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The AN TI TAN NIN G I ssu e VOL. XXVIII, 2010 NEW STUDIES LINK MELANOMA TO TANNING MELANOMA AND SUNNY VACATIONS ADDICTED TO TANNING? THE DECLINE OF CELEBRITY TANNING BANNING THE TAN AROUND THE WORLD MICK FANNING, WORLD CHAMPION SURFER TEAM SCF: ATHLETES AGAINST SKIN CANCER www.SkinCancer.org © Clinique Laboratories, LLC © Clinique Laboratories, LLC The The power power to to even even skskin in tone tone with with results results equal equal to to a leading a leading prescription prescription ingredient. ingredient. New.New. Clinique Clinique EvenEven Better Better Clinical Clinical DarkDark SpotSpot Corrector. Corrector. Dermatologist-developed Dermatologist-developed to be safe, to becomfortable. safe, comfortable. Yet in clinical Yet in clinical trials our trials our serumserum was comparable was comparable to a leading to a leading prescription prescription ingredient ingredient in creating in creating a morea more even skin eventone. skinAtone. verifiAed verifi 53% edimprovement 53% improvement in skinintone. skin tone. One difference—Clinique One difference—Clinique Even Better Even Better Clinical Clinical is idealisfor ideal skins forthat skins may thatnot may benot be able toable tolerate to tolerate other skin-evening other skin-evening treatments. treatments. Use it,Use comfortably, it, comfortably, long-term. long-term. In as little In asaslittle 4 weeks, as 4 weeks, all ethnicities all ethnicities enjoy aenjoy morea uniformly more uniformly radiantradiant complexion. complexion. At 12 weeks, At 12 weeks, see a visible see a visible reduction reduction in darkinspots, dark spots, age spots, age spots, and the and traces the traces of acne ofpast. acne Even past.stubborn Even stubborn dark spots dark spots will seem will seem improved. improved. ApplyApply twice atwice day.aNever day. Never forgetforget the sunscreen. the sunscreen. And results And results are guaranteed. are guaranteed. See what See53% whatimprovement 53% improvement looks looks like at like clinique.com/evenbetter at clinique.com/evenbetter pub11553a_v3.indd 1 3/18/10 5:24:36 PM Client: Job ID: Proof: � Fighting deep eye wrinkles is a 24-hour job.� Andie MacDowell *based on in-vitro testing. ©2010 L’Oréal USA, Inc. WANT TO STOP DEEP-SET EYE WRINKLES? Start with the first nonstop AM + PM eye repair duo. AM REPAIR + PROTECT 24 HR EYE REPAIR DUO SPF 15 MORE THAN SMOOTHING, ADVANCED AM/PM EYE REPAIR: AM Repair + Protect: Pro-Retinol A + SPF 15 PM Repair + Restore: Pro-Retinol A + Fiber-Restoring Complex* CLINICALLY PROVEN RESULTS: REPAIR + RESTORE PM Reduces deep crow� s feet and under-eye creping lines. B BEFORE AFTER 8 WEEKS CLINICAL TEST ON DEEP-SET WRINKLES Women aged 40-60 � ll Because you� re worth it� lorealparis.com PARSOL® ® Your QualitY Seal PARSOL PA Your Quali Your QualitY Seal PARSOL Offering a full range of high-performance UVA and UVB filters and technical support to meet your sunscreen formulation requirements, while guaranteeing the highest standards in quality, safety, reliability and compliance. ® ® PARSOL Your QualitY Seal North AmEricA DSM Nutritional Products, Inc. 45 Waterview Boulevard, Parsippany, NJ 07054; United States of America Phone: +1 800 526 0189 Email: [email protected] EricA For further information, please visit nal Products, Inc. North AmEricA w Boulevard, Parsippany, NJ 07054; United States of America www.dsmnutritionalproducts.com 800 526 0189 Email:North [email protected] AmEricA Products, Inc. DSM Nutritional Your QualitY Seal DSM Nutritional Products, Inc. Parsippany, NJ 07054; United States of America AmEricA 45North Waterview Boulevard, 45 Waterview Boulevard, NJ 07054; United States of America DSM Nutritional Products,Parsippany, Inc. Phone: +1 800 526 0189 [email protected] Phone: +1 800Boulevard, 526 0189 Email: [email protected] 45 Waterview Parsippany, NJEmail: 07054; United States of America Phone: +1 800 526 0189 Email: [email protected] er information, please visit smnutritionalproducts.com ForForfurther pleasevisit visit furtherinformation, information, please For further information, please www.dsmnutritionalproducts.com www.dsmnutritionalproducts.com visit www.dsmnutritionalproducts.com Offering a full Offering a full range of high-performance UVA and UVBrange filters of high-pe and technical support to me and technical support to meet your sunscreen formulation requirements, guarant requirements, while guaranteeing the highest standards while in Offering a fullsafety, range of high-performance UVA andquality, UVB filters quality, reliability and compliance. sa and technical support to meet your sunscreen formulation Offering a full range of high-performance UVA and UVB filters standards in requirements, while guaranteeing the highest and technical support to meet your sunscreen formulation quality, safety, reliability and compliance. requirements, while guaranteeing the highest standards in quality, safety, reliability and compliance. 12| 2009foUndATionnEWSroUndUp 15| prESidEnT’SmESSAGE 17 17| LAndmArkrESEArCHLinkS mELAnomAToUvrAdiATion MarkTeich 18| THErviSrEAdYToroLL: THEroAdToHEALTHYSkinToUriSBACk BEAUTY 23 20 | BronzErnoTrEQUirEd BEAUTYTrEndSfromTHEExpErTS ElizabethMichaelson 23 | mELAnomASCrEEninGSAvESLivES Shawn Allen, MD 25| HoWTopErformASkinSELf-ExAm RogerCeilley,MD,FAAD 28| TAnninGAddiCTion:THEnEWformofSUBSTAnCEABUSE Robin L.Hornung,MD,MPH, andSolmazPoorsattar 30| AppEArAnCETrUmpSHEALTHASAnAnTi-TAnninGArGUmEnT JoelHillhouse, PhD 28 32 LifESTYLE 32| TEAmSCf:ATHLETESAGAinSTSkinCAnCEr 38 | A TEnniSpLAYEr’SExpEriEnCE WilliamStebbins,MD, and C.WilliamHanke,MD, MPH 42| fromBArdoTToBECkHAm:THEdECLinEofCELEBriTYTAnninG NinaG.Jablonski, PhD 42 46| SUnSAfETYAT SCHooL Janice ClarkYoung,EdD, CHES, and Brenda S.Goodwin, MS 48| UndErTHESUn,EvErYTHinGYoUWEArmATTErS SusanY.Chon,MD,FAAD 46 38 51 63 58 56 HEALTH 71 inTErnATionALAdviSorYCoUnCiL 51 | 63 | BAnninGTHETAnAroUndTHE WorLd:nATionSmoBiLizE CraigSinclair LipCAnCEr:noTUnCommon, ofTEnovErLookEd WilliamStebbins,MDand C.WilliamHanke,MD,MPH 66 | CLArE’SLEGACY 56 | THEriGHTWAYToTrEAT SEASonALdEprESSion MichaelTerman,PhD 58| proTECTYoUrEYES:EvErYdAYSTEpSToSUnSAfETY ReneS.Rodriguez-Sains,MD 60| BrEASTCAnCErAndmELAnomA: HoWTHEYArELinkEd SuLuoandHensinTsao,MD,PhD 8 68| THEroAdToGroUpi:HoWTHEinTErnATionAL AGEnCYforrESEArCHonCAnCErCAmETo CLASSifYindoorULTrAvioLET(Uv)TAnninGAS CArCinoGEniCToHUmAnS PhilippeAutier,MD,MPH 71| mELAnomAAndSUnnYvACATionS ProfessorJuliaNewtonBishop,MD ProfessorTimBishop,PhD PaulAffleck,MA SK I N C A NCER FOU N DAT ION JOU R NA L sun safety your destination for Sephora is honored to partner with The Skin Cancer Foundation for the fourth consecutive year in creating the Sephora Sun Safety Kit. Our award-winning set includes advanced protective products, all with SPF 15 or higher, housed in a beach-friendly clutch. With 100% of the net profits benefiting the Foundation, Sephora is committed to the education of sun safety to our clients and beyond. We are proud to work with the leaders in the fight against skin cancer. Pledge to uncover your most beautiful skin yet, and we will help you start—and stick to—a daily routine that lets you put your best face forward in four simple steps: CLEANSE, TREAT, MOISTURIZE, PROTECT. Plus, earn a FREE reward when you complete the challenge. Visit sephora.com/go/skincarechallenge for more information. SPF 60 SPF 55 SCF Journal Ad 2010.indd 1 3/8/10 11:54 AM ABOUT THE FOUNDATION 75 | INTERNATIONAL ADVISORY COUNCIL 76 | LEADER IN THE FIgHT AgAINST SkIN CANCER 78 | SCF OFFICERS & STAFF 80 | RESEARCH gRANTS AwARDED IN 2010 81 | pROFESSIONAL MEMBERS 88 | AMONETTE CIRCLE 90 | 2009 DONORS 92 | CORpORATE LEADERSHIp COUNCIL 93 | U.S. CORpORATE COUNCIL 94 | INTERNATIONAL CORpORATE COUNCIL 94 | SEAL OF RECOMMENDATION 95 | HIgHLIgHTS FROM SCF 2009 EVENTS 96 | REFERENCES 98 | SCF CATALOg 100 | ADVERTISERS’ INDEx 95 2010 Jo u r n a l st a f f Ad v ERTISINg Medical Editor Pearon G. Lang, Jr., MD Director of Corporate Partnerships Dan Latore Publishers Perry Robins, MD Mary Stine Managing Editor & Director of New Media Paul Melia Executive Editor Mark Teich Manager, Corporate Partnerships Pamela McLaughlin Assistant Manager, Corporate Administration Veronica Barlow Associate Editor Elizabeth Michaelson Individual copies of The Skin Cancer Foundation Journal are available for $5 (includes shipping & handling). Call (212) 725-5176 or visit www.SkinCancer.org for volume pricing and shipping. Journal d esign: Martin Fitzpatrick, FITZcreative.com Miss io n st a t e Me n t o f t h e sk in Ca n Ce r f o u n da t io n The first organization in the US committed to educating the public and medical professionals about sun safety, The Skin Cancer Foundation is still the only global organization solely devoted to the prevention, detection and treatment of skin cancer. The mission of the Foundation is to decrease the incidence of skin cancer through public and professional education and research. For more information, visit www.SkinCancer.org. The opinions expressed in the Journal are those of the authors and do not necessarily reflect the views of The Skin Cancer Foundation. The Skin Cancer Foundation Journal is published by The Skin Cancer Foundation 149 Madison Avenue, Suite 901 New York, NY 10016 Phone: 212-725-5176 Fax: 212-725-5751 E-mail: [email protected] Website: www.SkinCancer.org © 2010 The Skin Cancer Foundation All Rights Reserved 11 2009 Foundation News Round Up MAkingAniMpression TheFDAConsiDersreClAssiFyingUVTAnningDeViCes The Skin Cancer Foundation is a major skin cancer information resource for print and electronic media. In 2009, we generated 504 million impressions in print, television and radio, and 1.7 billion impressions in electronic media. Coverage of the Foundation and our information about skin cancer appeared on local and national news programs such as Good Morning America and TODAY; on websites like WebMD; in magazines such as SELF and Good Housekeeping, and in newspapers including The New York Times, USA Today and The Wall Street Journal. The Skin Cancer Foundation is often contacted by staff at these and other magazines, newspapers, and television stations when they are looking for an expert in the field of skin cancer. Physician members of the Foundation serve as spokespeople, informing the media about the prevention, early detection, and treatment of skin cancer. Forty two members participated in interviews for television, radio, print, and web in 2009. In November, the US Food and Drug Administration (FDA) announced that on March 25, 2010, members of a Medical Devices Advisory Committee Panel would meet to discuss the possible reclassification of UV-emitting tanning beds and lamps. As of early March 2010, tanning machines are Class I medical devices, in the same category as elastic bandages and tongue depressors. But according to the US Department of Health and Human Services, UV radiation from either the sun or tanning machines is a proven human carcinogen (cancer-causing agent), and considerable research shows it is the chief cause of skin cancer. Reclassification to Class II or III would permit stricter regulations and more oversight. The Skin Cancer Foundation has launched a campaign in support of reclassification. By the time you read this, the FDA may have made a decision. CAllingAllsoCiAlneTworkers We hope you’ll join us online by becoming a fan of The Skin Cancer Foundation on Facebook (www.Facebook.com/skincancerfoundation). Our expanded profile features regular updates on programs like the Road to Healthy Skin Tour, Team SCF, and our Go With Your Own GlowTM campaign. You can also view videos and photos, download skin cancer information, and help raise awareness of the cause. We’re also on Twitter — follow us at www.twitter.com/SkinCancer. org, and check in regularly for news, advice from the experts, and more. 12 SK I N C A NCER FOU N DAT ION JOU R NA L WE’RE VERY HONORED THE GLOW CAMPAIGN KEEPS GOING (AND GLOWING) In 2009, The Skin Cancer Foundation was honored — again — for its efforts to educate the public about skin cancer. In fact, the American Academy of Dermatology (AAD) presented us with f ve Gold Triangle Awards, setting a record for the number of wins at one time in the Health Community Organization category. Our honorees include the quarterly consumer newsletter Sun & Skin News; the PSA print ad campaign Go With Your Own GlowTM; our children’s educational program, The Sunsational Guide to Smart Sun Safety: Fun in the Sun 101; the Road to Healthy Skin Tour, presented by Aveeno® and Rite Aid, and our brochures Skin Cancer: If You Spot it, You Can Stop it and Understanding UVA and UVB. This brings our total number of Gold Triangles to 14. Since 2008, our Go With Your Own GlowTM ad campaign, created for us by Laughlin Constable, has received more than $3.7 million in ad space and has been featured in more than a dozen magazines, including TIME, PEOPLE, and Marie Claire. Our message — that tanning is no longer in fashion — has reached almost 300 million readers. Look for Go With Your Own GlowTM in your favorite magazines, and see where we’ve been featured here: www. SkinCancer.org/go-with-your-own-glow-in-magazines.html. raisin is a grape that didn’t have the sense to get out of the sun. And think about it, if the giant orb in the sky can do that to a little piece of fruit, imagine what it’s doing to your precious skin. Layers one to seven do not like being basted, toasted, roasted, fried, and all other manner of scorched. And how does your skin show it? Hello wrinkles. Hello crow’s feet. Hello blotches and burns and who-knows-what-all-else. Not to be prejudiced, but on the pecking order of brains, we humbly submit that human beings should have more sense than dumb grapes. T anning’s fifteen minutes are over. Let your inner health, beauty, and vitality shine through. Don’t you agree? Nothing looks better on you than the healthy, glowing, radiant shine ou know that indescribable something that radiates from deep inside? Some call it the glow. Some call it the inner shine. Some call it the eternal beacon of your all-that-is-good (but they are rather you were born with. Because long-winded types.) The bottom line, however, is the same. today, being healthy – truly healthy – is Nothing attracts like the fresh, natural, healthy glow of your what’s sexy. own skin. You’ve seen it yourself. After exercising. On pregnant women. It’s what you’re made of, and the fact of the matter is, nothing is as sexy as healthy. So, ask yourself this: why burn it, scorch it, fry it, sizzle it, dull it? Don’t have an answer? Neither do we. Go with your own glow www.skincancer.org © 2008 The Skin Cancer Foundation Campaign created by partners + jeary, www.partnersandjeary.com © 2010 The Skin Cancer Foundation Campaign created by Laughlin Constable, www.laughlin.com Rex Amonette, MD, Senior Vice President of The Skin Cancer Foundation, accepts a record-breaking f ve Gold Triangle Awards from American Academy of Dermatology President David Pariser, MD TEAM SCF IS HERE We’re thrilled to introduce Team SCF. Featuring a partnership with World Professional Surfers, including Mick Fanning and Damien Hobgood; US Women’s National Team soccer stars Christie Rampone and Lindsay Tarpley; snowboarder Shayne Pospisil; golfer Brian Davis; angler Preston Clark and others, Team SCF consists of elite sports professionals dedicated to sun safety. To learn more about how these athletes protect their skin despite rigorous schedules that require them to be outdoors (and usually in the sun) on a daily basis, please see “Team SCF: Athletes Against Skin Cancer” on page 32. © 2010 The Skin Cancer Foundation Campaign created by Laughlin Constable, www.laughlin.com BACK TO SCHOOL WITH THE SKIN CANCER FOUNDATION The Sunsational Guide to Smart Sun Safety: Fun in the Sun 101, has been garnering accolades. Not only did our program for middle and junior high school students win a Gold Triangle Award from the American Academy of Dermatology (AAD), The Washington Post called it “fun” and “kid-friendly.” Best of all, 95 percent of the teachers surveyed said they would use the program annually. The program consists of an interactive website (www.SkinCancer.org/school) and free downloadable materials. Last year, we distributed 15,000 kits — including 455,000 student journals — to teachers all over the US. Visit us online for new features and updates. 13 The Sun Knows No Season Five jane iredale products awarded the SCF Seal of Recommendation as effective UV sunscreens. Even in winter, the sun also rises. Luckily, jane iredale makes it easy to stay pretty, and protected, with five products awarded The Skin Cancer Foundation Seal of Recommendation as effective UV sunscreens: • Amazing Base ® SPF 20 • Dream Tint ® SPF 15 • PurePressed ® Base SPF 20 • LipDrink ™ SPF 15 • Powder-Me SPF ® SPF 30 When used regularly in the prescribed manner, these products may help reduce the potential risk of skin cancer due to overexposure to sunlight, and serve as an effective aid in the prevention of sun‑induced damage to the skin, including sunburn and possibly premature aging. jane iredale – THE SKIN CARE MAKEUP ® — supporting you in the fight against skin cancer. The #1 choice of skin care professionals At skin care specialists & beauty apothecaries in over 40 countries The prettiest protection is at janeiredale.com President’s Message During the past year, we’ve seen important developments in skin cancer awareness and anti-tanning efforts around the world, as new studies have strengthened the link between ultraviolet (UV) tanning and increased risk of melanoma. One key report for the first time declared UV radiation from tanning devices carcinogenic (cancer-causing) to humans; in another, genetic researchers revealed that most of the mutations found in a melanoma were caused by damage from UV radiation. These events prompted The Skin Cancer Foundation to campaign for stricter regulations and more oversight of tanning devices. We During the past year, we’ve seen important developments in skin cancer awareness and anti-tanning efforts around the world, as new studies have strengthened the link between ultraviolet (UV) tanning and increased risk of melanoma. commissioned a white paper summarizing the research on the dangers of UV tanning. This led members of Congress to petition the US Food and Drug Administration (FDA) to reclassify tanning machines to better reflect the serious dangers they pose. Thanks to our efforts, along with those of the National Council on Skin Cancer Prevention, the FDA met on March 25 to hear testimony on the reclassification of tanning beds and lamps. Reclassification to Class II or III would permit stricter regulations and more oversight. In July 2009, the International Agency for Research on Cancer (IARC), affiliated with the World Health Organization (WHO), added UV-emitting tanning devices to its list of the most dangerous forms of cancer-causing radiation. In this landmark report, UV radiation from tanning beds and lamps was included in the small group of radiation sources known to cause cancer in humans — a group including plutonium and solar UV radiation. We contacted Dr. Philippe Autier, former head of the IARC’s Prevention Group, which authored the report, and he agreed to share the story of how the group reached its momentous decision to list tanning beds among the world’s most virulent carcinogens. In his article (page 68), Dr. Autier traces the history of the research linking UVR from tanning devices with skin and eye cancers. In December 2009, the Wellcome Trust Sanger Institute in Hinxton, UK, achieved another milestone, revealing that its scientists had decoded the entire genetic makeup (genome) of a melanoma. The researchers found that the vast majority of the mutations found in the melanoma were caused by damage to the skin cells’ DNA by the sun’s UV radiation. This groundbreaking research is covered on page 17. These studies are of international importance, and to help spread our sun safety message to a global audience, we have taken steps to expand our International Advisory Council. Our 68 members, including new members from Jordan, Kuwait, and Thailand, represent 26 countries. They are invaluable to our international outreach and educational efforts. One of the centerpieces of our international outreach is the World Congress on Cancers of the Skin. This year, the 13th Congress was held from April 7-10 in Madrid, bringing together doctors from all over the world, including more than 120 speakers. The World Congress allows physicians a unique opportunity to interact with distinguished international faculty and to learn about breakthrough discoveries in the prevention, diagnosis, and treatment of all types of skin cancer. The coming year promises many more vital and exciting developments in the prevention, detection, and treatment of skin cancer. We urge you to visit and explore our wide-ranging website, www.SkinCancer.org, and to join our fight against the world’s most common cancer. President The Skin Cancer Foundation 15 8 3/8” I ng the N ew L o i c u d o ok r t of n ™ 8” Indulge Yourself with Luxurious Sun Protection for Beautiful, Sheer Touch SPF 80 C-Spray • Skin-nourishing antioxidants • Exotic island botanicals • Enriched with shea and mango butters © 2009 Tanning Research Laboratories, LLC 1047146 Radiant Skin Sheer Touch SPF 50 Crème me Lotion • Skin-nourishing antioxidants • Luxurious moisture • Very water resistant Mango After Crème Lotion Sun Cr • Luxurious moisture • Exotic island botanicals • Enriched with shea and mango butters Visit us at www.hawaiiantropic.com to see our entire NEW LOOK line! Landmark Research Links Melanoma to UV Radiation MArkTeiCh,eXeCUTiVeeDiTor In December 2009, a remarkable new study made perhaps the convincing proof of UVR’s involvement. But this new cataloging strongest case ever that some melanomas are caused by exposure of mutations, the results of which were published in Nature, all but