immunosuppressant drugs may have the same effect as UV, facilitating the clonal expansion of precancers. In the absence of exogenous influences, mutant clones and precancers tend to regress. There is little evidence that regression of precancers is immunological, though regression of melanoma appears to be. The chemotherapeutic agent 5-FU causes regression of dysplasias by removing initiated cells, perhaps by enhancing apoptosis. In contrast, retinoic acid temporarily suppresses clonal expansion. Most sunscreens are mutagenic, with as yet unknown consequences. Mice develop dysplasias and SCCs after UV irradiation. Initiation and clonal expansion of dysplasias is UV driven, but conversion to SCC and subsequent growth involve spontaneous events. With chemical carcinogens mice develop papillomas that usually regress and thus are precancers. Tumour promotion yields abundant low risk papillomas that contain Hras1 mutations but rarely progress to SCC. High risk papillomas are infrequent but do convert to SCC, particularly if re-treated with mutagens. Conversion to SCC is associated with TP53 mutations. The mechanisms of multiple mutation and clonal expansion observed in human and mouse systems, respectively, are beginning to converge into a coherent understanding of precancerous events in skin.

Tenkate T.D.
T.D. Tenkate, School of Public Health, Dept. of Environmental Health Sci., University of Alabama, 1665 University Blvd., Birmingham, AL 35294-0022 United States
Journal of Environmental Health (United States) 1998, 61/2 (9-15)

This article provides an overview of human exposure to ultraviolet radiation (UVR) and associated health effects, as well as risk estimates for acute and chronic conditions resulting from UVR exposure. For most people, the main source of UVR is the sun. Adverse health effects include photokeratitis, erythema, pterygium, some types of cataracts, basal and squamous cell carcinomas, and malignant melanoma . Human exposure is influenced by the following factors: type of occupation, protective measures employed, types of recreational activities undertaken, and personal behavior. Acute conditions may result within 30 minutes of noontime sun exposure, and the minimum risk estimate for nonmelanoma skin cancer (NMSC) in a person 70 years of age is two to three percent. Risks for NMSC are increased for outdoor workers and those participating in recreational sun exposure, but can be significantly reduced if sunscreen is used during childhood.

Wille L.; Gefeller O.; Kolmel K.F.
Dr. O. Gefeller, Abteilung Medizinische Statistik, Georg-August-Universitat Gottingen, Humboldtallee 32, D-37073 Gottingen Germany
H+G Zeitschrift fur Hautkrankheiten (Germany) 1998, 73/7-8 (467-473)

The use of sunscreens is regarded as protective behaviour against the development of malignant melanoma by the public. A meta-analysis on the importance of the application of sunscreens for primary prevention of malignant melanoma of the skin on the basis of all published case-control studies, however, implies that neither a quantitative nor a qualitative statement concerning the protective or detrimental effect of these agents is possible. This article discusses in detail the discrepancies between the studies leading to this decision. Furthermore, the paper deals with hypotheses for explaining these results. We conclude on the basis of the available epidemiologic studies that public health efforts should not emphasize the use of sunscreens for primary prevention of malignant melanoma . The necessary reduction of UV-radiation should be preferably ensured by staying in the shade and by wearing textile sun protection.

Drug and Therapeutics Bulletin (United Kingdom) 1998, 36/7 (49-51)

In the UK, the incidence of newly diagnosed skin cancer appears to be doubling every 10 years; there were over 40,000 new cases last year. Here we discuss the place of sunscreens in the prevention of skin cancer.

Murphy G.M.
G.M. Murphy, Photobiology Unit, Beaumont Mater Misericordiae Hosp, Dublin Ireland
Journal of Dermatological Treatment (United Kingdom) 1998, 9/Suppl. 2 (17-21)

Although not well understood a relationship exists between sun exposure and malignant melanoma . Sunscreens are important in reducing the damage that ultraviolet (UV) irradiation exposure from sunlight causes to the skin. Overall, the major risk for malignant melanoma seems to lie with excessive UVB exposure with some contribution by UVA. Therefore, reduction of both UVB and UVA exposure is advocated for both sporadic and familial malignant melanoma . If a sunscreen is only partly applied, or only UVA or UVB formulations are used, individuals will have a false impression of the level of protection provided and will expose themselves for prolonged periods increasing their risk of skin damage. Today, there are a number of effective sunscreens available, with relatively equivalent UVA and UVB protection and photostable ingredients. The effectiveness of even the best sunscreen, however, is completely dependent on whether or not it is used properly. It is important that individuals are advised on their behaviour in the sun, and the correct application and choice of sunscreen products.