confirms UV radiation as a cause of melanoma. to ultraviolet (UV) radiation. The link between melanoma and UV radiation is further Scientists at The Wellcome Trust Sanger Institute, in Hinxton, UK, mapped the complete genetic material (the genome) that com- reinforced by information gleaned from a companion study of a posed a melanoma taken from a patient with the disease. Using patient’s lung cancer genome, also recently mapped by scientists new molecular technology, the researchers identified thousands of at the Wellcome Trust Sanger Institute. The pattern of mutations mutations, the vast majority of which were caused by UV radiation. in both cancer genomes is extremely similar; just as the vast Many mutations, changes or errors that occur in genes due to majority of mutations in the melanoma genome were caused by radiation, viruses, and other causes, can ultimately lead to cancer. UV damage, a significant majority of the mutations in the lung Over the years, evidence has added up that most skin cancers cancer genome were caused by cigarette smoking. “The profile are caused by damage to the skin cells’ DNA by the sun’s UV of mutations we observed [in the lung cancer genome] is exactly radiation, but this was the first time UV damage could be seen all that expected from tobacco, suggesting that the majority of the through a melanoma’s genetic material. According to the Sanger 23,000 we found were caused by the cocktail of chemicals found Institute, “The melanoma genome contains more than 33,000 muta- in cigarettes,” according to Dr. Peter Campbell, senior author of tions, many of which bear the imprint of the most common cause of melanoma — exposure to ultraviolet light.” “The melanoma In the study, the genomes genome contains of both normal and melanoma more than 33,000 tissue were decoded. When mutations, many the tissues were compared, scientists were able to pinof which bear the point precisely where in the imprint of the most melanoma genome mutations common cause occurred. of melanoma — “With this genome sequence, exposure to we have been able to explore ultraviolet light.” deep in the past of each tumor, uncovering with remarkable clarity the imprint of these environmental mutagens [causes of the mutations] on DNA, which occurred years before the lung cancer study. Most lung cancer deaths are known to be the tumor became apparent,” the study’s coauthor, Professor caused by smoking, and it could well be that most melanoma Mike Stratton, MD, PhD, explained. “We can see the desperate deaths are caused by UV. “These are the two main cancers in the developed world for attempts of our genome to defend itself against the damage from ultraviolet radiation. Our cells fight back furiously to repair the which we know the primary exposure,” Dr. Stratton said. “For lung cancer, it is cigarette smoke and for malignant melanoma damage, but frequently lose that fight.” It’s not clear to just what extent UV radiation influences the it is exposure to sunlight.” Not all mutations cause cancer, so the scientists will next try development of melanoma, but this research strengthens the link between them. While 90 percent of all basal and squamous cell to determine exactly which mutations contribute to melanoma carcinomas (the two most common skin cancers) are known to be development. “The knowledge we extract over the next few years associated with exposure to UV radiation (UVR), some investigators will have major implications for treatment,” said Dr. Campbell. have disagreed about the role of UVR in melanoma development. “By identifying all the cancer genes, we will be able to develop Research has established that genetics are an important component new drugs that target specific mutated genes, and work out which in melanoma (a family history of the disease increases one’s risk of patients will benefit from these novel treatments.” developing it), and some scientists have maintained there was no 17 The RV is Ready to Roll: The Road to Healthy Skin Tour is Back By the time you read this, The Skin Cancer Foundation’s Road to Healthy Skin Tour, presented by AVEENO® and Rite Aid, will be back on the road. The Tour, now in its third year, provides free, full-body skin exams by local dermatologists. In 2010, the Tour bus (a 38-foot customized RV with two exam rooms) will make an estimated 80 stops in 24 states. Be sure to check www.SkinCancer.org/Tour regularly for exclusive highlights from the road, including schedule updates, photos of our volunteer dermatologists, tour statistics, and more. In the Tour’s first two years, 224 dermatologists donated their time and expertise to provide free full-body skin screenings to over 6,500 people and discovered 116 suspected melanomas. Since melanoma is the deadliest form of skin cancer, the tour has already potentially saved over 100 lives. Between 2008 and 2009, dermatologists also found 1,198 suspected actinic keratoses (the most common precancers); 574 suspected basal cell carcinomas, and 189 suspected squamous cell carcinomas. The American Academy of Dermatology recognized the Road to Healthy Skin Tour’s efforts by awarding The Skin Cancer Foundation a Gold Triangle in 2009. The Tour has also been featured on both Good Morning America and TODAY. Additional support for the Tour is provided by Columbia Sportswear, DUSA Pharmaceuticals, Inc.®, Solar Gard® Window Film, and Fitness magazine. If you won’t be able to attend the Tour, you should visit a dermatologist once a year for a full-body skin examination. Learn how to perform a skin self-examination on page 25. 18 SK I N C A NCER FOU N DAT ION JOU R NA L new data shows blocking UVA and UVB rays is not enough. AVEENO® POSITIVELY AGELESS fights the signs of aging on 3 key levels. TM LATEST FACTS: there is a need to not only protect against UV rays that may cause skin cancer and premature aging, but also neutralize excessive free radicals that can cause additional visible damage. NEWEST SCIENCE: only AVEENO® has ENVIROBLOCK ™ Triple Defense Technology with exclusive ACTIVE NATURALS® antioxidant complex that goes beyond sunburn protection to fight the signs of aging on 3 levels: 1 2 3 ENVIROBLOCK™ technology protects against UVB burning rays with one of our strongest available sunscreens, SPF 90. (UVB rays cause sunburn, skin cancer and skin damage over time) ENVIROBLOCK™ technology blocks UVA rays and helps prevent them from penetrating skin. (UVA rays go deeper into the skin, causing skin to lose elasticity and develop brown spots) ENVIROBLOCK™ technology neutralizes up to 80% of skin damaging free radicals* with formulas containing a super-antioxidant complex of ACTIVE NATURALS.® (free radicals can contribute to additional visible damage such as premature skin aging) from AVEENO,® the brand dermatologists have trusted for 60 years and the Skin Cancer Foundation recommends as an effective UV screen *in vitro testing against UV induced free radicals ©Johnson & Johnson Consumer Companies, Inc. 2010 the beauty of nature+science new beAUTy bronzernoTreQUireD:beAUTy TrenDsFroMTheeXperTs/20 MelAnoMAsCreening sAVesliVes/23 howToperForMAskin selF-eXAM/25 TAnningADDiCTion:Thenew ForMoFsUbsTAnCeAbUse/28 AppeArAnCeTrUMpsheAlThAs AnAnTi-TAnningArgUMenT/30 preventinganaddictionisfarbetterthantryingtotreatone. —TAnning ADDiCTion: The new ForM oFsUbsTAnCe AbUse (p.28) Bronzer Not Required Beauty Trends from the Experts elizAbeThMiChAelson,AssoCiATeeDiTor Getting ready for the warm weather? at the Marc Jacobs show, makeup artist According to fashion and beauty experts, François Nars actually used a ton of loose there’s never been a better time to flaunt powder to lighten the skin tone — the your (properly sun-protected) untanned, complete opposite of a tanned look.” The waning of the deep, dark, dangerous natural beauty. “We love the pale look — the luminous, glowing skin that reflects your tan is apparent in magazines, too, Chao said. natural skin tone,” said Eleanor Langston, “For fashion shoots, you never want a model Beauty Director at Fitness. Her colleagues to be very tan. It’s not high fashion.” The at Marie Claire, Cosmopolitan, and model’s real skin color — be it ivory, tawny, Allure agree. They discussed this welcome olive, or deep brown — is the right shade. “I think the mindset has shifted in the trend — and how to wear it — with The past couple of years,” Langston observed. Skin Cancer Foundation. “Today, the trend is towards embracing your natural skin tone. It just looks fresher, and onsTAge,AnDonThepAge Fashion runways and magazines are the so much more sophisticated.” She thinks twin bellwethers of beauty trends — if a the current popularity of untanned skin look is in, you’ll find it there. “At the recent is “a natural progression, the result of shows, many designers showed models who all the news about skin cancer from The weren’t totally tanned,” said Ning Chao, Skin Cancer Foundation and dermatoloMarie Claire’s senior beauty editor. “Even gists.” Tanning is often associated with an Dolce & Gabbana!” (The iconic Italian brand “overdone, fake look.” But at Fitness, she said, often features bronzed models). “Designer “We want to promote a look that’s realistic, Michael Kors is known for a sun-kissed healthy, and natural, and the models we look. But Dick Page, the makeup artist at look for have those qualities.” The tan-free aesthetic is visible in the his show, said he didn’t want the superbronzed look. He used bronzer for contour editorial pages as well as the fashion pages. rather than for all-over darkening. And For instance, Fitness no longer advises 20 Clockwise from top left: Ning Chao, Senior Beauty Editor, Marie Claire Victoria Kirby, Beauty Editor, Allure Eleanor Langston, Beauty Director, Fitness Leah Wyar, Beauty Director, Cosmopolitan readers to wear darker makeup in the summer; this was standard when everyone was assumed to tan in the warmer months. “You shouldn’t have to switch foundation shades in the summer. We hope people’s skin tones remain the same year round,” Langston said. At Marie Claire, “in our June issue, we’re running an article on how to get bronzer-free perfect legs,” Chao said. If you’re worried that vibrant shades may make you look clownish, Kirby reassured us that while “bright makeup colors can look tacky on bronzed skin, a vivid cherry lip gloss or coral blush against a milky complexion is beautiful.” Celebswholook gorgeoUs,noTTAn A tan used to be the default look for many stars, but that’s changed in the past few years. “I really noticed it at the Oscars last year,” said Chao. “You had Anne Hathaway, Amy Adams, Nicole Kidman, Meryl Streep, all untanned and beautiful.” The oft-mentioned Kidman and Adams (both natural redheads with very fair skin) are noted for their beautiful, sophisticated, and always tan-free looks. But you don’t need to be alabaster-pale to make an impact. Many stars, not all of them so dramatically pale, have luminous, untanned skin. The editors love the bronze-free looks of Drew Barrymore, Kate Beckinsale, Kristen Bell, Halle Berry, Jessica Biel, Cate Blanchett, Emily Blunt, Mariah Carey, Kirsten Dunst, Isla Fisher, Jennifer Garner, Selena Gomez, Scarlett Johansson, Eva Mendes, Kristen Stewart, and Michelle Trachtenberg. springAnDsUMMer2010: iT’sAllAboUTColor But tan-free doesn’t mean monochrome: “There’s so much color right now,” explained Leah Wyar, Cosmopolitan’s Beauty Director. “That’s after years and years of the ‘natural’ face — just mascara and a glossy lip.” Ironically, with the ‘natural’ look, “people did tend to pile on the bronzer, because that let you wear less makeup everywhere else,” Wyar added. But now “color is coming back: hot pink lipstick, teal eyeliner and blue shadow… You don’t need to wear bronzer with these looks; the color supports itself.” Bronzer isn’t necessary, Langston agreed. “If you’re fair, a little color and contrast will keep you from looking sallow. Some luminosity will enhance your skin tone — I like a little champagne- or pearltoned highlighter on the tops of cheeks, and cream blushes, since powders often cake FroMbronzeTobeAUTiFUl in the heat.” The editors also noted that some celebs Victoria Kirby, Allure’s Beauty Editor, appear to have toned down their tans, a is also a blush fan. “It’s very important if move they applaud. “Many celebrities, you’re fair-skinned and you’re not wearing such as Christina Aguilera, used to wear bronzer. Skip it only if you’re wearing a tons of bronzer,” Wyar pointed out. “She bright lip color.” She favors shades of poppy doesn’t seem to be doing that anymore.” coral and hot pink this season. Langston has observed the same change in Like Langston, Chao is seeing a lot of Jessica Alba, noting, “Now she embraces products with a bit of luster. “Another her olive skin tone.” big trend is a skin brightener in a pearly Kirby cited Nicole Richie, recalling, pink color rather than an orange-y bronze. “When The Simple Life first came out, Brighteners shouldn’t have a distinctive she was very bronzed. She had that shimmer, but they should give the skin a celebutante look — streaky blond hair and dewy sheen.” bronzer. But now it looks like she’s letting herself be naturally beautiful, rather than conforming to a certain idea.” TheglowoFheAlTh Whether you play up your natural skin tone with bright colors, or apply a hint of self-tanner or bronzer, your glow will be healthy only when you avoid UV tanning. Today, beauty experts understand that there’s nothing healthy about damaging your skin. “Tanning is not aspirational!” Langston declared. “Everyone’s gotten the memo about how the dark tan look is out, and not flattering. It looks healthier to embrace and enhance your natural skin tone… It shows you’re taking care of your skin, and that you think avoiding sun damage is important. That’s a look we like!” howToweArbolDColors Wyar, Kirby, and Chao all mentioned teal, predicting we’ll see it and other equally vibrant shades in eyeliners and eye shadows. But if your idea of a bright hue is taupe, take heart: It’s not hard to “find your comfort level with color,” according to Wyar. “For a lot of people, lip color is the easiest way to experiment. For instance, if you want a pop of color, use a gloss.” When she hears the siren call of fuchsia lipstick, Wyar applies the bright color before anything else. “You get a sense of how much color is on your face, and you can adjust the rest of your makeup accordingly.” Rich pigments lend themselves to a light touch. “You can build color by layering. If you’re pale, you might want just a wash of bright color. If you’re darker, look for a creamy formulation that goes on more boldly,” Wyar advised. Besides, many bright hues are surprisingly easy to wear: “Teal blue on the eyes works with any complexion,” Chao promised. “As long as you don’t go overboard!” 21 T:8.375 in Daily defense for the face Cetaphil UVA/UVB Defense SPF 50—our most advanced facial moisturizer ® • High SPF in a moisturizer designed specifically for the face1 • Broad-spectrum daily defense against both UVA and UVB rays1 • Micronized titanium dioxide leaves no filmy white residue1 • Cosmetically elegant, lightweight, non-greasy and non-irritating1 • Prolonged hydration over 8 hours1 Reference: 1. Data on file. Galderma Laboratories. ©2010 Galderma Laboratories, L.P. Galderma and Cetaphil are registered trademarks. Galderma Laboratories, L.P., 14501 N. Freeway, Fort Worth, TX 76177 CETA-149 Printed in USA 03/10 www.cetaphil.com Melanoma Screening Saves Lives The Benefits of Total-Body Skin Examination and Skin Self-Exams Shawn Allen, MD M elanoma is by far the deadliest form of skin cancer and a major public health concern. The American Cancer Society estimated that about 68,720 new melanomas were diagnosed in the US during 2009, resulting in about 8,650 deaths.1 As with many cancers, the sooner melanoma is detected, the better the prognosis. The risk of dying from the disease, in fact, is directly related to the depth (thickness) of the cancer, which is related to the amount of time it has been growing unnoticed. Fortunately, skin cancers are usually readily visible. Patient skin self-examination, physician-directed total-body skin exams, and patient education are the keys to early detection. Taking issue with this, in February 2009 the United States Preventative Services Task Force (USPSTF) stated that “current evidence is insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous [skin] melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.”2 However, the USPSTF position is based solely on a review of studies from 1999 to 2005, and omits more recent research clearly showing the benefits of skin self-exams and total-body skin exams.2 Importantly, it did not look at the value of skin cancer screenings performed by board-certified dermatologists as opposed to a primary care physician. Currently, there is compelling evidence that both skin self-exams and total-body skin exams can play major roles in detecting potentially deadly melanomas and other skin cancers. Skin Self-Examinations With skin self-exams, it is possible for patients to detect their own melanomas. Brady, et al found that up to 57 percent of newly diagnosed melanoma patients first spotted their own melanomas by skin self-exams.3 We see similar findings in our clinics, as many melanoma and other skin cancer patients come to us complaining of a new or changing mole. For this reason, educating patients and the public about skin self-exams is critical. [See “How to Perform a Skin Self-Exam” on page 25.] Studies have also shown that people who perform skin 23 BEAUTY self-exams have thinner (and therefore less advanced) melanomas;4,5 self-exams and the corresponding earlier detection of melanomas may reduce mortality by as much as 63 percent.6 Professional Total-Body Skin Exams Physicians’ total-body skin examinations are also of great importance, especially since only about one third of individuals at risk for melanoma actually perform skin self-exams.7,8 Additionally, many patients are unaware of melanomas on their skin: A recent study showed that most melanomas detected in a general dermatology practice setting were found as a result of dermatologist-initiated total-body skin exams. Overall, 56.3 percent of melanomas were found by the dermatologist and were not mentioned by the patient as a reason for the visit.9 Multiple studies indicate that physicians are also more likely to detect melanomas at a thinner (earlier) stage than non-physicians7,10,11 (See Table 1). Kantor and Kantor found that detection initiated by a dermatologist was significantly associated with melanomas under 1.0mm, the definition of a thin melanoma,9 and Aitken, et al found that whole-body clinical skin examination in the three years before diagnosis was associated with a 14 percent lower risk of being diagnosed with a melanoma thicker than .75mm. This is perhaps the strongest evidence to date that whole-body clinical skin examination reduces the incidence of thick melanomas, and suggests that total-body skin exams would significantly reduce melanoma mortality.12 (For more information on melanoma thickness and its relationship to prognosis and staging, visit www.skincancer.org/melanoma/stages-of-melanoma.html.) Although the USPSTF currently maintains there is not enough evidence to support total-body skin exams by primary care physicians, the fact that they did not consider screenings by dermatologists (who are intensively trained in skin cancer recognition) in their analysis is significant. Nonetheless, a welltrained primary care physician can be extremely helpful in cases where a concerned patient requests a total-body skin exam. When the patient asks about a specific lesion, if there is any suspicion that it may be a cancer, he or she can be referred to a highly trained dermatologist. Despite the recent USPSTF position statement, it is clear from both clinical studies and common sense that total-body skin exams and skin self-exams play a critical role in early detection of melanoma, a potentially deadly skin cancer when discovered at later stages. References available on p.96. DR. ALLEN is Director and Founder of Dermatology Specialists of Boulder, PC, and Assistant Clinical Professor in the Department of Dermatology at the University of Colorado School of Medicine. Table 1: Differences in the Mean Thickness of Melanomas Detected By Physicians vs. Non-Physicians STUDY MEAN THICKNESS (mm) Physician Non-Physician Carli, et al7 .68mm .90mm Epstein, et al10 .23mm .90mm Swetter, et al11 .60mm .98mm*; 1.43mm** *Spouse/partner **Patient 24 SK I N C A NCER FOU N DAT ION JOU R NA L How to Perform a Skin Self-Exam 6 roger CeilleY, mD, faaD Skin self-exams should be performed once a month, in addition to an annual full-body skin exam by your physician. A skin selfexam involves systematically examining your entire body for skin changes that could be warning signs of the most common skin cancers (basal and squamous cell carcinomas and melanoma). Basal cell carcinoma is rarely fatal, but like squamous cell carcinoma (SCC), can be disfiguring if not treated in a timely fashion. SCC also causes about 2,500 deaths per year in the US. Warning signs for these skin cancers include: • A spot, sore, shiny bump or nodule, scaly lesion, or wart-like growth that continues to itch, hurt, crust, scab, erode, ooze, or bleed • An open sore or wound that does not heal within 2-3 weeks • A white, yellow, or waxy scar-like area, or a reddish patch or irritated area. Melanoma is the deadliest form of skin cancer, killing an estimated 8,650 people in the US this past year alone. Melanomas are often mistaken for moles. However, moles and melanomas differ in significant ways. The ABCDEs, below, describe the characteristics that can help you identify potential melanomas. the aBCDeS of melanomaS A The mole is asymmetrical; the two sides do not match B The mole is irregular in outline or border C The mole changes color or appears pearly, translucent, tan, brown, black, or multicolored D The mole is bigger than 6mm in diameter, or the size of a pencil eraser E The mole evolves or changes in any way Also be on the lookout for moles that appear after age 21. Any new skin growth, beauty mark, mole, brown spot, wound, or sore that doesn’t heal can be cause for concern; consult your physician if you have questions. To perform a self-exam, you’ll need a bright light, full-length mirror, hand mirror, two chairs or stools, and a blow dryer. 