Tsao H.; Rogers G.S.; Sober A.J.
Dr. A.J. Sober, Department of Dermatology, Massachusetts General Hospital, Bartlett Hall, Blossom St., Boston, MA 02114 United States
Journal of the American Academy of Dermatology (United States) 1998, 38/5 I (669-680)

Background: Although the survival benefits of early stage melanoma have been clearly documented, the potential economic impact of early versus late stage disease has not been assessed.

Objective: Our purpose was to estimate the annual direct cost of diagnosing and treating melanoma, based on the number of projected cases of melanoma entering each stage in 1997.

Methods: A model was constructed with assumptions derived from the literature and clinical experience at the Massachusetts General Hospital Melanoma Center and the Boston University Medical Center. Cost estimates were based on 1997 Boston area Medicare reimbursements.

Results: The annual direct cost of treating newly diagnosed melanoma in 1997 was estimated to be $563 million. Stage I and II disease each comprised about 5% of the total cost; stage III and stage IV disease consumed 34% and 55% of the total cost, respectively. About 90% of the total annual direct cost of treating melanoma in 1997 was attributable to less than 20% of patients (those patients with advanced disease, that is, stage III and stage IV).

Conclusion: In addition to the potential survival advantages, aggressive primary prevention through sun protection and intensive screening to enhance earlier detection should reduce the economic burden of melanoma care.

Gordon M.L.; Hecker M.S.
Dr. M.L. Gordon, Department of Dermatology, Mount Sinai Medical Center, New York, NY United States
Geriatrics (United States) 1997, 52/8 (56-68)

Intrinsic skin changes with advancing years include dryness, decreasing elasticity, increasing skin fragility, and more prominent vasculature. Extrinsic skin aging, caused primarily by cigarette smoking and exposure to sunlight, includes mottled pigmentation and yellow discoloration, rough leathery textural changes, and wrinkling. Major premalignant and malignant neoplasms in photodamaged skin are actinic keratosis, basal cell carcinoma, squamous cell carcinoma, and melanoma . Nonmalignant lesions include solar lentigines and seborrheic keratoses. The A, B, C, D criteria can assist in the evaluation of pigmented nevi. Physicians play an important role in educating patients about the health risks associated with excessive sun exposure and about sun protection to prevent further skin damage.

Bergfeld W.F.
Dr. W.F. Bergfeld, Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH 44195 United States
International Journal of Fertility and Women's Medicine (United States) 1997, 42/2 (57-66)

In the past, sun exposure has been an integral part of the American life style. Along with increased leisure time, outdoor recreational sports, and sun bathing has come greater exposure to the sun. The cumulative effects of unprotected sun exposure coupled with the changes in the ozone layer have resulted in a large photodamaged population and an epidemic of the most dangerous skin cancer, malignant melanoma . Photodamage begins early, with a child's first unprotected sun exposure. Clinical studies show that 50% of an individual's ultraviolet light exposure occurs before the age of 18 years. This damage from acute and chronic ultraviolet light exposure has produced the explosion of skin cancers. Over the next 4 years, it is expected that skin cancer will become the most common type of cancer, and malignant melanoma will become the leading cause of death from skin cancer. This growing hazard to the public has profound medical and psychological ramifications. This paper will focus on prevention, identification, evaluation and treatment of photodamage to skin, as well as skin cancer. Special emphasis will be given to the National Skin Cancer Prevention Education Program.

Ferrini R.L.; Perlman M.; Hill L.; Devlin M.
M. Devlin, 1660 L. Street, NW, Washington, DC 20036 United States
American Journal of Preventive Medicine (United States) 1998, 14/1 (83-86)

Based on a review of current literature and recommendations, the American College of Preventive Medicine presents a practice policy statement on skin protection from ultraviolet light exposure.

Langley R.G.B.; Sober A.J.
Dr. A.J. Sober, Harvard Medical School, Massachusetts General Hospital, 40 Blossom Street, Boston, MA 02114 United States
Cancer Investigation (United States) 1997, 15/6 (561-567)

Strong epidemiological evidence exists that solar radiation is causally related to a significant proportion of cutaneous melanoma . The nature of the relationship is, however, complex and the details are not entirely clear. There appears to be a complex interplay between solar exposure in individuals with a characteristic phenotype. Although the exact quantitative and qualitative nature of this exposure is not clear, it is probable that intermittent exposures and intense exposures with consequent sun-burns in a high-risk phenotype are critical in increasing the risk of developing melanoma . Despite the lack of complete understanding of this relationship, the evidence is convincing that solar radiation is causally related to cutaneous melanoma and consequently exposures to UV radiation should be reduced from early in life. The preventive measures involve reducing exposure to ambient solar radiation, by avoiding peak exposures, wearing protective outerwear, and using broad-spectrum sunscreens.