1 In front of a full-length mirror, study your face, especially the nose, lips, mouth and ears — front and back. 2 Examine the palms, hands, fingers, fingernails, and fronts and backs of the forearms. Look at the neck, chest and torso; women should check underneath the breasts. Use both mirrors to view the lower back, buttocks, and backs of the legs. Sit down, and prop your foot on another chair or stool. Using the hand mirror, examine your genitals. Look at the legs, especially ankles, tops and undersides of feet, and between the toes. On your next self-exam, note any changes in your skin, such as increases in size, differences in shape, and the appearance of any new growths. If your skin shows any warning signs of skin cancer, consult your physician. 3 5 7 8 Use a blow dryer to check your scalp, exposing each section to view. Check the upper arms, including underside and underarms. Next, turn your back to the full-length mirror and use the hand mirror to examine the reflection of the back of your neck, shoulders, and upper back. 4 DR. CEILLEY is Clinical Professor, Department of Dermatology, University of Iowa, Iowa City, and is in private practice in West Des Moines, IA. He is Past President of both the American Academy of Dermatology and the American Society for Dermatologic Surgery. He has authored or coauthored over 100 scientific publications, books, and chapters. The American Society for Dermatologic Surgery awarded Dr. Ceilley the 2003 Samuel J. Stegman Award for distinguished service. 25 thiS Skin CanCer foUnDation PUBliC SerViCe aDVertiSement iS aVailaBle for meDia USage. for more information, PleaSe ContaCt: Jamie SYlVeS, (212) 725-5176 ext. 120 [email protected] T anning’s fifteen minutes are over. Let your inner health, beauty, and vitality shine through. © 2010 The Skin Cancer Foundation Campaign created by Laughlin Constable, www.laughlin.com 618124D1_1_GC-journal:CLAR100078_ANNUAL_JOURNAL 2/19/10 11:48 PM Page 1 Your gorgeous tan, with or without the sun! Delectable Self Tanning Mousse SPF15 Clarins Laboratories introduce a self-tanning mousse to delight your senses: a whipped cream texture with a silky feel and delicious fruity fragrance. Enriched with mirabelle oil, vitamin E and aloe vera, skin is cocooned in softness and quickly develops a natural-looking, sun-kissed glow. Perfectly tanned, skin is also protected from the sun thanks to SPF 15. Clarins, No. 1 in European luxury skin care. Discover all our expertise at www.clarins.com NEW BEAUTY TANNING ADDICTION The New Form of Substance Abuse Robin L. Hornung, MD, MPH, and Solmaz Poorsattar UVR and Skin Cancer Skin cancer is the most common form of cancer in the United States, and one of the most preventable. Exposure to ultraviolet radiation (UVR) from the sun or from indoor tanning machines has been identified as the principal avoidable risk factor for the development of both melanoma and nonmelanoma skin cancers (NMSC).1 Despite overwhelming evidence linking UVR to skin cancer, exposure to the sun and indoor tanning machines continues to increase.2,3 Multiple studies show that despite repeated health warnings and increased knowledge about the dangers of excessive UVR exposure, many individuals, particularly adolescents and young adults, still use little or no skin protection outdoors and when visiting tanning salons.4 This continued, purposeful exposure to a known cancer-causing agent suggests 28 Many frequent tanners report relaxation and mood-enhancing effects as their motivation for tanning, suggesting psychological dependence. that factors besides lack of knowledge are driving individuals to tan. While many report that the desire for a tanned appearance is the strongest motivation for sunbathing and tanning bed use,4 tanners also report mood enhancement, relaxation, and socialization.5 It has been suggested by the popular media and suspected by dermatologists for years that one reason tanning is so popular is that UV light is addictive. It’s easy to see why tanning would be compared to other substance dependencies. Common behaviors involved in abuse and addiction, like cigarette smoking and heavy drinking, are prevalent among adolescents and young adults. They are often initially perceived as image-enhancing, and practiced despite knowledge of their dangers. Some of the reported benefits of frequent tanning — mood enhancement and relaxation — are also consistent with addiction. Furthermore, many frequent tanners report difficulty quitting. SK I N C A NCER FOU N DAT ION JOU R NA L What We Know About Tanning Addiction Frequent tanners exhibit signs of both physical and psychological dependence. When a substance causes physical dependency, repeated use of that substance causes symptoms of increased tolerance, craving, and withdrawal.6 UV light has been shown to increase release of opioidlike endorphins, feel-good chemicals that relieve pain and generate feelings of wellbeing, potentially leading to dependency. A 2006 study used naltrexone, a drug that blocks the endorphins produced in the skin while tanning, to induce symptoms of withdrawal in frequent tanners. In this study, 50 percent of frequent tanners given naltrexone before UVR exposure exhibited withdrawal symptoms, including nausea and jitteriness. These symptoms were not observed in any of the infrequent tanners given naltrexone in the study.7 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (a.k.a. the DSM-IV) defines substance dependency as having three or more of the following use-related symptoms over a 12-month period: tolerance, withdrawal, difficulty controlling use, negative consequences, significant time or emotional energy spent, putting off or neglecting other activities, and desire to cut down.11 The CAGE questionnaire is a clinical tool used to diagnose substance-related disorders. A version of it modified to measure tanning addiction includes four questions: Have you ever felt you needed to Cut down on your tanning? Have people Annoyed you by criticizing your tanning? Have you ever felt Guilty about tanning? Have you ever felt you needed to tan first thing in the morning (Eye-opener)? Many recent studies show that a number of frequent tanners score positive on the Some of the reported benefits of frequent tanning — mood enhancement and relaxation — are also consistent with addiction. Another study found that frequent tanners were able to distinguish between otherwise identical UV and non-UV lightemitting tanning beds.8 Tanners in this study showed an overwhelming preference (95 percent) to tan in the UV light-emitting bed. Participants suggested that UV tanning created a more relaxed mood and even relieved pain, possibly due to endorphin release.9 Psychological dependence refers to the effect of a substance on the brain’s reward system and its memory of rewards. The production of sensations of pleasure or well-being encourages repeated use.6 Many frequent tanners report relaxation and mood-enhancing effects as their motivation for tanning, suggesting psychological dependence. Also supporting this idea of psychological dependence is a recent study in which 21 percent of 14–17-year-old indoor tanners reported difficulty quitting. Quitting was most difficult for those who started tanning at age 13 or younger,10 and those who tanned more frequently. The CAGE Questionnaire The American Psychiatric Association’s CAGE, meeting criteria for a UV light substance-related disorder.12 In one survey, 18 percent of undergraduate students in Washington State who acknowledged purposely tanning their skin scored positive on the CAGE.5 These students also demonstrated difficulty in controlling use — they admitted continuing high-risk tanning behavior despite adverse personal experiences, such as blistering sunburns or a family history of skin cancer. A survey of beachgoers in Texas found that 26 percent of sunbathers met tanning-modified CAGE criteria and 53 percent met a tanning-modified DSM-IVTR (Text Revision) diagnosis for a UV light tanning dependency.13 What We Can Do Indoor tanning is also associated with other behavioral health risk factors, such as smoking, alcohol, recreational drug use, and eating disorders.14 All these findings warn us that frequent tanning can lead to unhealthy dependence or addiction in some individuals. Preventing an addiction is far better than trying to treat one. Early primary prevention should include public education targeting young children, adolescents, their parents and caregivers. Preventive behaviors learned early in life will more typically be practiced later in adulthood.15 Seatbelt use in automobiles is a good example of this. Since tanning in childhood and adolescence is linked to more difficulty in quitting, banning indoor tanning in children may help prevent the habit from developing. Thirty-one states currently have some form of legislation in place.16 We can also learn from those who have studied addictive behaviors and their treatment. Human behaviorists have developed the Stages of Change model, where the stage of addiction is first identified in order to find an intervention that will be most effective.17 As patients are then treated for their addiction, they go through different stages of change, from Precontemplation (not yet acknowledging their behavior problem) to Maintenance (maintaining positive behavioral changes). Future research on behavior change models will help us better target optimal interventions. In the meantime, simple measures can be effective. For those who seek the golden look, self-tanning creams and sprays, which use non-UV chemicals to tint the skin, have never been associated with increased skin cancer risk. For an endorphin boost (which self-tanners do not supply), exercise could be a competing — and healthy — coping response. Finally, tanners should avoid high-risk relapse situations, such as tanning environments and associating with other tanners. Of course, it always helps to solicit support from family and friends. DR. HORNUNG works as a pediatric dermatologist at The Everett Clinic, a large, nationally recognized multispecialty clinic in Washington. Previously, she spent nine years as Chief of Pediatric Dermatology at Seattle Children’s Hospital and the University of Washington, where she conducted much of her research in skin cancer prevention and indoor tanning issues. She is Board-certified in Dermatology, Pediatric Dermatology, and General Preventive Medicine and Public Health. Solmaz Poorsat t ar is a medical researcher with a special interest in the primary prevention of skin cancer and high-risk tanning behavior, and a doctoral candidate at the University of California - San Francisco School of Medicine. References available on p.96. 29 BEAUTY Appearance Trumps Health As an Anti-Tanning Argument Joel Hillhouse, PhD 30 to improve their appearance, then credible information on how tanning harms the appearance should dissuade many from the habit. So our workbooks also draw attention to tanning’s unattractive effects on the skin (fine lines, wrinkles, sagging, and brown spots, for instance), with images of people with weathered faces. Additionally, the workbook contains several humorous images to aid memory retention, including close-ups of tortoise skin, a baby’s bottom, and a burned chicken. However, our research shows that focusing on the benefits of avoiding UV tanning is more effective than heavy reliance on scare tactics. Of course, young people still want to look good. If they feel they do not have better options, many will convince themselves, or be convinced by the tanning industry, to return to UV tanning. For this reason, our approach also teaches young people about alternative means to look good, such as exercise; healthy weight control; wearing stylish clothes that don’t require a tan (such as long-sleeved shirts and long pants); and, for those who still desire the tanned look, sunless tanning. This approach has proven consistently effective in several studies, reducing tanning behaviors and intentions by 33-50 percent in college-aged female indoor tanners.1,2 [See Figure 1.] This corresponds with a growing body of research on the effectiveness of appearance-based tanning interventions.3-6 After 15 years of research, we’ve found an approach that seems highly effective for young tanners. In the future, we hope to discover whether these methods can be widely disseminated through communication channels popular with youth, such as the internet, cell phones, and texting. Mean Number of Visits to Indoor Tanning Salons over a Three-Month Period “I know I’ll probably get skin cancer from tanning, but that will be when I’m old, like in my forties.” Those words, from a student of mine, changed how I looked at skin cancer prevention in young people. Both my personal focus and professional training had always emphasized the value and importance of health. If you know something is unnecessarily harming your health, and you know ways to prevent it, you’d change what you were doing, right? That student taught me that not everyone values health the same way I do. She also gave me insight into why traditional educational efforts, with their focus on long-term health issues, were having little impact on young people’s risky sun habits and tanning behavior, especially indoor UVR (ultraviolet radiation) tanning. Since that day more than 10 years ago, my colleagues and I have pursued a skin cancer prevention strategy focusing on appearance, which our empirical research demonstrates is a key factor in young people’s decision to tan indoors. In our tanning interventions, we provide college-aged, female UVR tanners (71 percent of tanning salon patrons are girls and women aged 16-29) with a workbook that resembles a women’s fashion magazine. It depicts attractive, untanned models, as well as images of bronzed television stars who have publicly stated that they use non-UVR tanning products (“sunless tanning”) and wear sunscreens with an SPF of 30+. We theorized that if young people tan primarily Our experience persuading young people to reduce and even quit tanning has taught us a number of important lessons: • Know your audience. What do they value and what is important in their daily lives? • Respect your audience. If they don’t value health in the same way you do, they aren’t necessarily unintelligent or uneducated. You cannot reach an audience you talk down to. • Persuade your audience. Provide credible information on the short-term, appearance-damaging effects of exposure, and discuss healthy, non-tanning alternatives to improve appearance. This may help young people rethink their tanning decisions. Pre Post 10 8 6 4 2 0 Treatment Group Control Group Figure 1. Indoor tanning visits before and after (“pre” and “post”) appearance-focused intervention DR. HILLHOUSE is Professor of Public Health, East Tennessee State University, Johnson City References available on p.96.. SK I N C A NCER FOU N DAT ION JOU R NA L WHEN PRINTING NO WHITE BEHIND “RECOMMENDED” WHEN PRINTING NO WHITE BEHIND “SUNSCREEN” COPY SCF SEAL SUNSCREEN (SPOT COLORS) SPECIFICATIONS SKIN CANCER FOUNDATION SEAL COMPANY/DIVISION: SKIN CANCER FOUNDATION CONTACT INFO: 245 Fifth Avenue SUITE 1403 NY,NY 10016 SCF SEAL SUNSCREEN (PROCESS COLORS) T 212.725.5176 F 212.725.5751 [email protected] PRODUCT: SEAL DATE: 09/14/05 PMS 7455 U or 7455 C PMS 7455 PC PMS 128 U or PMS 129 C PMS 128 PC SIZE: U.S.A.: FILE NAME: SCF SEAL SUNSCREEN PROGRAM : ADOBE ILLUSTRATOR CS FONTS: AVENIR LIGHT, AVENIR ROMAN, GILL SANS BOLD CONDENSED K/O WHITE COMMENTS: Note: Must use fonts provided by SCF on disk Note: SEAL must be no smaller than 1/2 inch width “SKIN CANCER” K/O TO WHITE “FOUNDATION” K/O TO WHITE SUN ARCS: PMS 128 U or 129C “RECOMMENDED” & BACKGROUND: PMS 7455 “SUNSCREEN” COPY: PMS 7455 K/O WHITE “SKIN CANCER” K/O TO WHITE “FOUNDATION” K/O TO WHITE SUN ARCS: PMS 128 PC “RECOMMENDED” & BACKGROUND: PMS 7455 PC “SUNSCREEN” COPY: PMS 7455 PC Body & Hand Wash With Sunscreen The world’s only liquid body & hand washes containing natural emollients, skin conditioners and SPF 15 sunscreen with UVA/UVB protection. Your skin feels clean and soft without any greasy residue. Solise Sun Wash offers you daily protection from the harmful effects of the sun by doing nothing more than taking your regular daily shower and routine hand washing. Giving you SPF 15 protection with every washing, daily Solise use combats the effects of sun damage that cause cancer as well as aging. Developed in the desert of Arizona, Solise contains revolutionary skin care technologies that offers you all the benefits and protections of sunscreen, with none of the hassle! Order Solise Sun Wash Products online or pick up at your local retailer. www.solise.com 5245 South 39 Street • Phoenix AZ, 85040 Phone: 602-792-9249 • Toll Free: 866-454-6238 Fax: 602-438-0138 • Email: [email protected] Product is not actual size. lifeStYle team SCf: athleteS againSt Skin CanCer / 32 a tenniS PlaYer’S exPerienCe / 38 from BarDot to BeCkham: the DeCline of CeleBritY tanning / 42 SUn SafetY at SChool / 46 UnDer the SUn, eVerYthing YoU wear matterS / 48 as long as implicit messages about sun protection run counter to medical facts and public health messages, we will be fighting an uphill battle against skin cancer. – from BarDot to BeCkham: the DeCline of CeleBritY tanning (p. 44) TEAM SCF Athletes Against Skin Cancer What do World Professional Surfers including Mick Fanning and Damien Hobgood, soccer superstars Christie Rampone and Lindsay Tarpley, snowboarder Shayne Pospisil, record-setting angler Preston Clark, and PGA Tour golfer Brian Davis have in common? They’re not just renowned athletes, but people committed to protecting themselves from skin cancer, the world’s most common cancer. And they’ve joined Team SCF, a group of dedicated sports professionals, to talk about their sun protection habits. Playing the sport you love in the fresh air, for up to twelve hours a day, seven days a week — what’s not to love? While these athletes are devoted to their work, they often face one very unappealing job hazard: the high risk of skin cancer. 32 People who spend a lot of time outdoors are particularly vulnerable to the cumulative damage caused by the sun’s harmful ultraviolet (UV) radiation. Almost 90 percent of nonmelanoma skin cancers (NMSC) like basal and squamous cell carcinoma, the two most common skin cancers, are associated with exposure to UV radiation. Recent research also shows that the vast majority of mutations (gene changes or errors due to radiation, viruses, and other causes) found in melanoma, the deadliest form of skin cancer, are caused by UV radiation. BeComing ProS at SUn SafetY The world’s #1 surfer, Mick Fanning, grew up with good sun protection habits. Today the two-time and current Association of Surfing Professionals (ASP) World Champion still wears a high-SPF sunscreen and a shirt or long-sleeved rash guard (an athletic shirt made of material such as spandex or nylon) when surfing. And while he’s chasing waves seven days a week, the Australian is careful. “I avoid surfing in the middle of the day, when the sun is most intense, and every time I get out of the water, I reapply sunscreen.” While Australians tend to be welleducated about sun protection (Australia has the highest melanoma rates in the world, and most citizens are familiar with one or more skin cancer awareness campaigns), many Europeans are not so lucky. UK native Brian Davis has already been treated for two basal cell carcinomas (BCC) and a squamous cell carcinoma (SCC), even though he’s only in his thirties. The first European to win the PGA Tour SK I N C A NCER FOU N DAT ION JOU R NA L From left: Preston Clark, Christie Rampone, Brian Davis, Shayne Pospisil, Lindsay Tarpley, Mick Fanning, Damien Hobgood Qualifying Tournament, in 2004, the golfer “never heard anything about skin cancer in the UK. We just didn’t wear sun protection.” But when Davis and his family settled in Florida five years ago, they began hearing a lot more about the damage the sun can do. So when his wife noticed a discolored spot six months, or sooner if he notices changes to an existing spot. New Jersey resident and two-time Olympic Gold medalist in soccer Christie Rampone has also discovered that you don’t need to live in a sunny climate to sustain sunburn and sun damage. “The While these athletes are devoted to their work, they often face one very unappealing job hazard: the high risk of skin cancer. on his neck, Davis went to a dermatologist, who confirmed that the spot was a basal cell carcinoma. He’s since been treated for another BCC and an SCC on his nose. Today, Davis is a pro at skin self-exams as well as golf, and he sees his dermatologist every worst days aren’t the ones that are that hot and sunny. It’s the overcast days [up to 80 percent of the sun’s UV radiation can penetrate clouds] when you’re not thinking about the sun — then you really get burned.” The soccer wonder woman (captain of the US Women’s National Team and the 2009 Women’s Professional Soccer’s Hint Water Sportswoman of the Year, among other titles) is especially careful, since both her mother and grandfather have been treated for skin cancer. “I apply sunscreen about an hour before practice, and I get one with as high an SPF as I can find — at least a 35, usually a 50.” She also applies an eye cream with SPF around her eyes; she’s found that this skin is often neglected. Rampone’s US Women’s National teammate and fellow Olympic gold medalist Lindsay Tarpley makes sun protection as easy as she can for herself. When the St. Louis Athletica forward isn’t on the field, “I try to stay out of the sun!” But Tarpley, dubbed girls’ soccer ESPN RISE high school player of the decade in 2009, spends a lot of time outdoors training and 33 LIFESTYLE playing, and consequently has developed a comprehensive protection routine: “Every time I shower or wash my face, I apply a moisturizer with an SPF (usually a 30+). Then, about half an hour before I get on the field, I apply sunscreen.” Tarpley prefers a spray sunscreen for the face, which she puts on her hands and then applies. “I spray a lot on my hands,” she explained. For the body, she uses a lotion-based sunscreen. (The Skin Cancer Foundation recommends using one ounce, or two tablespoons, of sunscreen for skin cancer. “Two close family members [including Tarpley’s mother, who has had basal cell carcinoma] have been treated for skin cancer in the past few years,” she explained. “This really made it hit home for me. I’m pretty passionate.” Winter Weather Advisory: Protect Your Skin Most of the athletes we spoke to compete in hot weather, but sun protection is equally important in the winter. Snowboarder Sunscreen is a part of my equipment, my routine, and who I am and what I do. If it allows me to play golf, it’s good. — Brian Davis the entire body, including a nickel-sized dollop on the face, and reapplying every two hours, or immediately after swimming or sweating heavily.) Recently, Tarpley’s started wearing hats in addition to the sunglasses she slips on “pretty much every time I go out.” She also regularly performs skin self-exams and sees a dermatologist for an annual full-body skin exam. Her dedication stems, in part, from personal experience with 34 Shayne Pospisil, whose recent wins include the 2009 Oakley Arctic Challenge and Red Bull Snowscrapers, is well aware of the risks the snow poses. “The sun’s reflection off the snow increases exposure,” he pointed out. Thanks to the glare, up to 80 percent of UV rays hit the skin twice. And for every 1,000 feet of elevation, UV exposure increases 8-10 percent. “I’m up on Mount Hood in Oregon a lot,” Pospisil said. “That’s over eleven thousand feet above sea level.” In addition to the cold- and wet-weather gear that covers his torso and limbs, “I wear a mask that protects my whole face,” Pospisil explained. He’s rarely without a cap that covers his scalp and ears, and wears sunscreen on all exposed areas. He’s particularly careful to apply a white zinc oxide product to the lips. When the face mask is not in use, Pospisil wears oversized snow goggles or sunglasses. The Accessory Advantage Bass fishing may sound like a recipe for relaxation, but it’s a demanding sport. “You spend ten to twelve hours a day standing up, with no ‘time outs’ for weather,” explained angler Preston Clark, best known for his record-breaking 11 pound, 10 ounce catch in the 2006 Bassmaster Classic. “It takes a toll on your body.” The Florida-based Clark knows what he’s talking about. When he was in his mid-thirties, Clark’s long-unprotected skin began showing signs of sun damage. “My ears were always peeling, bleeding, and cracking,” he said. “They’d never heal. My nose and lips were in bad shape, too.” But since impulse-buying a French foreign legion hat (a visored hat with flaps that cover the ears and neck) a few years ago, Clark’s never looked back. “Not only do I wear a SK I N C A NCER FOU N DAT ION JOU R NA L sunscreen with an SPF of 50 every time I go out, I also wear UV-blocking sunglasses and shirts, usually long-sleeved, with a high UPF.” (UPF, or Ultraviolet Protection Factor, measures clothing’s ability to screen out UV light; a shirt with a UPF of 30 would let just 1/30th of the sun’s UV radiation penetrate the fabric. The Skin Cancer Foundation recommends clothing with a UPF of 30+.) It’s working, and Clark’s ears have healed, too. The importance of sun-protective clothing and accessories can’t be overemphasized. Damien Hobgood has picked up surfing trophies all over the world, winning WORLD PROFESSIONAL SURFERS Members of Team SCF Michel Bourez Taj Burrow Ben Dunn Bede Durbridge Mick Fanning CJ Hobgood Damien Hobgood Phil MacDonald Jake Pato Tiago Pires (above) Luke Stedman David Weare Gony Zubizarreta tournaments from Brazil to Fiji. He has already had several suspicious lesions removed from his face and back, despite of the fact that he’s always been careful about applying sunscreen. Hobgood usually wears a rash guard, or, in colder waters, a wetsuit (a long-sleeved synthetic rubber suit that provides UV protection from the shoulders and trunk on down). Hobgood’s even donned a hooded wetsuit with a bill, like a baseball cap. This not only protects the vulnerable scalp, but offers a bit of shade to the upper face. No Excuses Some athletes, professional and amateur alike, have expressed concern that sunscreens, hats, sunglasses, and protective clothing might not feel comfortable and end up impeding their game. Davis admitted he originally had doubts: “The first time I wore [UV-blocking] sunglasses, I thought, ‘I can’t play with these on!’ But I got used to it — now I compete with them on.” Sunscreen on his hands doesn’t interfere with his grip, either. “I wipe my hands down before every shot, anyway,” he said. Sunscreen running into the eyes is a perennial concern (and an occasional excuse for not wearing any), but the pros have ways of dealing with this: Fanning and Tarpley are careful to allow enough time for the sunscreen to be absorbed into the skin (at least 30 minutes) before practice, while Tiago Pires, Portugal’s first ASP World Tour surfer, uses a non-greasy, water-resistant stick sunscreen in the eye area. Clark likes sunscreens with a zinc oxide base, which he finds tend not to run, and Rampone applies Vaseline to her eyebrows, since she’s found that it keeps the sunscreen on her forehead from migrating into her eyes. Davis said, “Sunscreen is a part of my equipment, my routine, and who I am and what I do. If it allows me to play golf, it’s good.” Fanning summed it up: “There’s always a way to protect yourself. You’ve got to take those extra couple of minutes to get ready.” The Next Generation Although kids are notorious for not wanting to wear sunscreen or protective clothing, the professionals are up to the challenge. Christie Rampone’s young daughter “is always in hats. She likes stick sunscreen, since she can put it on herself. Then I get any spots she’s missed, and apply a spray.” But Davis may have found the most effective method to keep his two boys sun-safe. “They cannot go outside if they’re not wearing sunscreen, so we don’t have a problem getting it on them!” 35 Formula innovations backed by scientific development and clinical research Clinically proven appropriate for sensitive skin, including rosacea Now enriched with replenishing antioxidants to help fortify skin’s natural defenses Powerful tear-free sun protection formula with Zinc Oxide PHOTOSTABILITY ® GUARANTEED GUARANTEED © 2010, Schering-Plough HealthCare Products, Inc., a subsidiary of Merck & Co., Inc. All rights reserved. Printed in USA For more information, visit coppertone.com. Use as directed. sun protection – a way of living™ SkinCancer.org The World Professional Surfers is proud to partner with The Skin Cancer Foundation. © 2010 The Skin Cancer Foundation Campaign created by Laughlin Constable, www.laughlin.com LIFESTYLE A Tennis Player’s Experience WILLIAM STEBBINS, MD, AND C. WILLIAM HANKE, MD, MPH William Stebbins, MD, and C. William Hanke, MD, MPH, spoke to Jennifer Reinbold, a former pro tennis player who coaches in Indianapolis. Jennifer competed in nine grand slam tournaments, reaching the Wimbledon quarterfinals in 1983 before losing to the eventual winner, Martina Navratilova. After years of sun exposure, and some experience with skin cancer, Jennifer practices what she preaches: Respect the sun! Q: What was your experience with sun exposure as a young tennis player? A: I grew up in South Africa, two hours north of Johannesburg. I started tennis at eight, to spend more time with my older brother and his friends. We played outdoors year-round — there were no indoor facilities then. I had very light skin, so I was susceptible to sun damage. But little information was available about the long-term dangers of sun exposure. When I was a young child, my mother was vigilant about my sun exposure because she didn’t want me to get wrinkles. She 38 was a pretty advanced thinker! She always had me wear a hat and sunscreen, which really stung when it got in my eyes. But I remember several blistering sunburns during summer beach vacations. While competing, I wore sunscreen on my face, but not always on my body — I was concerned that sunblock might trickle onto my hands, interfering with my grip. And in higher competition, I often skipped wearing a hat because I thought it might be a distraction. Q: When did you start becoming aware of the harmful effects of the sun? A:When I was a teenager on tour in England, my father had a melanoma, the most dangerous skin cancer, removed from his forearm. My parents didn’t like to give me bad news when I was away, so they told me about it only after the fact. Fortunately, the surgery was successful. Q: How have you altered your sun protection behavior? A:After retiring from the tour, I married and began teaching SK I N C A NCER FOU N DAT ION JOU R NA L tennis in the Indianapolis area. In summers, I was often on courts eight hours straight. By then, I usually wore long-sleeved shirts; a bandana around my neck; and a wide-brimmed hat, along with sunscreen. But the effects of sun damage I sustained over the years started to appear. I’ve had several skin precancers removed at every visit to the dermatologist, which is at least twice a year. I had a basal cell carcinoma, the most common skin cancer, removed from my neck, and a squamous cell carcinoma, another common skin cancer, removed from my forearm. Once a person gets one skin cancer, they face about a 50 percent risk of developing another within five years. Q: How do you reduce your risk of getting further cancers? A:First, I do a careful head-to-toe skin check once a month. If I notice anything abnormal, I see my dermatologist. (This is in addition to my regular twice-yearly appointments). Also, I always use protective clothing and sunscreen, and avoid playing and teaching outdoors in the middle of the day, when UV exposure is most intense. Q: Do you think the message about sun protection is getting through? A:There is more sun awareness today. Most players I teach or play with wear sunscreen and have a hat in their tennis bags. However, they don’t usually reapply sunscreen when playing for extended periods. Also, just because they have a hat or visor doesn’t mean they use it! Many players don’t realize their scalps are as vulnerable as the rest of their bodies. Q: What information have you passed along to your children? A:When my sons Derek and Graham were babies, I bought special UV-protective clothing for them to use at the beach. Now, one son carefully protects himself, wearing a hat and sunscreen when playing tennis outdoors, and a long-sleeved SPF 50 swimshirt when he swims. My other son is more resistant, and likes to tan. I have tried to educate him, providing sunscreen, hats, and protective clothing; the rest will be up to him! I know other teenage tennis players with his attitude — they know the dangers of sun exposure, but still like the look of a tan, and like most teenagers, believe they are invincible. Q: Any last words of advice for tennis players? A:Don’t forget to protect yourself. And keep your eye on the ball! DR. STEBBINS is currently a Mohs micrographic surgery and procedural dermatology fellow under the direction of Dr. C. William Hanke at the Laser & Skin Surgery Center of Indiana and St. Vincent Hospital, Indianapolis, Indiana. DR. HANKE is the Director of the Laser & Skin Surgery Center of Indiana in Carmel, IN, and Senior Vice President of The Skin Cancer Foundation. He was the first physician in the United States to earn triple full professorships in Dermatology, Otolaryngology Head and Neck Surgery, and Pathology and Laboratory Medicine. He is past President of the American Academy of Dermatology, and has served as President of five surgical specialty societies: the American Society for Dermatologic Surgery, American College of Mohs Micrographic Surgery and Cutaneous Oncology, the International Society of Cosmetic Laser Surgeons, International Society for Dermatologic Surgery, and the Association of Academic Dermatologic Surgeons. He has written more than 350 publications including 91 book chapters and 20 books. Figure 1: Jennifer (age 3) at a beach in South Africa with her older brother, Trevor Mundel, now Global Head of Research and Development at Novartis Pharmaceuticals. Figure 2: Jennifer (seen at age 22) played on the women’s professional tennis tour for eight years. Figure 3: (L to R) Jennifer with PA Nilhagen, renowned coach and Director of Tennis at 5 Seasons Sports Club in Indianapolis, along with her son Derek, 17, a member of the 2009 Indiana State High School Championship Tennis Team. 39 sun protection – a way of living™ SkinCancer.org © 2010 The Skin Cancer Foundation Campaign created by Laughlin Constable, www.laughlin.com LIFESTYLE From BARDOT to BECKHAM The Decline of Celebrity Tanning 1960 1970 nIna g. JaBLonSkI, Phd T he 1960s gave us many things — like The Beatles, birth control pills, and photos of Brigitte Bardot on the beach. The iconic French film star epitomized the freedom of the era by flouting traditions of modesty and sun avoidance. Photos of Bardot circulated widely, and “le topless” became an institution on French beaches. Her suntan itself became a statement. It was the seamless tan of a woman of leisure, and it announced that she controlled her own body, and wasn’t confined by the social norms of past eras. At the time, people who protested were not considered prudent, just prudes, and in the 1960s that was as good as being dead. 42 SK I N C A NCER FOU N DAT ION JOU R NA L 1980 1990 2000 2010 1) Brigitte Bardot 2) George Hamilton 3) The popularity of Sid the Seagull, the icon of the original “Slip! Slop! Slap!” campaign in Australia, led to the rapid adoption of sun protection and sun avoidance behaviors in Australia during the 1980s and 1990s. The campaign name was officially changed to “SunSmart” in 1988, and the slogan has been extended to “Slip! Slop! Slap! Seek! Slide! Protect yourself in five ways from skin cancer.” Illustration: Pauls Sloss; based on character by Alex Stitt. Provided courtesy of The Cancer Council of Victoria. 4) Nicole Kidman 5) Victoria Beckham Bardot’s look was youthful and sexy, and inspired thousands to follow her example. Before long, magazines and movies were filled with tanned celebrities of both sexes, including men like George Hamilton, whose year-round tan became synonymous with a life of leisure and privilege, along with sex appeal. Through the 1980s, tanning was de rigueur, and the tanned look came to denote both the good life and good health. Pallor was for corpses. The sun-tanning phenomenon of the mid-20th century, and the many kinds of tanning available today, are not anomalous fads. They were instigated and are maintained by celebrities, whose images are widely propagated by the media. Celebrities command our attention and induce imitation. After all, we as a species are highly imitative: As infants we observe and imitate our mothers, and we imitate others throughout childhood. Imitation teaches us to survive; it also helps insure that positive behaviors are directed toward us. As teenagers, we increasingly imitate people outside of our families, creating and cementing connections within peer groups. As teenagers and adults, we imitate to gain and maintain higher social status, an effect that is more pronounced in women than in men.1 The celebrity-inspired rise of sun-tanning behaviors from the 1960s through 1980s had two major consequences. The first and most important was the increased incidence of melanoma and nonmelanoma skin cancers.2-4 This trend became a matter of public concern first in Australia, which has the highest skin cancer incidence and mortality rates in the world.5 The prevalence and high costs of skin cancer in Australia spawned the first widespread public health campaigns — including the current “SunSmart” program — aimed at promoting sun protection and sun avoidance.6 This campaign notably didn’t invoke celebrity 43 LIFESTYLE promotion, but was propelled by the memorable cartoon f gure of “Sid the Seagull,” whose actions were widely imitated, even if his appearance was not (Figure 3). The second consequence of the post-60s tanning craze was the rise of technologies for customized, on-demand tanning. This began with development and widespread marketing of ultraviolet (UV) radiation-emitting tanning lamps, beds, booths, and facilities — often glamorized by the name “salons” — where Whether from booth, bottle, or spray, on-demand tanning established and maintained popularity thanks to celebrity adoption and highly effective marketing. these devices could be used. Then followed the development of non-UV artif cial tanning agents (“self-tanners”), which could simulate the tanned look for people who were unable to tan or who for the sake of safety or convenience, preferred to tan without exposure to UVR. Whether from booth, bottle, or spray, on-demand tanning established and maintained popularity thanks to celebrity adoption and highly effective marketing. The so-called “healthy glow” — achieved by UV exposure, spray-on tanning, or cosmetics — became and still is big business. The appeal of the tanned look comes not only from its association with glamour and sex appeal, but from the physiological reinforcement of UV-based tanning behavior.7 Researchers have found that UVR exposure releases mood-lifting hormones called endorphins that can literally create a dependency known as “tanning addiction,” stimulating tanners to seek more UVR exposure. [For more on tanning’s addictive qualities, see p.28.] This dangerous combination of addiction and so-called glamour means that many people at greatest risk of skin cancer remain highly motivated to tan,8 even when they know the dangers. Today, highly imitated female celebrities such as Britney Spears and Paris Hilton famously mix and match real and fake tanning, giving much impetus to booth-and-bottle, look-good-feel-good promotions at tanning establishments. THE BRONZE AGE EBBS However, more female celebrities today are proudly pale, including some — like Victoria Beckham and Nicole Kidman — who have explicitly abandoned the bronzed look in favor of their natural color. Their renunciation of even the spray-on fake tan, as they opt instead to “go with their own glow,” is signif cant because they are taking the glamour and prestige out of the tanned look. Female celebrities increasingly appear to realize that their looks and behavior have immediate ramif cations on hundreds of thousands of young women. More celebrities need to understand that their every word and action can inf uence the behavior of devoted followers, many of whom are slavishly imitative young women whose skin is highly vulnerable to potentially carcinogenic sun exposure. Australian model Elle Macpherson’s recent declaration, “I tan safely,” was strongly criticized by dermatologists,9 but was taken as encouragement by many people seeking reinforcement for their unsafe, outdated approach to sun exposure. When a behavior is as popular and consistently reinforced as tanning, celebrities don’t have to engage in egregiously “SunStupid” behaviors to negate hard-won gains in sun safety. We have not yet reached the “End of the Bronze Age.”10 Although models and celebrities with susceptible, pale-skinned and lighteyed phenotypes are less likely to be portrayed with dark tans today than they were two or three decades ago,11 continuing promotion of the tanned look is worrisome and dangerous. As long as implicit messages about sun protection run counter to medical facts and public health messages, we will be f ghting an uphill battle against skin cancer. DR. JABLONSKI is a biological anthropologist who conducts studies on the evolution of humans and their primate relatives using fossil and other evidence. Her greatest interest is in reconstructing parts of human evolution that don’t have a fossil record, like skin. She is the author of Skin: A Natural History (University of California Press, 2006), and is Professor and Head of the Department of Anthropology at Penn State, University Park. References available on p.96. raisi n is a grap e that abou didn t it, ’t ha if th ve th e gian e sens hat it’ t orb e to s doin get ou in th basted g to e sky t of th , toas yo can ur pr e sun. ted, ro do th ecious And asted, skin at to skin. think show fried a little Laye , and it? H piece rs on all ot ello w burn e to of fr her m rinkl seve s and uit, anne es. H n do who r ell of not lik o crow -kno scorch on th ws-w e bein ’s feet ed. An e peck hat-a g . d how Hell ing or ll-els o blot does e. N der of bein ches ot to your gs sh brains and be pr ould , we ejudi ha hu ve ced, Don mbly more ’t yo but subm u agre sens it th e th at hu e? N an du than othing man the he mb look grap althy, s bette es. glow you r on ing, ra were you dian born t shin with toda e . Be y, be caus ing e health truly y – health y – is what’s sexy . imag GO WITH YOUR OWN GLOWTM I n 2 0 0 8, The S k i n C a nc e r Foundation launched its Go With Your Own GlowTM campaign to inform the public — including the more than 30 million Americans who use tanning salons every year — that tanning is no longer in fashion: Loving your own natural shade is what’s in. Thanks to the $3.7 million in ad space donated by magazines including TIME, PEOPLE, O: The Oprah Magazine, SHAPE, and Food & Wine, our public service announcements have reached more than 280 million readers to date. The print campaign, created pro