Ley R.D.; Reeve V.E.
Dr. R.D. Ley, The Lovelace Institutes, 2425 Ridgecrest Drive SE, Albuquerque, NM 87108 United States
rley@Iri.org
Environmental Health Perspectives (United States) 1997, 105/Suppl. 4 (981-984)

The use of chemical and physical sunscreening agents has increased dramatically during the last two to three decades as an effective means of preventing sunburn. The use of high sunprotection factor sunscreens has also been widely promoted for the prevention of skin cancer, including melanoma . Whereas sunscreens are undoubtedly effective in preventing sunburn, their efficacy in preventing skin cancer, especially melanoma, is currently under considerable debate. Sunscreens have been shown to prevent the induction of DNA damage that presumably results from the direct effects of ultraviolet radiation (UVR) on DNA. DNA damage has been identified as an initiator of skin cancer formation. However, both laboratory and epidemiological studies indicate that sunscreens may not block the initiation or promotion of melanoma formation. These studies suggest that the action spectrum for erythema induction is different than the action spectrum for the induction of melanoma . Indeed, recent reports on the wavelength dependency for the induction of melanoma in a fish model indicate that the efficacy of ultraviolet A wavelengths (320-400 nm) to induce melanoma is orders of magnitude higher than would be predicted from the induction of erythema in man or nonmelanoma skin tumors in mice. Other strategies for the chemoprevention of skin cancer have also been reported. Low levels and degree of unsaturation of dietary fats protect against UVR-induced skin cancer in mice and humans. Compounds with antioxidant activity, including green tea extracts (polyphenols), have been reported to inhibit UVR-induced skin carcinogenesis.

Autier P.; Dore J.-F.; Cesarini J.-P.; Boyle P.
J.-F. Dore, INSERM U 453, Centre Leon Berard, 28, rue Laennec, F-69373 Lyon Cedex 08 France
Annals of Oncology (Netherlands) 1997, 8/5 (435-437)

Background: Psoralens are potent tanning activators that have been introduced in France and in Belgium in some tanning lotions and sunscreens. It was shown that poor tanners who ever used psoralen tanning activators display a four-fold increase in melanoma risk when compared to poor tanners using regular sunscreens. Although psoralens have now been banned from suntan lotions, it is likely that the increase in melanoma risk linked to their previous use will persist for several years.

Methods: The melanoma risk attributable to psoralens use was calculated to evaluate the population at risk in France and Belgium.

Results: Melanoma incidence for the year 1995 was estimated to be of 10.2 per 100,000 in France and of 10.0 per 100,000 in Belgium, representing 5,900 and 1,000 melanoma cases. From the melanoma incidence among poor tanner who ever used psoralens (52 per 100,000) and and estimation of the percentage of psoralen users among poor tanners, it can be derived that, for the year 1995, 267 melanoma cases could be attributed to psoralen tanning activators.

Conclusions: Subjects who used psoralen suntan activators should be informed of their increased melanoma risk and be encouraged to participate in clinical programmes for early detection of melanoma, more especially when they are poor tanners and display a high naevi count. Such an action could save a significant number of lives.

English D.R.; Armstrong B.K.; Kricker A.; Fleming C.
Dr. D.R. English, Department of Public Health, University of Western Australia, Perth, WA 6907 Australia
Cancer Causes and Control (United Kingdom) 1997, 8/3 (271-283)

Epidemiologic evidence on the relation between sunlight and cancer is reviewed. Strong evidence implicates sunlight as a cause of skin cancer, although, for melanoma and basal cell carcinoma, the relationship is complex. Both types of cancer are associated more strongly with nonoccupational exposure than with occupational exposure, and the pattern and amount of exposure each appear to be important. Squamous cell carcinoma appears to be related more strongly to total (i.e., both occupational and nonoccupational) exposure to the sun. The evidence that sunlight causes melanoma of the eye is weak. It shows no latitude gradient and the results of case-control studies are conflicting. There is inadequate evidence to suggest that sunlight does or does not cause any other type of cancer.