bono by advertising agency Laughlin Constable, originally featured three full-color PSA ads; we now have seven. The ads address the reader directly, with 44 a chatty exhortation to Go With Your Own GlowTM — that is, to cultivate your skin’s natural beauty and, most importantly, avoid tanning. You can see all the places where Go With Your Own GlowTM has been featured at www.skincancer. org/go-with-your-own-glow-inmagazines.html. © 201 0 The Skin Cancer Founda tion Campaig n crea ted by Laughli n Con stable, ww ine w w.laugh lin.com SK I N C A NCER FOU N DAT ION JOU R NA L ThIS SkIn cancEr FoundaTIon PuBLIc SErvIcE advErTISEMEnT IS avaILaBLE For MEdIa uSagE. For MorE InForMaTIon, PLEaSE conTacT: JaMIE SYLvES, (212) 725-5176 ExT. 120 [email protected] raisin is a grape that didn’t have the sense to get out of the sun. And think about it, if the giant orb in the sky can do that to a little piece of fruit, imagine what it’s doing to your precious skin. Layers one to seven do not like being basted, toasted, roasted, fried, and all other manner of scorched. And how does your skin show it? Hello wrinkles. Hello crow’s feet. Hello blotches and burns and who-knows-what-all-else. Not to be prejudiced, but on the pecking order of brains, we humbly submit that human beings should have more sense than dumb grapes. Don’t you agree? Nothing looks better on you than the healthy, glowing, radiant shine you were born with. Because today, being healthy – truly healthy – is what’s sexy. © 2010 The Skin Cancer Foundation Campaign created by Laughlin Constable, www.laughlin.com LIFESTYLE Sun Safety at School Janice Clark Young, EdD, CHES, and Brenda S. Goodwin, MS T he risk of skin cancer begins with a child’s first exposure to sunlight. The sun’s ultraviolet (UV) radiation damages the skin, eyes, and immune system,1 and the effects are cumulative. Although light-skinned people are the most susceptible to skin cancer, everyone is vulnerable and should be vigilant about sun safety. Sun protection should begin at birth, since establishing healthy routines in childhood can foster positive lifelong preventive habits.2 Sun safety is especially important for young people because multiple sunburns (in fact, just one blistering sunburn) during childhood and adolescence more than double the risk of melanoma in the future.3 For Students The World Health Organization (WHO) notes, “UV radiation exposure during the school years contributes significantly to total lifetime sun exposure.”1 During a child’s typical weekday, six to nine hours are spent at school. Sunlight is most intense between 10 AM and 4 PM, when students are often outdoors for recess and other 46 school or after-school activities. Many school grounds lack the adequately shaded areas needed to limit UV exposure. Shade can be provided by solid roof structures, gazebos, awnings, shade cloth, and natural shade, such as thickly leaved trees.4 However, these partial shade of priority),” an article in Health Education Research advises.5 Teachers, coaches, and staff should model sun protection behaviors during outdoor activities. Rescheduling these activities to avoid midday exposure is also especially important, since some schools prohibit wearing caps, hats, and Sun safety is especially important for young people because multiple sunburns (in fact, just one blistering sunburn) during childhood and adolescence more than double the risk of melanoma in the future. methods still allow some UV exposure (even on gray days, since UV rays pass through clouds, rain, and fog), so more sun protection strategies are needed. Children must be instructed to “protect themselves when outdoors by using shade, clothing, hats and sunscreen (in that order sunglasses on school property due to the association with gang activities and/or drug use.6 For Schools Professional development for school staff should address sun safety policies, SK I N C A NCER FOU N DAT ION JOU R NA L PROMOTING SUN SAFETY AT SCHOOL8 Parents • Apply sunscreen to children’s exposed skin before school, and provide sunscreen for reapplication later in the day. • Provide sunscreen for outdoor school field trips. • Remind children to be sun-safe when outdoors. • Work with the principals, teachers, PTA, and school board to support district-wide sun protection policies. Teachers and School Personnel • • • • Integrate sun safety lessons into appropriate academic areas. Be a “sun-safe” role model for students. Remind students to practice sun protection behaviors. Educate parents and community members about sun protection behaviors. Principals • Promote sun safety to students, school personnel, and community members. • Work with parents and community members to develop a sun safety policy and curricula for students and staff. School Superintendents and Board Members • Approve sun safety in-service training for teachers and staff, and classroom sun safety education for students. • Implement a district-wide sun safety policy. • Provide outdoor shade for playgrounds and athletic areas. Community Health Care Providers • Regularly discuss sun safety with young patients and parents. • Begin sun safety education at birth before mother and baby leave the hospital. (Infants should not be exposed to the sun in their first six months.) • Educate teachers, staff, administrators, and school board members about sun safety. • Help develop sun safety policies in school districts. practices, and teaching strategies.1 Teachers can take advantage of the many free, age-appropriate sun protection curricula or lessons. K-8 classroom materials are available through the SunWise School Program (www.epa.gov/sunwise), as are lessons from the Sun Safety Activity Guide (www.nsc.org). For grades K-12, the Melanoma Foundation (www.melanomafoundation.com) offers SunSmart America, and the Shade Foundation (www.shadefoundation.org) provides the Sun Safe School Guide. The Skin Cancer Foundation also has free materials for teachers and students in grades 5-8 at www.SkinCancer.org/school. Many US school districts lack written sun safety policies. This plus misunderstanding and lack of knowledge of UV radiation risks contributes to children’s poor sun protection practices.7 Certain existing policies define sunscreen as “medicine,” require parental/ medical permission for its application, or prohibit teachers/aides from applying it to children.6 A revised sun protection policy might recommend that parents 1) include sunscreen in students’ supply kits; and 2) sign permission slips allowing their children to apply sunscreen before going outside. Permission slips would be kept in the students’ permanent school health records.6 Suggestions for creating a policy, as well as a sample policy, are available at www.sunsafetyforkids.org/schoolpolicy/. From top: Shade structures covering playground equipment; shade trees at school. For Communities Community members, businesses, and organizations can assist in sun protection efforts by 1) serving on school sun safety committees; 2) donating money to buy trees/shrubs and shade structures; 3) planting trees or installing shade structures on school grounds; and 4) making sunscreen available for school/ recreation use. Additionally, in some states, grassroots advocacy is needed to pass laws allowing the legal distribution of sunscreen and the use of hats in schools and community recreation programs. It behooves all adults to become positive role models who practice and promote sun protection behaviors.2 School personnel and parents can be instrumental in establishing these lifelong healthy behaviors. For more information, go to www.cdc.gov/cancer/skin/pdf/ sunsafety_v0908.pdf Dr . Yo u n g is an Associate Professor in the Department of Health and Exercise Sciences at Truman State University, Kirksville, MO. Br e n da G o o dw in is an Instructor in the Department of Health, Physical Education and Recreation at Missouri State University, Springfield, MO. References available on p.96. 47 LIFESTYLE Under the Sun, Everything You Wear Matters SUSAN Y. CHON, MD, FAAD W hat’s the best way to protect your skin from sun damage? Dermatologists tell patients to avoid the sun or seek the shade during the most intense part of the day (between 10 AM and 4 PM), and to consistently apply broad spectrum sunscreens with an SPF of 15 or higher. “Broad-spectrum” means that the sunscreen provides some protection against both UVA and UVB rays, while SPFs refer specifically to UVB protection. SPF 15 sunscreens filter out 93 percent of the sun’s UVB radiation; SPF 30s filter out 97 percent. Both shade-seeking and sunscreen should be key elements in anyone’s sun safety program. However, studies have shown that clothing is the single most important factor in daily sun protection. Unfortunately, not all clothing is created equal. Have you talked with your dermatologist about what to wear? What’s the best way to dress to protect your skin from sun damage? Our clothing choices have a huge impact on our cumulative sun exposure. Basal and squamous cell carcinoma, the two most common types of skin cancers, account for more than one million cases a year in the US alone and up to 96 percent of all skin cancers.1 The primary cause of these two skin cancers is UV radiation from the sun.2 So what we wear each day really counts. Sun-Safe Women’s Wear You may already own some clothing that provides betterthan-average sun protection. In general, tightly knit, dark- or bright-colored clothes block more UV radiation, as opposed to whites and pale pastels. For women, some current fashion trends feature “drapey” looks that offer more coverage. For instance, long shirts or blouses, also known as tunics, have been in vogue for several years. Tunics, typically with long, loose sleeves and hems that can reach the knees, cover more of the torso than the usual shirt and are often paired with jeans or leggings. Jeans are perennially stylish, and also offer terrific sun protection: Dark blue denim is estimated to let just 1/1700th of the sun’s UV radiation reach the skin. Like jeans, leggings are often dark-colored, and they tend to be made of thick, tightly woven fabrics that let little light through. For a more elegant and modest feminine look, long or “maxi” dresses, which usually reach the ankles, are quite popular. They expose a lot less leg than their shorter counterparts. Lightweight scarves can now be seen throughout the year and provide both color and sun protection to the often-exposed neck 48 and upper chest. Scarves are also great for layering, another current fashion trend. Manly Coverings We’re seeing more coverage in men’s clothing as well. Men’s shirts and shorts have increased in sleeve and leg length, shielding more of the arms, legs, and torso than in years past. For a change from shorts, three quarter-length pants (a.k.a. clam diggers) provide more leg coverage but are still casual and comfortable. Headwear is also seeing a renaissance, with retro men’s styles like the fedora and the newsboy surging back into popularity. While not as wide-brimmed or protective as a floppy beach hat, they are a big improvement over men’s most common hat style, baseball caps, which have no brims in back or on the sides. Fedoras Clothing is the single most important factor in daily sun protection. Unfortunately, not all clothing is created equal… sport brims from 1” to 4” all around, and newsboys have broader crowns than caps as well as more substantial, often visor-like, front brims. The fedora and newsboy provide critical continuous protection for the often exposed scalp and upper face, and a fedora or Stetson provides extra protection for the ears and neck, which receive virtually no coverage from baseball caps. The Joys of Unisex The Skin Cancer Foundation recommends wide-brimmed (3” or greater) hats for both men and women, and many chic styles can be found today for both sexes. Bucket and outback hats for women can be every bit as stylish as fedoras and Stetsons can be for men. And whatever your gender, if you wear an oversized straw hat, the weave should be tight, so that little or no light gets through. When purchasing sunglasses, the important thing for sun safety isn’t style or price, but UVA-UVB protection; look above all for a label stating that the pair blocks 99-100 percent of UVA and UVB rays. Wraparound styles with side shields and extra large frames SK I N C A NCER FOU N DAT ION JOU R NA L are fashionable, and provide excellent sun protection. Finally, in the past few years, the hooded sweatshirt, or hoodie, has become ubiquitous for both sexes. Unlike other sweatshirts, casually stylish hoodies can help protect the scalp and back of your neck. Wash and Wear: Laundry Additives and UPF Labels Several clothing lines today make special sun-protective attire with a high UPF (ultraviolet protection factor). A UPF label indicates that the clothing item absorbs a certain percentage of UV rays. For instance, a shirt with a UPF of 30 allows just 1/30th of the sun’s UV light to penetrate the fabric. [The Skin Cancer Foundation recommends clothes with a UPF of 30 or higher; for information on clothes with our Seal of Recommendation, please see www.SkinCancer.org/seal]. Companies such as Coolibar and Columbia Sportswear make clothes ranging from swimwear to golf shirts to light jackets that block up to 95 percent of the sun’s UV rays. Many sun-protective clothing lines can be found in large retailers such as Target, Academy, and REI. To boost the protection provided by your everyday clothing, you can mix an additive (like Sunguard™, by Rit®) into your next load of laundry. When it is washed into your clothes, the product’s active ingredient absorbs up to 96 percent of UV rays and can last up to 20 washings. A white cotton t-shirt typically has a UPF of about 5, but when washed with a UV absorber, can provide a UPF of about 30. Dress Smart So what should you wear to your next barbeque? Tank top and shorts? You might be better off with a tunic and leggings or a long-sleeved shirt and three quarter-length pants washed in Sunguard™. The tunic top would add much-needed protection to the vulnerable shoulders and upper chest, and the leggings or long shorts would provide greater coverage of the lower thighs and even the lower legs. You could also add a high-UPF light jacket. Since the material is so light and breathable, you could wear your original outfit and not worry about sweating off your sun protection. Is wearing the right clothing enough? Well, it’s a great start. But remember, for ideal sun protection, implement all the methods we’ve discussed: Avoid the midday sun, seek shade, apply a broad spectrum sunscreen with an SPF 15+ daily, and wear broadbrimmed hats, UV-blocking sunglasses, and clothing that can offer solid sun protection. When you get out of bed in the morning, think twice: The clothes you choose each day help determine not just how others see you, but how well you protect yourself from lifelong sun damage. DR. CHON is an Assistant Professor in the Department of Dermatology at the University of Texas MD Anderson Cancer Center, Houston. She screens and treats patients for skin cancers and melanoma. References available on p.96. Internet Sites for Sun-Protective Clothing www.sunprecautions.com (Solumbra) www.coolibar.com www.athleta.com www.exofficio.com Information about Sunguard™ by Rit®: www.sunguardsunprotection.com 49 hEaLTh LIP cancEr: noT uncoMMon, oFTEn ovErLookEd / 51 ThE rIghT waY To TrEaT SEaSonaL dEPrESSIon / 56 ProTEcT Your EYES: EvErYdaY STEPS To Sun SaFETY / 58 BrEaST cancEr and MELanoMa: how ThEY arE LInkEd / 60 Since good mood, sunlight, and spring and summer tend to go together, many once believed that sprawling in the sun or a tanning bed was the answer to Sad — that the ultraviolet (uv) light they give off was a virtually magical cure. – ThE rIghT waY To TrEaT SEaSonaL dEPrESSIon (p.56) LIP CANCER: Not Uncommon, Often Overlooked wILLIaM STEBBInS, Md, and c. wILLIaM hankE, Md, MPh S kin cancer is the most common type of cancer the two most common skin cancers, basal and squa- in the US. Despite increased awareness that mous cell carcinoma (BCC and SCC). Most frequently it is usually caused by the harmful effects of occurring in fair-skinned males over the age of 50, ultraviolet (UV) light, one in five Americans will develop cancer of the lip comprises approximately 0.6 percent of skin cancer in their lifetime.2 all cancers in the US.3 Studies have shown that males 1 The lips are a not uncommon, but often overlooked are 3-13 times more likely to develop lip cancers, likely site for nonmelanoma skin cancers (NMSC), including due to occupation-related sun exposure combined with HEALTH greater tobacco and alcohol use.4,5 The lower lip is approximately 12 times more likely to be affected, owing to its greater exposure to sunlight. A recent 25-year retrospective study of 2,152 patients with lip cancer revealed that 81 percent occurred on the lower lip,4 with males predominating by 3 to 1. Large epidemiological studies have shown that up to 95 percent of NMSCs on the lower lip are SCCs.6 Given their highly visible location, the majority of lip cancers are easily detectable and treatable at an early stage. The most commonly employed treatments include surgery, radiation, and cryotherapy (freezing with liquid nitrogen), with cure rates for early lesions nearing 100 percent.7 Although cancers of the lip have relatively low rates of spread to nearby lymph nodes and papillomavirus (HPV) in certain oral cancers, but it has not to date been found to be a major cause of lip cancers. The most important risk factor by far is cumulative UV exposure, which is associated with up to 90 percent of all NMSCs.9 A study of Canadian farmers showed they had a threefold increased risk of lip cancer compared to people with indoor occupations, even after accounting for a history of smoking.10 Immunosuppressed populations in particular must remain extremely vigilant about lip cancer. Kidney transplant patients have a 30-fold increased risk due to use of immunosuppressive anti-rejection drugs.11 People receiving higher doses of immunosuppressants tend to develop more NMSCs than those on lower doses,12 and patients with HIV also demonstrate higher skin cancer risk.13 Studies have shown that males are 3-13 times more likely to develop lip cancers, likely due to occupation-related sun exposure combined with greater tobacco and alcohol use. distant sites, the relapse rate after treatment can range from 5-35 percent, and the mortality associated with large or recurrent SCC of the lip is as high as 15 percent in some studies.6 Once these cancers spread to local lymph nodes, five-year survival rates decrease to approximately 50 percent.8 Distribution of Lip Cancers To assess incidence and gender associations for lip cancers, we prospectively evaluated 100 consecutive patients visiting our practice. The type of skin cancer, specific location on the lips, and gender of the patient were included in the evaluation. Our study population consisted of 51 males and 49 females with a total of 68 SCCs and 32 BCCs. Figure 1 [page 54] demonstrates the normal anatomy of the lip, while Figure 2 [page 54] shows the distribution and type of skin cancers among the patients. As in numerous prior studies, the most common location was the lower lip. Also consistent with earlier studies was an overwhelming predominance of SCCs compared to BCCs on the lower lip (50 vs. 5), and a higher proportion of upper lip cancer in females compared to males; 60 percent of upper lip cancers occurred in females vs. 40 percent in males. About 70 percent of these upper lip cancers in women were BCCs. Across both sexes, BCCs accounted for 60 percent of upper lip cancers, compared to only nine percent of lower lip cancers. Finally, while most studies cite a significantly higher ratio of men with lip cancers compared to women, in our study, incidence was virtually 1:1. This is likely due to smaller study numbers and the predominance of patients from the same geographic area, which may not be representative of the general population. Risk Factors Lip cancer has been associated with smoking, alcohol consumption, and immunosuppression. Emerging data implicate human 52 Immunocompromised patients, especially those with chronic sun exposure (which further suppresses the immune system), must be monitored closely. Treatment of Lip CancerS When detected and treated early, lip cancer is almost always curable. However, large or recurrent cancers (possibly resulting from insufficient initial treatment) elevate the risk for local and distant spread. For several reasons, including greater conservation of healthy tissue and an extremely high cure rate, Mohs micrographic surgery is commonly used to treat lip tumors. Mohs surgery involves removing thin layers of skin tissue, which are then color-coded, mapped, and microscopically examined. If malignant cells are detected, more tissue from the affected area is removed. This process is repeated until no more cancer can be found. Mohs surgery offers the highest cure rate of any treatment modalities for primary or recurrent lip tumors,14 with cure rates of 90-100 percent. In one study of 49 patients with SCC of the lip, the five-year cure rate was 92 percent, compared to 80 percent for (non-Mohs) surgical excision and radiation therapy.14 Tumors often extend beyond what the naked eye can detect, but Mohs surgery, with its use of microscopic examination, allows targeted removal of malignant cells while sparing normal skin. This permits optimum functional and cosmetic results. [See Figure 3.] Prevention of Lip Cancers Regular use of photoprotective lip blocks (lip products that contain sunscreen) reduce the risk of lip cancer.15 However, many people remain unaware how important consistent lip protection is. In a study of 299 beachgoers, 94 percent demonstrated a high awareness of the risks of UV damage to the skin in general, but only SK I N C A NCER FOU N DAT ION JOU R NA L Current Science with a Global Perspective. The Archives of Dermatology publishes relevant research and studies from around the world to enhance the understanding and pathophysiology of cutaneous disease. Quality papers deliver information to physicians for optimal patient care. For subscription and publication details visit archdermatol.com HEALTH 69 percent demonstrated a high awareness of risk factors specifically for lip cancer.16 Seventy percent of beachgoers used no lip protection whatsoever, and even among those who otherwise properly applied sunscreen, only 37 percent used any lip protection. Furthermore, while photoprotective lip blocks can be effective in reducing UV exposure, most people do not apply them properly. From a practical standpoint, the actual Sun Protection Factors (SPFs, which measure protection against the sun’s UVB rays) provided by lip blocks are almost always lower than the number on the package because the blocks are not applied thickly or frequently enough.17 Additionally, many commercially available photoprotective lip blocks may be poorly absorbed and can be broken down quickly by UV light, losing their effectiveness — two compelling reasons for frequent reapplication.18 CONCLUSION Despite being exposed to large amounts of UV light, the lips are often overlooked as a potential site for skin cancers. It is critical to exercise careful sun protection through a combination of sun avoidance and shade-seeking; frequent application of a high-SPF lip block; and careful monitoring of skin changes. Any changes to the lip that concern you should be brought to the attention of your physician immediately. DR. STEBBINS is currently a Mohs micrographic surgery and procedural dermatology fellow under the direction of Dr. C. William Hanke at the Laser & Skin Surgery Center of Indiana and St. Vincent Hospital, Indianapolis, Indiana. DR. HANKE is the Director of the Laser & Skin Surgery Center of Indiana in Carmel, IN, and Senior Vice President of The Skin Cancer Foundation. He was the f rst physician in the United States to earn triple full professorships in Dermatology, Otolaryngology Head and Neck Surgery, and Pathology and Laboratory Medicine. He is past President of the American Academy of Dermatology, and has served as President of f ve surgical specialty societies: the American Society for Dermatologic Surgery, American College of Mohs Micrographic Surgery and Cutaneous Oncology, the International Society of Cosmetic Laser Surgeons, International Society for Dermatologic Surgery, and the Association of Academic Dermatologic Surgeons. He has written more than 350 publications including 91 book chapters and 20 books. Figure 1: Normal anatomy of the lips PHILTRUM VERMILION BORDER ORAL COMMISSURE VERMILION (Red Portion of Lip) Figure 2: Distribution of BCCs and SCCs Vermilion Border (upper) BCC: 6 SCC: 6 Vermilion (upper) BCC: 11 SCC: 4 Oral Commissure (upper) BCC: 10 SCC: 8 Oral Commissure (lower) BCC: 2 SCC: 18 Vermilion (lower) BCC: 1 SCC: 17 Vermilion Border (lower) BCC: 2 SCC: 15 Figure 3 A B This patient presented with a 1x1 cm SCC of the lower vermilion lip. A) Appearance of lower lip after removal of tumor using Mohs micrographic surgery. B) Natural healing of lower lip 4 weeks after procedure. References available on p.96. 54 SK I N C A NCER FOU N DAT ION JOU R NA L HEALTH The Right Way to Treat Seasonal Depression Michael Terman, PhD Is the cold, dark winter making you SAD? If you sit at a light box — usually for 30 Seasonal affective disorder (SAD) is a minutes after rising — even your most condition that can bring on a full-blown disruptive clinical symptoms can clear depression that reappears yearly, usually in up quite quickly, sometimes within days. So, if you see a salon advertising UV winter, with major relief in the late spring and summer. It can destroy your ability to tanning as a cure for SAD, don’t believe work, meet family obligations, and engage it. Early morning sunlight, which light socially (or sexually). Feelings of anxiety therapy approximates, provides the lowest amount of UV radiation of the day, and and despair are also common. SAD-related depression is usually the UVR therapy hypothesis was disproved accompanied by physical symptoms: dif- when investigators found no reduction ficulty waking up, sleeping longer hours, craving carbohydrate-rich foods, and gaining weight that is easily lost in late spring. Nearly 10 million people in the US have SAD, and three times as many have “winter doldrums,” with similar, though UV radiation is not the not clinically severe, symptoms. Since good mood, sunlight, and spring solution: bona fide light and summer tend to go together, many once therapy works through the believed that sprawling in the sun or a eyes, not the skin. tanning bed was the answer to SAD — that the ultraviolet (UV) light they give off was a virtually magical cure. And, as it turns out, light does play a role in the treatment of SAD. But it’s visible light, not UV, that accounts for light’s antidepressant effect. of antidepressant effect when UVR was What’s the right way to treat SAD and eliminated from light boxes.1 However, in the winter doldrums? Visible light therapy, a recent study, college women who showed which is generally provided by a light box. either mild or severe symptoms of SAD This light provides a spring-like sunrise were far more likely to abuse indoor tansignal that travels from the retina in the ning (having 40 sessions or more per year).2 eye to the biological clock in the base of Since UVR stimulates the body to produce the brain, so that the internal clock and endorphins, chemicals that produce feelthe clock on the wall stay coordinated. ings of calm and well-being, this temporary Ordinary indoor lighting is about 50-300 “high” may influence tanning’s popularity lux (the equivalent of twilight), while a among women with SAD. However, it is not light box with 10,000 lux of illumination the solution; bona fide light therapy works provides a true, early, outdoor daylight level. through the eyes, not through the skin. 56 HOW SAD MAKES US SAD SAD is linked to melatonin, a sleeprelated hormone. Generally, melatonin levels in the body are higher at night and lower in the morning. For people with SAD, however, the cycle is often delayed, and melatonin levels remain elevated into the morning, causing them to oversleep or leaving them fatigued. Meanwhile, the brain’s internal clock relies on early morning light to keep our circadian rhythms in sync with local time, but the late sunrises of winter deny our bodies that essential signal. Depression can result when we have to keep waking up while it’s still dark. SAD is more frequent in the northern half of the US, where winter sunrise is significantly later than in the south. It is also more common toward the western edge of time zones – sunrise is about an hour earlier on the eastern edges. SK I N C A NCER FOU N DAT ION JOU R NA L Photo © Center for Environmental Therapeutics. with a dermatologist before starting bright light therapy. Additionally, people with conditions including age-related macular degeneration, lupus erythematosus, chronic actinic dermatitis, and solar urticaria may react poorly (photosensitively) to the blue light produced by light boxes. For these SAD patients, a milder form of light therapy, dawn simulation, has seen initial clinical success.6 In dawn simulation, timed lights are activated automatically to gradually replicate a low-level springtime sunrise while you’re still in bed. It can be difficult to tell whether your winter slump is clinically significant. You can get anonymous, confidential feedback online using the Personal Inventory for Depression and SAD in the Self-Assessment section at the nonprofit Center for Environmental Therapeutics (www.cet.org). If your depression is severe, consult a mental health specialist. Print out the report, and discuss it with your doctor if indicated. Light Box Essentials Many light therapy products are commercially available. However, few have been clinically tested, and some may pose risks to the skin or eyes. Here are some guidelines, based on the recommendations of the Center for Environmental Therapeutics: • The light box should have been tested successfully in peer-reviewed, placebo-controlled clinical trials. • The box should be able to provide 10,000 lux illumination. • The box should have a smooth diffusing screen that filters out the small amount of UVR emitted by the fluorescent bulbs in most light boxes. The safest light boxes use a polycarbonate diffuser. • The light should project downward toward the eyes to minimize glare. • Smaller is not better. Miniature devices cause glare, and even small head movements will take your eyes out of the therapeutic range. In general, light boxes should be no smaller than 15” wide and 12” high (180 sq. in.). Finally, the lamp should give off white, not colored, light. Soft white light is highly recommended. Full spectrum and blue (or bluish) light provide no known therapeutic advantage — blue light causes glare, and over the long term may harm the retina.3 Boxes that give off inadequately filtered UV are particularly hazardous to the skin and eyes4 of people taking photosensitizing drugs (medications that sensitize the skin to the sun). Photosensitive people may develop rashes, itchiness, bumps, or lesions on the skin as a result of exposure to UV light and have a higher risk of developing skin cancer. Typical UV photosensitizers include antibiotics and NSAIDs (non-steroidal antiinflammatories, like ibuprofen). Everyone who uses a light box should make sure it has a polycarbonate diffuser to screen out UV light adequately, but for people taking photosensitizing drugs, a filter is especially important. Other drugs can photosensitize people to visible blue light, which exists in varying degrees as a component of white light. Anyone using tricyclics or neuroleptics5 (common psychiatric drugs), antiarrhythmics, or antimalarial drugs should check Conclusion Light therapy for SAD can be a boon for quality of life for half the year. But users must keep an eye out for safety and efficacy: much commercial apparatus has received inadequate testing, or none at all. Many doctors are still unacquainted with this powerful non-drug technique. To learn more about light therapy, the newly published Chronotherapeutics for Affective Disorders7 is a comprehensive guide. And remember: Visible light, not harmful UV radiation, is the key to relieving symptoms of SAD. A light box, not a tanning machine, can help improve your mood and sleep without risking your health. DR. TERMAN directs the Center for Light Treatment and Biological Rhythms at Columbia University Medical Center (www.columbia-chronotherapy.org). He is President of the nonprofit Center for Environmental Therapeutics (www. cet.org), a consortium of doctors and researchers dedicated to developing and disseminating nondrug interventions for mood and sleep disorders. References available on p.97. 57 HEALTH PROTECT Your Eyes Everyday Steps to Sun Safety RENE S. RODRIGUEZ-SAINS, MD For most of us, the eyes are the most cherished of our senses. Yet we potentially expose them to danger simply by going outside. Over time, the sun’s rays can seriously damage the eyes and surrounding skin, sometimes leading to vision loss and conditions from cataracts and macular degeneration to eye and eyelid cancers. However, simple daily protective strategies will help keep our eyes and the sensitive skin around them healthy. Don’t Take the Sun Lightly Certain types of light from the sun can wreak havoc: Ultraviolet A and Ultraviolet B light: Ultraviolet A (UVA) and ultraviolet B (UVB), powerful, invisible rays with wavelengths shorter than visible light, are the most dangerous parts of sunlight. They can cause cataracts, eyelid cancers and other skin cancers,1,2 and are believed to play a part in macular degeneration, a major cause of vision loss for people over age 60.3 In addition, UV rays can prematurely wrinkle and age the skin around the eyes. High-Energy Visible Light (HEV light)/Blue Light: HEV light – high-energy visible light in the violet/blue spectrum – is a potential contributor to cataracts and other serious eye maladies.1,2 Blue light can damage the retina over time, leading to macular degeneration. The retina is the membrane where images are formed and transmitted to the brain. The macula, the region of sharpest vision located near the center of the retina, is the most likely area to be damaged. 58 Are You at Risk? The fairer your skin, the greater your age, and the lighter your eyes, the higher your long-term risk, especially if your work or recreation involves prolonged sunlight exposure. Light eyes are at increased risk for skin cancer and certain eye diseases because they contain less of the protective pigment melanin. But all of us are susceptible to these cancers or other conditions caused by the sun. We need to protect ourselves daily, because the damage keeps adding up. How Sunlight Damages the Eyes Although designed to protect the eye, the eyelid’s skin is thin and contains many fragile tissues vulnerable to UV light. Inside the eye, the lens and cornea, both transparent, filter UV rays, but years of UV absorption can damage them. The lens, the eye’s focusing mechanism, can turn yellowish and cataractous. The cornea, the area in front at the outer layer of the eye, admits light and images to the retina. UV damage can cause: Eyelid cancers: Eyelid skin cancers, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma, account for 5 to 10 percent of all skin cancers.4,5 Most occur on the lower lid, which receives the most sun exposure. BCCs make up about 90 percent and SCCs 5 percent or more of all eyelid cancers, while melanomas account for 1-2 percent.4-6 While BCCs elsewhere on the body rarely spread, eyelid BCCs potentially can spread to the eye itself and surrounding areas. SCCs grow faster and have greater potential to spread. Both SCC and BCC are found mainly in patients with a long history of sun exposure,7 while melanomas are especially associated with intense, intermittent sun exposure and sunburns. When diagnosed and treated early, eyelid cancers usually respond well to surgery and follow-up care, with the eye and eyelid largely retaining normal function. But left untreated, they can be dangerous. Watch for these early warning signs: • a lump or bump that bleeds or does not disappear • persistent red eye or eyelid inflammation that does not respond to medication • new flat or elevated pigmented lesions with irregular borders and growth • unexplained loss of eyelashes If you have any of these signals, consult a skin cancer specialist or ophthalmologist, even if you feel no discomfort. Intraocular melanoma: Although rare, it is the most common eye cancer in adults.8 It starts in the uveal tract, the middle layer of the eye containing the iris (the colored part of the eye) and choroid (the layer under the retina). Symptoms may include blurred vision and a change in the shape of the pupil (the dark area in the center of the iris). Conjunctival cancers: Once rare, these have been rising rapidly in incidence, especially among older people. Incidence among white men increased 295 percent over a 27-year period.9-11 Melanomas of the conjunctiva, the protective membrane SK I N C A NCER FOU N DAT ION JOU R NA L covering the outside of the eye and the inside of the eyelids, may be more common in patients with atypical mole syndrome;12 these patients sometimes have 100 or more moles, as well as one or more moles 8 mm (1/3 inch) or larger in diameter, and one or more moles that are atypical. All patients with cutaneous (skin) melanomas and/or atypical moles should have yearly ophthalmologic evaluations. Cataracts: The most common cause of treatable blindness,13 cataracts are a progressive clouding and yellowing of the crystalline lens, the eye’s focusing mechanism. At least 10 percent of cataract cases are directly attributable to UV exposure,4 especially UVB. In the US alone, more than one million operations to remove cataracts are performed every year.4,14,15 Macular degeneration: Often referred to as age-related, or senile, macular degeneration, it is now believed to be caused by cumulative UV damage to the retina. The macula, the region of sharpest vision near the center of the retina, is the most likely area to be damaged. Macular degeneration is one of the major causes of vision loss in the US for people over age 60.3 Some studies point to UVA and HEV light as potential causes.1,2,16 Keratitis, or corneal sunburn: Excessive UV exposure from the sun or tanning machines can burn the cornea, the clear refracting surface that admits light and images to the retina. Protective lenses are always advisable when you are exposed to UV. They are a must for skiers or snowboarders, since UV is more intense at high altitudes, and since snow reflects back about 80 percent of the sun’s rays, so that they hit your eyes a second time. Water and sand also reflect UV rays.17,18 Virtually all these conditions can be found during a routine ophthalmologist’s exam. Ideally, have a complete yearly exam, including dilated funduscopy. Best Defense Lenses that absorb/block UV offer strong defense against eye and eyelid damage. It’s best to wear sunglasses year-round in the sun.13 UVA light can damage the eyes and the skin around them throughout the year. Even on overcast days, UV can penetrate through clouds and haze. Check if the glasses meet ANSI and/or ISO standards for traffic signal recognition, meaning they permit good color recognition. Sunglass lenses come in many shades, with neutral gray, green, or brown usually For proper protection, sunglasses should offer the following: • The ability to absorb and block 99 to 100 percent of UVA and UVB light. Ideally, they should also guard against HEV light. • Sufficient size to shield the eyes, eyelids, and surrounding areas. The more skin covered, the better. Wraparound styles with a comfortable, close fit and UV-protective side shields are ideal. • Durability and impact resistance. • Polarized lenses to eliminate glare, especially when driving, but also out in the snow or on the water, where reflection greatly magnifies glare. Continuing glare can cause fatigue, headaches, and even migraines. offering the most comfortable vision. Choose the color that works best for you. Before purchasing sunglasses, check tags, labels, or packaging to make sure the lenses provide proper UV protection. For extra assurance, look for The Skin Cancer Foundation’s Seal of Recommendation. Other Defenses Other safety measures are also important. Wearing a hat with at least a 3” brim all around can block up to half of all UVB rays from your eyes and eyelids.13 Hats or tinted visors also help block UV from entering your eyes from above. Since sunglasses and hats cannot cover your entire face, sunscreen is also important. Finally, whenever outside, seek shade, especially between 10 AM and 4 PM. Remember, practice all these strategies year-round — including when you’re on vacation, spring, summer, winter and fall. References available on p. 97. DR. RODRIGUEZ-SAINS is an ophthalmic plastic and reconstructive surgeon, ophthalmic oncologist, and ophthalmologist. He is a Clinical Assistant Professor at NYU-Langone Medical Center and a professional member of The Skin Cancer Foundation. 59 HEALTH Breast Cancer and Melanoma: How They Are Linked SU LUO AND HENSIN TSAO, MD, PHD Since breast cancer is the most frequently diagnosed noncutaneous (non-skin) cancer among women in the United States,1 it is not surprising that many individuals with breast cancer will develop melanoma (the deadliest form of skin cancer) and vice versa. However, recent studies exploring how often individual patients develop both cancers suggest that it has to do with more than just coincidence: A recent study by Murphy, et al, for example, found that patients with either breast cancer or melanoma were almost four times more likely to develop the other malignancy than probability would lead researchers to expect.2 Specific causes linking the diseases may be in play, and genetic or environmental factors may also contribute. On the other hand, the association may at least partly result from more rigorous detection – in other words, a detection bias. This occurs when health care providers who carefully monitor cancer patients detect a second cancer that might otherwise have been missed. Whatever clues we can gather about an association between breast cancer and melanoma may help lead to patient interventions that could reduce the risk of a second cancer. Just what do we know so far about the links between these two cancers? Population-Based Studies Population-based data provide the most statistically significant estimates of cancer incidence.3 When exploring the frequency of two primary cancers occurring together, epidemiologic studies often focus on a population-based registry of one cancer, then evaluate data for the development of the second. The findings are presented as a standardized incidence ratio (SIR), a ratio of observed to expected number of cases. 