Keller K.L.; Fenske N.A.; Glass L.F.
Dr. L.F. Glass, Div. of Dermatology/Cutaneous Surg., College of Medicine, University of South Florida, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612 United States
Clinics in Geriatric Medicine (United States) 1997, 13/2 (339-361)

This article focuses on the common precancers and skin cancers in the older patient. The hazards of ultraviolet radiation are explained briefly in relation to photoaging and the development of skin cancer. The etiology, clinical appearance, histopathologic diagnosis, treatment, and follow-up for each type of cancer are reviewed thoroughly. It is hoped that early recognition and treatment by geriatric physicians will have a positive impact on the reduction of the morbidity and mortality associated with these cancers in the elderly.

Naylor M.F.
Dr. M.F. Naylor, Oklahoma Ctr. for Molecular Medicine, Univ. of Oklahoma Health Sci. Ctr., 941 Stanton L. Young Blvd, Oklahoma City, OK 73104 United States
Archives of Dermatology (United States) 1997, 133/3 (373-375)

Ultraviolet-induced erythema is now recognized as an important clinical marker for skin cancer risk. People with a history of repeated erythematous exposures to sunlight are more likely to develop both melanoma and nonmelanoma skin cancers. Is erythema the most important thing we need to be concerned about in terms of protecting the public from the harmful effects of sunlight? What do we know about UV-induced erythema, and why is it a powerful influence on skin cancer risk?.

Harvey I; Frankel S; Marks R; Shalom D; Nolan-Farrell M
Department of Social Medicine, University of Bristol, UK.
Br J Cancer (Scotland) Oct 1996, 74 (8) p1308-12

This study aimed to identify risk markers for prevalent solar keratoses (SKs) and squamous cell carcinomata (SCC) combined, for incident SKs and for spontaneous remission of SKs and to evaluate primary preventative measures. It was a cross-sectional study, with follow-up, conducted in South Wales, and involved 1034 subjects aged 60 years and over. The main outcome measures were the presence of and changes in SKs, and presence of skin cancers, on sun-exposed skin, and risk factors for prevalent SKs/SCCs and for incidence and remission of SKs. We found that variables independently associated with prevalent SKs/SCCs were: age [80 + years vs 60-64 years, odds ratio (OR) 3.7]; sex (male vs female OR 2.2); cumulative sun exposure (top quintile vs bottom quintile OR 3.3) and skin type (skin type 1 vs 4 OR 12.4). Use of sunscreen or protective clothing was not protective after controlling for confounders. Males and those who sunbathe infrequently showed greater remission of SKs. Older subjects and those spending most time in the sun in the preceeding 2 years were most likely to develop new SKs. We conclude that the risk factors identified are consistent with results from sunnier countries. The failure of sunscreen or clothing to emerge as protective raises doubts as to whether these measures are as effective in routine use in the general population as theoretical considerations and the limited trial evidence would predict. Recently reported sun exposure appears to influence the risk of developing new SKs.

Reynolds KD; Blaum JM; Jester PM; Weiss H; Soong SJ; Diclemente RJ
Department of Health Behavior, University of Alabama at Birmingham 35294-2010, USA.
J Adolesc Health (United States) Dec 1996, 19 (6) p409-15

PURPOSE: With the increase in melanoma incidence, the sun exposure and protective behaviors of adolescents are of great concern. Limited data are available on the prevalence and predictors of risk behavior in adolescents in the southeastern United States. This study examined the levels of sun exposure and variables predictive of sun exposure among adolescents in two Alabama middle schools.

METHODS: A total of 509 sixth-graders completed a self-administered survey assessing: (a) their knowledge, attitudes, and beliefs about malignant melanoma ; and (b) their sun exposure and sunburns for a specific weekend and for the summer.

RESULTS: Levels of sun exposure and frequency of sunburn were high. Regression models determined the predictors of weekend and summer sun exposure, and weekend sunburn. Significant predictors varied by outcome and included gender, perceived importance of a suntan, parent and peer modeling, and sunscreen use.

CONCLUSION: Reducing the risk of melanoma will require a three-pronged intervention strategy with efforts directed at adolescents, their parents, and the broader community.

Donawho C; Wolf P
University of Texas M.D. Anderson Cancer Center, Department of Immunology, Houston 77030, USA.
Curr Opin Oncol (United States) Mar 1996, 8 (2) p159-66

This paper reviews the current epidemiologic and experimental evidence regarding the effect of sunburns on cutaneous malignant melanoma and the possible effectiveness of sunscreens in preventing those effects. Although there is growing agreement that sunlight exposure, particularly the ultraviolet wavelengths in solar radiation, contributes to the etiology of cutaneous malignant melanoma, there are at present insufficient data on the effective ultraviolet waveband and whether the use of sunscreens may be useful in preventing melanoma . The main obstacle in answering this question is that the exact role of sunlight in the pathogenesis of melanoma still remains undefined. However, new experimental animal models are now available that will assist in determining and defining the mechanism of initiation and promotion of melanoma by sunlight and, particularly, ultraviolet radiation in sunlight. While we await more definitive data, it is reasonable to recommend an overall "safe sun strategy" in which the use of sunscreens certainly must be accompanied by other protective measures of overall reduction of sunlight exposure. (57 Refs.)

Bartak P
Statni zdravotni ustav, Praha.
Cas Lek Cesk (Czech Republic) Jul 26 1996, 135 (13) p403-4

Since the beginning of the 19th century the scientific knowledge concerning the effect of the sun rays upon the human organism, mainly on the skin, has been studied and the components of the sun spectrum were specified. During the last years the ozone layer was seriously damaged due to the so called civilization and the very harmful UVC component of the spectrum has entered the earth atmosphere. The accumulation of the unhealthy human habits and the new sun aggression threaten the human skin. The result is the growing number of the skin cancer, incl. melanoma of young people. The whole world dermatologists common opinion is that only the proper knowledge of this sun danger and the daily behaviour change combined with adequate dress and reliable sunscreen are able to prevent the serious damage in not very distant future.

Farmer KC; Naylor MF
Department of Pharmacy Practice, College of Pharmacy, University of Oklahoma Health Science Center, Oklahoma City 73117, USA.
Ann Pharmacother (United States) Jun 1996, 30 (6) p662-73

OBJECTIVE: To review the role of sunlight in skin aging and skin cancer formation, and to provide guidelines on the use of sunscreens to minimize the adverse effects of sun damage.

DATA SOURCES: A MEDLINE search of applicable articles on ultraviolet (UV) radiation, melanoma, sunscreens, and skin cancer, evaluating both human and animal studies. Published and unpublished original research as well as clinical experience were also used.

DATA SYNTHESIS: The interaction of UV radiation and skin type plays a central role in melanoma formation. Mortality from melanoma is highest in geographic locations near the equator, where UV intensity is greatest. The incidence of melanomas in light-complected individuals (skin types I-III) is several times higher than those with darker skin types (types IV-VI), even in similar geographic regions. The UVB portion of the spectrum appears to be primarily responsible for skin cancer formation and photoaging, while short wave UVA rays play a significant contributing role. Regular sunscreen use has been shown to reduce the formation of precancerous actinic keratoses (AK) lesions by 36%. A dose-response relationship has also been found between the amount of sunscreen used and AK formation.

CONCLUSIONS: Sunscreens have now been shown to reduce the carcinogenic effects of sunlight in humans. Patients should be advised of the long-term consequences of sun exposure and the benefits of regular sunscreen use. (87 Refs.)

Kubar WL; Rodrigue JR; Hoffmann RG 3rd
Center for Pediatric Psychology Research, University of Florida Health Science Center, Gainesville 32610-0165, USA.
Psychol Rep (United States) Dec 1995, 77 (3 Pt 2) p1136-8

This study examined the relationships among measures of knowledge of skin cancer, attitudes toward sun exposure, intentions to use sunscreen, and self-reported use of sunscreen by 105 fifth-grade children. Positive correlations were obtained between knowledge and intentions to use sunscreen, knowledge and healthier attitudes, and intentions to use sunscreen and healthier attitudes toward sun exposure. Surprisingly, knowledge, attitudes, and intentions were not significantly associated with reported use of sunscreen . Researchers designing interventions to effect behavioral change, i.e., sunscreen use, in children might further explore the predictive utility of these constructs as well as examine the utility of other important variables not measured here.

Marks R
University of Melbourne, Department of Medicine (Dermatology), St Vincent's Hospital Melbourne, Australia.
J Dermatol (Japan) Nov 1995, 22 (11) p853-7

Non-melanoma skin cancer (NMSC) comprised of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common cancers in humans in many countries. Sunlight plays a major part in the development of these tumours which appear predominantly on areas of the most frequently exposed skin. The site distribution for BCC and SCC is not the same, with SCC being most common on the sites of very heavy exposure and BCC becoming more common on areas of only moderate exposure, e.g. upper trunk in men and women and lower leg in women. Incidence rates of NMSC, where they are being recorded, show rises over time. Mortality rates, on the other hand, have been dropping most of this century until they have been levelling out recently. The case fatality rate due to SCC appears to be between 1-2%. The malignant transformation rate of actinic keratoses to SCC appears to be very low. Studies on similar populations at different latitudes allow estimates to be made of increases which might occur with increasing exposure to ultraviolet radiation (UVR) over a life time. These have been used to estimate the possible increases in NMSC due to stratospheric ozone depletion. Finally, recent studies on the reduction of existing actinic keratoses and prevention of new ones with regular use of sunscreen augurs well for prevention of NMSC in the future. (27 Refs.)