60 Melanoma After Breast Cancer Recent registry-based studies offer SIRs ranging from 1.16 to 2.74 for melanoma development after breast cancer, meaning that 1.16 to 2.74 times the number of expected melanoma cases occurred after a breast cancer occurred.4-6 (The range may reflect differences in methodology or variations in the composition of the examined population.) An accurate estimate may A recent study found that patients with either breast cancer or melanoma were almost four times more likely to develop the other malignancy than probability would lead researchers to expect. be a 29 percent excess risk for melanoma in breast cancer patients, as found in the largest group study of over 500,000 breast cancer patients.7 Higher-risk still were breast cancer patients age 50 or younger, who in a study by Goggins, et al, had a 46 percent higher risk of melanoma after breast cancer.4 Breast cancer patients who receive external radiation therapy (XRT) also have an especially heightened melanoma risk4,6 — Goggins, et al found a 42 percent higher risk of melanoma4 — even at nonirradiated sites.8 However, patients who undergo XRT for breast cancer may be examined more frequently, reflecting a detection bias that could lead to more melanomas being found. Breast Cancer After Melanoma Studies of melanoma patients have not generally shown statistically significant higher risks of a subsequent breast cancer.9,10 However, using the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) data from 1973-1999, Goggins, et al did detect modest but significant increases in breast cancer risk after melanoma and vice versa.4 The risks of breast cancer among female melanoma survivors and melanoma among breast cancer survivors were elevated by 11 percent and 16 percent, respectively. This mutual association, especially among breast cancer patients age 50 or younger, suggests genetics may play a role.4 Genetic Associations Investigators looking for a possible genetic link have zoomed in on several genes that are known risk factors for either melanoma (such as the CDKN2A gene) or breast cancer (such as the BRCA2 gene). A small number of melanoma cases are familial (occurring in people who have one or more close relatives with melanoma). Of these, about 20-40 percent have mutations in the CDKN2A gene. A study of familial melanoma cases with CDKN2A mutations showed these families not only had multiple cases of melanoma, but also an increased risk of breast cancer.11 However, the association between the two cancers was still quite weak. To date, genetic testing for mutations in high-risk genes for melanoma such as CDKN2A among breast cancer patients is not warranted.12 However, people who have high-risk genes for breast cancer may be predisposed to melanoma. The Breast Cancer Linkage SK I N C A NCER FOU N DAT ION JOU R NA L Consortium found that BRCA2 mutation carriers have 2.58 times greater risk than non-carriers of developing melanoma.13,14 The Xeroderma Pigmentosum group D gene (XPD) has also been recently implicated in both melanoma and breast cancer. This gene is associated with xeroderma pigmentosum, an inherited skin condition in which sufferers are dangerously vulnerable to ultraviolet light (UV) exposure, and often suffer multiple skin cancers, including melanoma. Certain variations in the XPD gene are modestly associated with heightened breast cancer risk, while others are modestly associated with melanoma in patients over age 50.15 Detection Bias Detection bias can increase the apparent risk of a second malignancy. The SEER analysis found a higher than expected number of localized (but not thicker, later-stage) breast cancers diagnosed after melanoma, suggesting some role for detection bias; increased scrutiny may have led to earlier detection of the breast cancers.4 Indeed, patients as well as their physicians may be more vigilant with their skin examinations. However, this possible detection bias has not shown up with melanomas discovered after breast cancers; studies have demonstrated that the increased melanoma risk among breast cancer patients has fluctuated very little over time. A detection bias would have shown a gradual decline in risk, as intense scrutiny eased.7 Environmental and Hormonal Influences Socioeconomic factors could also contribute to the association of breast cancer with melanoma.3 For instance, behaviors such as tobacco, alcohol and sunscreen use or lack thereof could all be related behaviors in certain economic strata. The role of female hormones (such as estrogen receptors3), already known to play a role in breast cancer, have also been a concern with regard to stimulating melanoma growth, especially in light of associations between melanoma and pregnancy.16 (While pregnancy does not increase the risk of melanoma, melanomas diagnosed during pregnancy tend to be thicker, and more dangerous, than those in non-pregnant patients.) Conclusions While epidemiologic studies have long noted an association between breast cancer and melanoma, the exact nature of this relationship is far from understood. It could be that DNA damage and genetic changes hindering DNA repair may affect the risk of many different types of cancers. For patients who have had breast cancer, an annual total-body skin check by a trained professional makes sense, and more frequent exams may be needed for those who have gone through radiation therapy. Likewise, post-melanoma surveillance typically should involve evaluation of the lymph nodes near the breast. Teaching patients to examine this area routinely could lead to earlier detection of breast cancer metastases. SU LUO is a medical student at the University of Miami Miller School of Medicine. She is conducting research in mutation analysis of pigmented lesions at the Wellman Center for Photomedicine, Massachusetts General Hospital. She will receive her MD in 2011. DR. TSAO is the Director of the Melanoma and Pigmented Lesion Center and the Melanoma Genetics Program at Massachusetts General Hospital, and Associate Professor of Dermatology at Harvard Medical School. He leads a cancer genetics laboratory at the Wellman Center for Photomedicine at MGH. Dr. Tsao is widely published and has lectured internationally about melanoma, genetics, and skin disease. References available on p.97. 61 ADVERTISEMENT IDENTICAL TWINS (NO SURGERY) ☎ Darrick E. Antell, MD, FACS 212-988-4040 web: www.antell-md.com e-mail: [email protected] Diplomate, American Board of Plastic Surgery 850 Park Avenue, New York, NY 10075 Please cut out for educational purposes What could more purely demonstrate the effects of photodamage than a study of identical twins? Please feel free to cut these photos out, and show them to help educate your patients. Darrick E. Antell, MD, a New York City plastic surgeon has performed multiple studies of aging in identical twins and the photos above demonstrate the effects of sun damage firsthand. At the time of these photos, both twins were 59 years old. However, the twin on the left had a long history of sun exposure, and had been a practicing nudist. As they are genetically alike, any variation in the damage to their skin was clearly due to environmental factors, in this case ultraviolet (UV) exposure. The more sun-damaged twin has deeper wrinkles and sagging skin, when compared to her twin sister. Visit Dr. Antell’s website for more information, or see interviews on this topic with the twins on YouTube, search under Dr. Antell identical twins. Darrick E. Antell, MD, FACS Diplomate, American Board of Plastic Surgery 850 Park Avenue, New York, NY 10075 ☎ 212-988-4040 web: www.antell-md.com e-mail: offi [email protected] ADVERTISEMENT A PUBLICATION OF THE SKIN CANCER FOUNDATION • VOL. 11, 2010 nEWS frOM THE inTErnATiOnAL ADviSOry cOUnciL The iArc’s damning report on tanning was a kind of final straw, and on november 9, 2009, the Brazilian national Health Surveillance Agency (AnviSA) banned Uv cosmetic tanning altogether throughout the country. — Banning The Tan Around The World (p.65) BANNING THE TAN AROuND THE WORLD Nations Mobilize crAig SincLAir In the 2008 issue of this Journal, I described the case of Clare Oliver, a young journalist who died from melanoma, the deadliest skin cancer, a few years after using tanning beds. In her last days, Clare gave broadcasts from her hospital bed, urging fellow Australians to refrain from tanning. In the year after her death, her cautionary tale and warnings were continually cited by journalists, health groups, and politicians calling for legislation to control the indoor tanning industry in Australia. Two years later, I can report that Clare’s impact, bolstered by convincing new international research on tanning’s harmful effects, has been monumental, not just in Australia but around the world. The evidence is so strong now against indoor tanning that many nations have been roused to action, lobbying and legislating against the dangers posed to their young people and other citizens by tanning devices. THE TAnning PAnDEMic In the past three decades, since being introduced to America by Friedrich Wolff in 1978,1 tanning salons have been a notable growth industry. Indoor tanning is now widely practiced in most developed countries with sizable light-skinned populations, particularly Northern Europe, New Zealand, the US, and Australia. 63 INTERNATIONAL In the US, nearly 30 million people tan indoors yearly,2 the Cancer (IARC), affiliated with WHO, published a report adding tanning industry raking in about $5 billion.3 About 10 percent UV radiation (UVR) from tanning beds to its group of the most of Northern Europeans use sunbeds on a regular basis,4 with as dangerous forms of cancer-causing radiation for humans, alongside elements such as radon and plutonium as well as solar UVR.14 many as one in three women reporting sunbed use in the UK.5 This tanning explosion has particularly been embraced by Then, researchers at the Wellcome Trust Sanger Institute (and marketed to) young people, who are especially vulnerable to in Hinxton, England, mapped the genetic material that made long-term damage from tanning lamps’ ultraviolet (UV) radiation; up a patient’s melanoma, discovering that the vast majority of it can age their skin prematurely and leave them at significantly mutations found in the melanoma were caused by UVR. Many higher lifetime risk of skin cancer. mutations — changes or errors occurring in genes due to radiation, Despite the scope of the problem, restrictions on youthful tan- viruses, and other causes — can lead to cancer.15 ning (and tanning in general) in most countries have been minimal. Convincing evidence now links skin cancer to frequent use For example, the US Food and Drug Administration (FDA) ranks of tanning beds and tanning bed use among young people. One tanning machines as a Class I medical device, about as dangerous study found that people who use tanning beds are 2.5 times more as elastic bandages, and its limited federal regulations reflect this.6,7 likely to develop squamous cell carcinoma (SCC), the second most Until the past few years in Europe, the only countries to limit the common skin cancer, and 1.5 times more likely to develop basal amount of ultraviolet B (UVB) radiation coming from sunbeds were cell carcinoma, the most common cancer.16 Other research shows Belgium, France, and Sweden.8 (Typically, UVA made up about 95 percent and UVB five percent of tanning bed radiation.) In the UK, there is no effective control of the suppliers or operators of sunbeds; the industry is almost With the weight of evidence entirely unregulated. Children mounting, many countries at virtually any age can walk have awakened to the dangers into a tanning automat alone, and with no one in attendance of tanning beds, launching for screening or oversight, can legislation to regulate and drop in some coins and have the reduce their use, especially tanning session of their choosamong young people. ing. The media have reported the devastating first degree burns some children sustained; one girl burned 70 percent of her body in 16 minutes.9 Even supervised salons come up lacking. In a study of 332 tanning salons in Northern Ireland, for example, a high number were found to have shockingly poor that the overall risk of melanoma for all tanning bed users is 17 standards. In one fifth of the salons, skin type was not even increased by 15 percent, and that first exposure to tanning beds 18 discussed with customers, and only 44 percent of customers in youth increases melanoma risk by 75 percent. In general, the highest skin cancer rates are found in nations with skin type I (people with the lightest skin type, who can burn badly but cannot tan) were advised not to tan. In a quarter where people are fairest-skinned and where the tanning culture is strongest: Australia, New Zealand, North America, and Northern of the salons, the staff itself was not trained about UV risks.10 Europe.19 Skin cancers have surged in all these places, and indoor tanning must be playing a part. Aftermath: a Surge in Skin Cancers Indoor tanning in Australia, for example, has been associated What has been the effect of this skyrocketing sunbed use? Research with a 22 percent increased melanoma risk among all solarium suggests a significant increase in skin cancers. The World Health Organization (WHO) reports that 132,000 cases of melanoma and users, and up to 98 percent increased risk for those who became 20 over two million cases of other skin cancers occur worldwide each users when younger than 35. According to the Queensland 11 Institute of Medical Research, tanning beds cause 281 cases of year, with estimates as high as 66,000 melanoma-related deaths 8 melanoma a year in Australia, killing 43, and are responsible for a year. Frequent tanners using new high-pressure sunlamps 17 may receive as much as 12 times the annual UVA dose compared 2,572 squamous cell carcinomas. In the UK, where skin cancer incidence has quadrupled since the to the dose they receive from sun exposure,12 and WHO reports 5 that 10 minutes in a sunbed matches the cancer-causing effects 1970s, rising faster than any other cancer, it is widely believed that 13 this meteoric rise significantly involves increased use of artificial of 10 minutes in the Mediterranean summer sun. Two important international reports in the past year strongly tanning devices. At least 100 of the 1,800 annual melanoma-related 21 reinforced the association between tanning, melanoma, and other deaths are attributed to artificial UV radiation. Similarly, in Norway and Sweden, the annual incidence rate skin cancers. First, the International Agency for Research on for melanoma has more than tripled in the past 45 years,19 with 64 N ews from the I nternational A D V I S O R Y C O U N C I L the desire to have a tan and the accompanying growth in sunbed use considered prime causes. One study showed a significant increase in melanoma risk for Norwegian and Swedish women who regularly used sunbeds.19 An International Wake-up Call With the evidence mounting, many countries have launched legislation to regulate sunbed use, especially among young people. • In the US, California, Texas, and at least 29 other states have passed their own legislation governing the use of tanning facilities by minors.22 California led the way in 2004, banning sunbed use for teens under age 14,23 and Texas recently passed the most restrictive law in the country, prohibiting use for all children and adolescents under age 16.5.24,25 • In 2007, the European Commission of Health and Consumer • • • • Services ruled that all new tanning machines brought into the European Union must reduce UVB to 1.5 percent of their UV emissions, not exceeding an “erythemal-weighted irradiance” of 0.3 W/m2, about 12 on the ultraviolet index scale. This lower UVB intensity should reduce the risk of sunburn, allowing slightly greater margin for error in determining exposure times. In Europe, France, Belgium, Germany, Scotland, Spain, and Portugal all now restrict sunbed use for persons under age 18. In France, the regulations also require all UV radiationemitting appliances to be declared to the health authority. Trained personnel must supervise all commercial establishments, and any claim that they provide health benefits is forbidden.19,26 In addition to its recently passed legislation banning under-18s from using sunbeds, Scotland has mandated that all sunbed salons be supervised, with proper information provided to customers.26 The province of New Brunswick in Canada also now bans under-18s from using sunbeds.26,31,32 As so often in the field of UV protection, Australia has taken a leadership role. All five states in Australia have banned sunbed use for teens.27-9 [For more on Australia’s antitanning efforts in the past two years, see “Clare’s Legacy” on page 66.] Finally, Brazil recently one-upped all other nations. With their long tradition of outdoor tanning, Brazilians had increasingly embraced indoor tanning as well in recent years (especially in the south), even as melanoma rates were climbing. Some legislative controls were in place regulating operation of sunbeds, in an attempt to reduce their impact on health, but inspections showed these regulations were not being followed. A government working group was established to review existing legislation, and after extensive discussions with health authorities and the sunbed industry, it was determined that the health benefits of sunbed tanning were little or none, certainly not enough to outweigh their dangers. The IARC’s damning report on tanning was a kind of final straw, and on November 9, 2009, the Brazilian National Health Surveillance Agency (ANVISA) banned UV cosmetic tanning altogether throughout the country.30 Gathering Steam Following the lead of these nations, and swayed by the mounting research, other countries are now jumping on the anti-tanning express. • In the US, though the FDA has not yet strengthened its tanning bed regulations, it recently held a public meeting to consider raising sunbeds from a Class I medical device to Class II or III, thereby allowing the FDA to increase safety regulations and oversight.31,6 • The Canadian Dermatology Association (CDA) has launched a campaign called “Indoor Tanning Is Out” to educate Canadians about the dangers of tanning beds, gathering support to convince Parliament to ban indoor tanning for people under age 18.5. As part of the campaign, young tanners who are now battling skin cancers have publicly presented their personal stories.31,32 • Lawmakers in the UK, urged by the British Association of Dermatologists, have also initiated efforts to ban teenagers from using tanning beds, and to eliminate the dangerous coin-operated unmanned booths.33 Nearly 90 percent of the population surveyed backs these proposals, and legislation is likely forthcoming to ban young people under age 18.34 Wales is very close to final approval of such legislation. Odds are, this momentum will only keep building as more and more research comes to light. Given the mounting evidence about the risks of tanning beds and the number of countries introducing legislation to control these risks, I expect that one day public use of these dangerous devices will be a thing of the past, reserved for medical use in doctors’ offices, where they rightfully belong. CRAIG SINCLAIR is Director of the Cancer Prevention Centre, Cancer Council Victoria, Australia. He is also Head of the World Health Organization’s Collaborative Center for UV Radiation, and Chairman of both the Cancer Council Australia’s National Skin Cancer Committee and the Standards Australia Committee on Artificial Tanning. References available on p.74. 