Bourke JF; Graham-Brown RA
Department of Dermatology, Leicester Royal Infirmary, U.K.
Br J Dermatol (England) Aug 1995, 133 (2) p264-6

The incidence of melanoma in the U.K. is increasing more rapidly than that of most other malignant tumours. Sunburn in childhood increases the risk of malignant melanoma in later life and it is therefore essential that protection of children is improved if primary prevention of melanoma is to be effective. We asked 238 parents in Leicester how they protected their children against sunburn, how often their children suffered sunburn, and whether they had heard of malignant melanoma . Although most (80%) had heard of melanoma, 47% did not regularly ensure that their children used a sunblock lotion, and only 34% regularly protected them from the midday sun. Forty-eight per cent of parents stated that their children burned at least once a year. New approaches to public education about melanoma may be needed to improve the protection of children against sunburn.

Autier P; Dore JF; Schifflers E; Cesarini JP; Bollaerts A; Koelmel KF; Gefeller O; Liabeuf A; Lejeune F; Lienard D; et al
Int J Cancer (United States) Jun 9 1995, 61 (6) p749-55

Use of sunscreens is widely advocated as a preventive measure against sun-induced skin cancers. However, to date, no epidemiologic study has reported a decreased melanoma risk associated with sunscreen use. We have conducted a case-control study aimed at evaluating the influence of sunscreen use on the occurrence of cutaneous malignant melanoma . In 1991 and 1992, 418 melanoma cases and 438 healthy controls were interviewed in Germany, France and Belgium. The questionnaire used differentiated between regular sunscreens, psoralen sunscreen (prepared with 5-methoxypsoralen, a tanning activator and photocarcinogen), and self-tanning cosmetics (which produce a tan without ultraviolet radiation). After adjusting for age, sex, hair colour and holiday weeks spent each year in sunny resorts, the melanoma risk was of 1.50 (95% Cl:1.09-2.06) for regular sunscreens, and of 2.28 (95% Cl: 1.28-4.04) for psoralen sunscreens. No melanoma risk was associated with use of self-tanning cosmetics. Among subjects with a poor ability to tan, psoralen sunscreen users displayed a melanoma risk of 4.45 (95% Cl: 1.25-15.8) when compared with regular sunscreen users. There was a significant negative interaction between regular sunscreen use and sunburns experienced in adulthood. Use of sunscreens, especially psoralen sunscreen, was associated with higher density of pigmented lesions of the skin. Although we cannot exclude the presence of an unknown confounding factor, our results support the hypothesis that sunscreens do not protect against melanoma, probably because of their ability to delay or avoid sunburn episodes, which may allow prolonged exposure to unfiltered ultraviolet radiation. Serious doubts are raised regarding the safety of sunscreens containing psoralens.

Holly EA; Aston DA; Cress RD; Ahn DK; Kristiansen JJ
Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco 94143, USA.
Am J Epidemiol (United States) May 15 1995, 141 (10) p923-33

A population-based case-control study of cutaneous malignant melanoma (CMM) was conducted in 452 women with melanoma and 930 control subjects aged 25-59 years in five San Francisco Bay Area counties between 1981 and 1986. Women were interviewed in their homes with regard to history of sunlight exposure and sunburns during different periods in their lives, phenotypic and host characteristics, medical history, occupation, and demographic factors. Data were analyzed by the patients' histologic type of melanoma ; 355 women were classified as having superficial spreading melanoma (SSM), 61 had nodular melanoma (NM), 13 had lentigo maligna melanoma, and 23 had other melanomas that could not be further classified upon histologic review by University of California dermatopathologists. Univariate results from analysis of factors related to sun exposure showed that the risk of all histologic types of CMM, SSM, and NM increased with increasing tendency of the subject to sunburn and with history of increased severity and/or frequency of sunburns up to age 12 years. Risk of all types of CMM and SSM also increased with increasing number of sunburns for all age groups and with lack of use of sunscreen . After adjustment for each other and for phenotypic factors, history of sunburn up to age 12 and lack of sunscreen use were the primary sun-related factors associated with an increased risk of all types of CMM and SSM, while tendency to sunburn when exposed to 1/2 hour of noontime sun and lack of use of sunscreen were related to NM. Although having frequent sunburns before age 12 and having severe sunburns before age 12 were both strongly associated with melanoma, having large numbers of sunburns during any time period from elementary school through age 30 years and having sunburns during the 10 years prior to diagnosis or interview were all associated with a doubling of risk for SSM after adjustment for other factors. These results suggest that the increased risk of melanoma related to sunburns is not confined to childhood sunburns. Maintenance of an all-year tan provided no protective effect against melanoma after adjustment for tendency to burn. No association was noted with use of fluorescent lights or exposure to sunlamps for all types of CMM, SSM, or NM.

Westerdahl J; Olsson H; Masback A; Ingvar C; Jonsson N
Department of Surgery, University Hospital, Lund, Sweden.
Melanoma Res (England) Feb 1995, 5 (1) p59-65

The relation between use of sunscreens, different host factors and malignant melanoma was investigated in a population-based, matched case-control study of malignant melanoma in the South Swedish Health Care Region, which has the highest risk for melanoma in Sweden, between 1 July 1988 and 30 June 1990. In total, 400 melanoma patients and 640 healthy controls aged 15-75 years answered a comprehensive questionnaire regarding different epidemiologic variables, including questions on use of sunscreens and different constitutional factors. The use of sunscreens was not found to protect against developing malignant melanoma . Instead, an unexpected relation between the use of sunscreens and the risk of developing malignant melanoma was seen (odds ratio (OR) 1.8 for almost always vs never using sunscreens). A tentative dose-response relation was found. Virtually the same ORs were seen in both sexes. Furthermore, persons younger than 50 years had a higher OR than persons older than 50 years. When different melanoma presentation sites were considered, lesions of the trunk were associated with sunscreen use in females (adjusted OR = 3.7 for almost always vs never using sunscreens), while lesions of the extremity or head and neck were associated with sunscreen use in males (adjusted OR = 3.2 for almost always vs never using sunscreens). Raised naevi on the left arm and freckling were shown to be the major constitutional risk factors (OR = 3.9 for more than three naevi vs none and OR = 1.4, respectively). The results were essentially unaltered in a histopathologically re-examined material. Further investigations are needed in order to form a basis for melanoma prevention.

Jansen C
Kliniska Institutionen, Abo Universitet.
Nord Med (Sweden) 1995, 110 (3) p85-7

Ultraviolet radiation (UVR) exerts a variety of effects on the skin, most of which are inimical. Best known is the effect of UVB radiation which readily burns unprotected skin, but we now know that even UVA radiation may exert penetrating effects on the skin, as well as causing DNA damage and increased risk of cancer. The markedly increased incidence of basal cell and squamous cell carcinoma and malignant melanoma among fair-skinned Caucasians in industrialised countries is attributed to increased exposure to UVR. Sunscreen creams may have exacerbated the situation. Effective phototherapy is a useful product of photomedical research, and it can be further improved. Recently new perspectives were opened up in basic research into UVR, when it was found that repair of DNA lesions via different pathways orchestrates a series of cellular phenomena such as oncogene expression, acid radical defence, immunomodulation, apoptosis and pigmentation induction. (12 Refs.)

Bourke JF; Healsmith MF; Graham-Brown RA
Department of Dermatology, Leicester Royal Infirmary, U.K.
Br J Dermatol (England) Feb 1995, 132 (2) p251-6

The city of Leicester, in conjunction with other centres throughout the U.K., was targeted for publicity about melanoma over a 3-year period from 1987 to 1989. We report the results of a survey to assess the level of awareness of melanoma, and to document current sunbathing practices subsequent to that period. The general level of awareness of melanoma in the community was good (74%). People who knew about melanoma were more likely to use a sunscreen at home and abroad (odds ratios 1.63, 95% CI 1.19-2.24 and 1.39, 95% CI 1.03-1.86), but paradoxically more likely to sunbathe than those who had never heard of melanoma (odds ratio 1.33, 95% CI 1.03-1.72). Females were more knowledgeable than males (odds ratio 1.74, 95% CI 1.26-2.22), but continued to sunbathe. Teenagers and young adults tended to be relatively ignorant of melanoma, and were less likely to protect themselves against sunburn while sunbathing than other age groups. Teenagers, young adults, and males need to be targeted more effectively in future publicity campaigns. Furthermore, many people who know about melanoma continue to put themselves at risk by sunbathing. New strategies need to be developed to influence behaviour as well as increasing awareness.

Grin CM; Pennoyer JW; Lehrich DA; Grant-Kels JM
Department of Medicine, University of Connecticut School of Medicine, Farmington.
Pediatr Dermatol (United States) Dec 1994, 11 (4) p304-9

Sun exposure in childhood has been implicated as a risk factor for the development of melanoma and nonmelanoma skin cancers. As an increasing number of young children are cared for in day-care centers, we were interested in examining the sun-protection practices in this setting. In our study of day-care centers, we found that while most day-care center staff were aware of the adverse effect of excess sun exposure and the need for sun protection, the use of sunscreen and protective clothing and avoidance of midday sun were limited. We conclude that intensive education of day-care center staff and parents regarding sun exposure and sun protection is necessary if we are to attempt to reduce the frequency of melanoma and nonmelanoma skin cancer.

Campbell HS; Birdsell JM
Division of Epidemiology and Preventive Oncology, Alberta Cancer Board, Calgary, Canada.
Prev Med (United States) Mar 1994, 23 (2) p160-6

BACKGROUND. There is considerable evidence that exposure to ultraviolet radiation increases the risk of many dermatologic conditions including nonmelanoma skin cancers and the more serious cutaneous malignant melanoma . Despite this, there is little data on healthy persons' exposure patterns and protection behaviors.

METHODS. As part of a larger survey for a cancer prevention demonstration program, a household survey of 3,843 adults ages 35-64 was conducted in four mid-size cities in Alberta, Canada. Self-administered questionnaires were used to collect data on sun-related knowledge, beliefs, occupational and recreational exposure and current protective behaviors.

RESULTS. Only 45% of respondents believed sun exposure affected their chances of getting cancer. With few exceptions, less than 50% of either sex were likely to routinely use any of the four protective measures: avoiding the sun, protective clothing, hats, or sunscreen . This propensity was inadequate even for those with sun-sensitive skin types. Men and women differed in the type of protection preferred. Older adults were more likely to take precautionary measures.

CONCLUSIONS. There is clearly a need for modification of the public's beliefs and protective behaviors if the predicted skin cancer epidemic is to be avoided. Knowledge of protective behaviors and age- and gender-specific preferences will help in planning future research and health education programs.

Wolf P; Donawho CK; Kripke ML
Department of Immunology, University of Texas M. D. Anderson Cancer Center, Houston 77030.
J Natl Cancer Inst (United States) Jan 19 1994, 86 (2) p99-105

BACKGROUND: Epidemiologic evidence suggests that exposure to UV radiation plays a significant role in the development of melanoma skin cancers. As early surgical removal of the melanoma is the only effective therapy, current strategies for reducing mortality from melanoma focus on prevention of the disease. Chemical sunscreens protect mice from development of skin cancers that resemble sunlight-induced human squamous cell cancers, but there appears to be a complex relationship between UV radiation exposure and development of melanoma .

PURPOSE: We asked whether common sunscreens would protect mice against UV radiation-induced enhancement of melanoma incidence.

METHODS: C3H mice were exposed to 4.8 kJ/m2 UVB from FS40 sunlamps twice a week for 3 weeks. Sunscreens containing 7.5% 2-ethylhexyl-p-methoxycinnamate, 8% octyl-N-dimethyl-p-amin obenzoate, 6% benzophenone-3, or the oil-in-water vehicle alone were applied to the ears and tails of the mice 20 minutes before irradiation. At various times during and after exposure, we determined UV radiation-induced inflammation by measuring ear swelling. We also examined the ears histologically for UV radiation-induced alterations. One day after the final irradiation, 2.5 x 10(4) syngeneic K1735 melanoma cells were injected into the external ears. Mice were examined weekly for tumor growth for 5-8 weeks after tumor cell injection. Control mice were treated in the identical way except for exposure to UV radiation.

RESULTS: The incidence of melanomas was significantly higher in the UV-irradiated mice. All three sunscreens protected against UV radiation-induced ear swelling and clearly diminished histopathologic alterations, including sunburn cell formation, epidermal hyperplasia, and mononuclear cell infiltrate in the dermis. However, the sunscreens failed to protect against UV radiation-induced increase in melanoma incidence. The sunscreens or vehicle alone did not significantly alter tumor growth.

CONCLUSIONS: Protection against sunburn does not necessarily imply protection against other possible UV radiation effects, such as enhanced melanoma growth.

IMPLICATIONS: Sunscreen protection against UV radiation-induced inflammation may encourage prolonged exposure to UV radiation and thus may actually increase the risk of melanoma development. These findings suggest that further research on the ability of sunscreens to prevent melanoma is urgently needed.

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