65 inTErnATiOnAL Clare’s Legacy Clare Oliver, a budding 26-year-old Australian journalist, died from melanoma on September 13, 2007. At age 19, she had made several visits to a tanning parlor, sustaining skin damage, and in the days before her death, she wrote a newspaper story and gave broadcasts from her hospice bed calling for a ban on tanning beds.1 Her words did not fall on deaf ears. Driven by the public outcry and media firestorm her case stirred up, legislators have passed laws across Australia significantly regulating the tanning industry. All five major states in Australia — New South Wales, Victoria, South Australia, Western Australia, and Queensland — have banned access to tanning beds for everyone under age 18.2,3 Most states also ban access to fair-skinned people (skin type I),2,3 and operators must display health warnings or risk up to million-dollar fines.4 This flurry of legislation has driven countless tanning parlors out of business, leaving the industry in peril.4 From 1996 to 2006, The Australian Yellow Pages® showed more than a 300 percent increase in tanning salons.5 In the most recent Yellow Pages® for each capital city, the number 66 had dropped by 32 percent in the past three years. Most striking was the change in Melbourne, with a 51 percent decrease in solarium businesses.5,6 Similarly, by late 2009, only half of the 150 businesses using sunbeds in South Australia were still operating, and some of those had stopped offering tanning beds as well.7,8 Victoria’s solarium industry was on the brink of collapse, with a 45 percent drop in tanning salons since the State Government regulations were introduced.4 It had gotten so bad for the tanning industry that its peak body, the Australian Tanning Association, had to disband after being legally challenged by government regulators for its actions.4 Researchers reported in a 2009 Australian and New Zealand Journal of Public Health that the number of tanning salons nationally had dropped from 406 to 278.5,6 And sometime this year, the number is expected to have dropped by up to 60 percent4 — not all the way there yet, but Clare would undoubtedly be proud of the progress that has been made. References available on p.74. N EWS F ROM T H E I N T ER NAT IONA L A DV ISORY COU NCI L 31st Annual Meeting of the International Society for Dermatologic Surgery ANNOUNCEMENT in cooperation with: The Romanian Society for Aesthetic Medicine and Dermatologic Surgery Mark your Calendar Bucharest/Romania September 23-26, 2010 Get detailed information at: info @ isdsworld.com // www.isdsworld.com ISDS Headquarters Office // Seeheimer Straße 3 // D-64297 Darmstadt/Germany Phone: +49 (0) 6151 9518 89 2 // Fax: +49 (0) 6151 9518 89 3 INTERNATIONAL The Road to Group I How the International Agency for Research on Cancer Came to Classify Indoor Ultraviolet (UV) Tanning as Carcinogenic to Humans Philippe Autier, MD, MPH I n 2009, a working group of the International Agency for Research on Cancer (IARC), affiliated with the World Health Organization (WHO), added ultraviolet radiation (UVR) from tanning machines to its Group I list of the most carcinogenic (cancer-causing) forms of radiation. Citing evidence from years of international research on the relationship between indoor tanning and skin cancer, the IARC placed this type of UVR in a danger category alongside offenders such as radon, plutonium, and solar UVR. UVB and Skin Cancer An estimated 90 percent of all skin cancers are associated with exposure to UV radiation, mainly from the sun. UV reaches the earth in the form of shortwave, ultraviolet B (UVB) and long-wave, ultraviolet A (UVA) rays. Scientists have been studying UVR for decades, and by the end of the 1980s had well documented the carcinogenic properties of UVB. They knew that in the lab, it caused DNA mutations in skin cells that led to the development of cancer; triggered the growth of what resembled human squamous cell carcinoma (the second most common human skin cancer) in rodents; and was more responsible than 68 UVA for inducing sunburn. At the same time, studies provided increasing evidence that sunlight was the main environmental cause of skin cancer, the risk of which was then strongly associated with a history of sunburn. Thus, UVB was believed to be the Visible Light Ultraviolet Light UVA 700–400 nm 400–320 nm (nm = nanometer or billionths of a meter) increasing wavelength UVB 320–290 nm major cause of skin cancer. Much less data was available on the role of UVA in skin cancer. However, scientists considered it of the utmost importance to learn more, believing that research could prompt innovations in sun protection, such as improved, broader spectrum sunscreen formulations. After a thorough review of all available data from laboratory, animal, and human studies, in 1992 a Working Group convened by the IARC first placed solar radiation, and more specifically the sun’s UV radiation, in the IARC Group I of the most dangerous carcinogenic agents for humans.1 (For details on the criteria for Group I, see www.iarc.fr — monograph program.) However, there wasn’t yet sufficient evidence to assign specific wavelengths, like UVB, to Group I, so both UVA and UVB were classified as “probably carcinogenic to humans,” placing them in the IARC’s Group IIa. Evidence suggested but was not yet conclusive that UVB was a human carcinogen, and UVA was suspected to be a carcinogen. Uncertainties primarily resulted from the many unanswered questions about the causes of melanoma, the deadliest form of N ews from the I nternational A D V I S O R Y C O U N C I L Figure 1. Risk of Melanoma in People <35 Years Old at First Sunbed Use4,6 STUDIES Swerdlow et al, 1988 Westerdahl et al, 1994 Chen et al, 1998 Walter et al, 1999 Westerdahl et al, 2000 Veierod et al, 2003 Bataille et al, 2005 Figure 1: A 2006 survey (meta-analysis) of key tanning bed studies over the past two decades found an overall 75 percent increase in melanoma when indoor tanning began before tanners reached age 35. [The size of the box on each line (each line repesenting a different study) is proportional to the number of the subjects included in each study.] Summary relative risk indicates the total range of relative risk, from 1.35 - 2.26. skin cancer. In animal studies, UVB was found to induce squamous cell carcinoma (SCC), but had not been found to cause tumors resembling human melanomas; nor had DNA mutations specific to UVB exposure been found in melanoma. Epidemiologic studies (statistical studies on human populations that explore the links between human health effects and specified causes) suggested that melanoma was due to intermittent, intense sun exposure, acquired mainly during tanning, leisure, or sports activities. This would explain why melanoma was frequently found on areas normally sun-protected in everyday life, such as the trunk and thighs. In contrast, SCC occurred most frequently on chronically sun-exposed areas (e.g., the head and neck) of elderly subjects, and was considered to be mainly due to cumulative sun exposure. At that point, the involvement of sun exposure, and of UVB in particular, in the development of melanoma simply did not appear as clear or important as it was in SCC. With even less known about UVA, it was deemed premature to make a clear-cut distinction between UVB’s and UVA’s roles in skin cancer. The Role of UVA The marketing of modern UV tanning devices started at the end of the 1980s, with the advent of fluorescent lamps mainly emitting UVA rays. (Some UVB — less than five percent of the lamps’ UV output — also Summary relative risk 1.75 (1.35 – 2.26) 0.5 1.0 1.5 2.0 2.5 3.0 5.0 7.0 Relative Risk was emitted, since this wavelength is better at inducing a deep, long-lasting tan.) With no convincing proof yet of UVA’s link to skin cancer and only a low amount of UVB included, tanning vendors could argue that acquiring a tan was safe (or safer) when obtained at a salon. Powerful UV tanning units may be 10 to 15 times stronger than the midday sunlight on the Mediterranean Sea, subjecting indoor tanners to UVA doses well above those experienced during daily life or even when sunbathing outdoors. During the 1990s and into the 2000s, indoor tanning became very popular among light-skinned populations, and is now suspected to be one cause of the rise in melanoma incidence. Powerful UV tanning units may be 10 to 15 times stronger than the midday sunlight on the Mediterranean Sea, subjecting indoor tanners to UVA doses well above those experienced during daily life or even when sunbathing outdoors. The fact is, repeated exposure to large, concentrated amounts of UVA constitutes a new experience for human beings. Studies have gradually strengthened the evidence for a causal relationship between UVA exposure from indoor tanning and skin cancer, especially melanomas of the skin and eyes. These data were systematically reviewed in an IARC monograph in June 2009, and the main results can be summarized as follows: 1. Extensive laboratory data and animal experiments document a role for UVA in skin cancer development.2,3 In fact, UVA penetrates the skin more deeply than UVB and can cause damage to cells in the middle layer of skin (the dermis), while UVB does most of its damage in the top layer (epidermis). UVB causes DNA mutations more directly, while UVA causes DNA damage more indirectly; however, in both cases the DNA mutations can lead to cancer. And there is some evidence that the body’s repair and removal of damaged DNA is less effective when the damage is caused by UVA. 2. Experiments in human volunteers show that tanning lamps produce the types of DNA damage associated with UV-induced skin cell mutations that can lead to cancer.4 3. Experiments in human volunteers also show that both UVA and UVB can damage the immune system.4 69 INTERNATIONAL 4. Systematic reviews of studies show that intermittent, intense sun exposure is the main environmental risk factor for melanoma5; this pattern can be simulated by indoor UV tanning. 5. While studies have not consistently shown that indoor UV tanning is a risk factor for melanoma, during a 2006 IARC review, all seven studies examined found a significant increase in melanoma risk (ranging from a 40 percent increase to a 228 percent increase) when indoor UV tanning started during adolescence or young adulthood.4,6 The meta-analysis (an analysis of the results of several studies) found an overall 75 percent increase in melanoma risk when indoor UV tanning began before tanners reached age 35 [Figure 1]. In another meta-analysis, the Working Group found some evidence that UV tanning increased the risk of squamous cell carcinoma, especially when tanning bed use started before age 20. These results were highly consistent with the considerable data pointing to childhood and adolescence as the key periods for initiation and development of melanoma in adulthood.7 6. Four studies have reported an increased risk for ocular melanoma among UV tanning device users.8 Again, the risk of this rare but dangerous cancer was greater for subjects who started indoor tanning before age 20. Further review of the studies by the IARC found no indication that the findings were due to any problems with study design. All the research substantiated a role for both UVA and UVB in human cancer development. Thus, the entire UV spectrum and UV-emitting tanning devices were classified as carcinogenic to humans.9 UV tanning’s relationship to the rise in melanoma incidence has been corroborated by a number of recent epidemiological studies. A few years ago, we predicted that we would begin seeing an increase in melanomas associated with tanning bed use on the trunk, especially in women.10 In areas where indoor UV tanning is popular, especially among teenagers and young adults, such as in Sweden, Iceland, and A = Men B = Women 12 12 10 10 8 6 4 2 References available on p.74. 8 6 4 2 0 1960 DR. AUTIER is the Research Director of the iPRI (International Prevention Research Institute), in Lyon, France, and the former Head of the Unit of Prevention Evaluation and Cluster Coordinator of the Biostatistics and Epidemiology Cluster at the International Agency for Research on Cancer (IARC), affiliated with the World Health Organization (WHO). Dr. Autier is a member of the editorial board of Melanoma Research and the European Journal of Cancer and a member and co-chairman of EPIMEL, the Epidemiology and Prevention section of the EORTC Melanoma Cooperative Group. He has published more than 140 scientific articles. B CASES PER 100,000 CASES PER 100,000 A 2. Melanoma in Sweden, 1960-200411 Figure Northern Ireland, sharp increases in the incidence of melanoma on the trunk have indeed been described.11,12 [See Figure 2]. In view of all the amassed knowledge on the detrimental effects of indoor UV tanning, public health officials need to increase control over indoor tanning, starting by preventing exposure to UV lamps by teenagers and young adults. 0 ’70 YEAR OF DIAGNOSIS ’80 ’90 ’00 Men, head-sites Men, trunk Men, upper limbs Men, lower limbs Men, multiple parts/unspec ’04 1960 ’70 YEAR OF DIAGNOSIS ’80 ’90 ’00 ’04 Women, head-sites Women, trunk Women, upper limbs Women, lower limbs Women, multiple parts/unspec Figure 2. Incidence (cases/100,000, European Standard Population) of melanoma by body site, men and women, Sweden 1960-2004. While leg melanomas have always predominated in light-skinned women, after 1975 incidence rates for women increased more rapidly on the trunk than on the legs, and by the end of the 1990s, the incidence of trunk melanomas had caught up to that of leg melanomas. Experts hypothesize that this phenomenon among women is largely due to increased full-body exposure to tanning devices. 70 N ews fr o m t h e I nternati o na l A D V I S O R Y C O U N C I L Melanoma and Sunny Vacations PROFESSOR JULIA NEWTON BISHOP, MD PROFESSOR TIM BISHOP, PHD PAUL AFFLECK, MA Melanoma, the most serious form of skin cancer, occurs everywhere in the world. However, it is much more frequent in fair-skinned peoples, particularly those living in sunny locales. The most common type of melanoma, superficial spreading melanoma, is seen mainly in people with fair skin. Over the last century, people developed more positive attitudes towards sun exposure [see From Bardot to Beckham; Skin Cancer Foundation Journal Vol. XXVIII, page 42], and holidays to sunny climes increased. People also began wearing far less clothing outdoors at beaches and other vacation areas. This growth in recreational sun exposure is believed to be the reason melanoma cases have increased so dramatically in the past 50 years. Sun Exposure Patterns and Melanoma Risk: What the Data Show Case-control studies comparing melanoma patients (cases) with non-patients (controls) provide strong evidence that sunburn is an important factor in the development of melanoma; people with the disease are more likely to have a history of sunburns than those without the disease. However, the relationship between the pattern of sun exposure and melanoma risk is complicated. We might have expected a fairly simple relationship, whereby increased overall sun exposure raises the risk of melanoma. However, the studies do not show this, and only by pooling data from many studies have we been able to understand why. Dr. Sara Gandini, of the European Institute of Oncology in Milan, did a type of study called a meta-analysis, in which she put together and then examined the results of many different studies on melanoma risk factors.1 Her research showed that intermittent, intense sun exposure (the kind obtained on a sunny holiday) was associated with an increased risk of melanoma, while large amounts of regular daily sun exposure were not. Recently, Yu-Mei Chang of the University of Leeds did an even more detailed study, a pooled-analysis, combining not just the results but the original data from various studies.2 Dr. Chang’s study confirmed that regardless of where people live, sunny holidays are associated with an increased risk of melanoma. Large amounts of sun exposure accumulated over a long period, 71 INTERNATIONAL DANGER: People with red hair are at increased risk, as are people with freckles regardless of hair color, and people with blue, green, or gray eyes. such as might result from working outside, were shown to be associated with increased melanoma risk only on certain body parts (such as the limbs); furthermore, this increase was mainly limited to very sunny countries, like Australia. The studies suggest a key role for sunny holidays and sunburn in melanoma development for people living in temperate zones. However, when pale-skinned people live in locales closer to the equator, both holiday sun exposures and very large cumulative sun exposures are believed to increase their melanoma risk. Large cumulative sun exposures are also known to increase the risk of the nonmelanoma skin cancer (NMSC) squamous cell carcinoma for people living either in temperate or warmer zones. The Role of Genetics In all case-control studies, inherited characteristics — such as skin type (how easily the skin burns in the sun), hair color, and eye color — have been shown to be important when it comes to melanoma risk. People with red hair are at increased risk, as are people with freckles regardless of hair color, and people with blue, green, or gray eyes. Our genes control these characteristics, and recent studies have highlighted the role they play. For example, the genes MC1R and TYR influence skin color and how the skin reacts to sunlight.3,4 Moles (benign nevi) are also an important risk factor. Studies of twins show that genes largely determine our number of moles. A mole is a growth of pigmentproducing cells (melanocytes). Though 72 normal moles are individually harmless, having a large number is a risk factor for melanoma; having over 100 indicates a higher melanoma risk than having red hair. The reason for the increased risk is probably that “mole genes” result in melanocytes that tend to divide more, over a longer period of one’s life, especially when the skin is exposed to the sun. More division This growth in recreational sun exposure is believed to be the reason melanoma cases have increased so dramatically in the past 50 years. of melanocytes means a greater chance of developing mutations that can lead to melanoma. Conversely, the risk of melanoma resulting from sunny holidays is lower in people with very few moles and dark skin that rarely or never burns. So, the number of moles we have and our skin color are determined at least in part by our genes (our heredity), and certain genes increase melanoma risk. The likelihood of developing a melanoma is then also influenced by sun exposure. The idea that disease results from both inherited genes and the environment is well accepted in many areas of health. For instance, smoking causes lung cancer, but whether a particular smoker will develop lung cancer partly depends on his or her genes. What is it about sunny holidays that appears to cause melanoma? Most people living in Europe and North America work inside, and many take relatively short but very sunny holidays. Often, most of the body is exposed to the sun on these vacations, and the combination of fair, unacclimatized skin and sudden intense sun exposure causes a lot of sunburn. Research has shown that the sun’s ultraviolet radiation can damage not only the DNA in our skin cells, but also our immune system, reducing the body’s ability to repair the damaged DNA. This dual challenge to the system may play a central role in causing melanoma. Intermittent, Intense Sun Exposure and Vitamin D Some sun exposure can be beneficial to psychological health, and since it also brings about vitamin D synthesis, many experts also consider it important to physical health. However, there is clear evidence that in fair-skinned and “moley” people, holiday sun exposure and sunburn have been resulting in a sustained increase in melanoma incidence. To control this dramatic increase, it will be necessary to N ews fr o m t h e I nternati o na l A D V I S O R Y C O U N C I L moderate this type of exposure in the vulnerable. However, because of vitamin D’s vital health benefits, such as bone-building and disease-fighting, this should be done without resulting in vitamin D deficiency. What are adequate levels of vitamin D? In cardiovascular disease studies, both low and high levels of vitamin D were reported as harmful.5 The effects of vitamin D on several aspects of health are considered most favorable at a serum level of around 70nmol/L (70 nanomoles of vitamin D per liter of blood). This level in the blood depends on very many things such as body mass index, genes, etc. In the US, the Office of Dietary Supplements has established tolerable upper intake levels for vitamin D at 25 mcg/1,000 International Units or IU, for babies under one year old; and 50 mcg/2,000 IU for everyone else. While rare, vitamin D toxicity can cause nausea, weakness, and raised blood levels of calcium, which may lead to mental confusion and heart rhythm problems. Since sunburn can start after a few minutes of unprotected sun exposure, it is safest for fair-skinned people to gain most of their vitamin D by eating vitamin D-rich foods and taking vitamin D supplements in line with recommended daily allowances. For those whose skin almost never burns, who are not “moley,” and who do not have a family history of skin cancer, the message is less clear. Such people should avoid sunburn but make sure they obtain enough vitamin D. Darker-skinned people living in temperate zones must be especially vigilant about taking in enough vitamin D, because the greater amounts of pigment (melanin) in their skin make them less able to produce the vitamin in response to UVB exposure.6 Conclusion Melanoma is not the only reason to practice sun protection, since large doses of sun exposure spread over a long period also accelerate skin aging and increase the risk There is clear evidence that in fair-skinned and “moley” people, holiday sun exposure and sunburn have been resulting in a sustained increase in melanoma incidence. • Avoid excessive sun exposure and sunburn. • Maintain adequate levels of vitamin D without compromising your health. PROFESSOR NEWTON BISHOP is a consultant dermatologist at St. James’s University Hospital in the UK city of Leeds, the head of the melanoma research group within the section of epidemiology and biostatistics at the University of Leeds, and the scientific coordinator of the international melanoma research consortium GenoMEL. PROFESSOR BISHOP is the head of the section of epidemiology and biostatistics within the Leeds Institute of Molecular Medicine at the University of Leeds, UK. PAUL AFFLECK is a project manager with the international melanoma research consortium GenoMEL. References available on p.74. of developing squamous cell carcinoma (a common form of NMSC that kills 2,500 Americans annually). Some combination of intermittent, intense exposure and long-term, cumulative exposure also plays a part in basal cell carcinoma, the most common skin cancer. So, despite a somewhat complicated picture, a clear message can be given: [Editor’s note: The Skin Cancer Foundation advises everyone to use sun protection outdoors and to obtain vitamin D chiefly through food and/or supplements. Adults who practice sun protection or have limited sun exposure may increase their intake of vitamin D to 1,000 IU daily.] 73 INTERNATIONAL References Banning the Tan Around the World (p.63) 1. The history of tanning beds, eHow, http://www.ehow.com/about_4805677_ history-tanning-beds.html 2. Kwon HT, Mayer JA, Walker KK, Yu H, Lewis EC, Belch GE. Promotion of frequent tanning sessions by indoor tanning facilities: two studies. J Am Acad Dermatol 2003; 46:700-5. 3. Demierre MF. Time for the national legislation of indoor tanning to protect minors. Arch Dermatol 2006; 139:520-4. 4. Sunbeds. www.who.int. 24 Mar 2009. http://www.who.int/uv/faq/sunbeds/ en/index.html 5. http://www.procprblog.com/tanning-makes-skin-cancer-the-most-commonform-in-young-women 6. Advocacy. The Skin Cancer Foundation. http://support.skincancer.org/site/ PageServer?pagename=FDA_Dec_2009_Petition 7.Learn if a Medical Device Has Been Cleared by FDA for Marketing, http:// www.fda.gov/MedicalDevices/ResourcesforYou/Consumers/ucm142523.htm 8. Under 18s ‘shouldn’t use sunbeds’. BBC News. 17 March 2005. http://news. bbc.co.uk/2/hi/health/4357689.stm 9.Hope J. Girl, 10, suffers burns on 70% of her body after 16 minutes in coinoperated tanning booth. Mail Online 1 May 2009. http://www.dailymail.co.uk/ health/article-1176167/Girl-10-suffers-burns-70-body-16-minutes-coin-operatedtanning-booth.html 10. Gavin A, Donnely C, Devlin A, et al. Public at risk – a survey of sunbed parlour operating practices in Northern Ireland. British Journal of Dermatology 2010; 162:627-632. http://www.qub.ac.uk/research-centres/nicr/FileStore/PDF/ Filetoupload,184170,en.pdf 11. Sun bed consultation. Environmental Health, Environmental Health Officers’ Association, Department of Health and Children, Dublin 2. http://www.ehoa.ie./ docs/sunbeds0608.doc. 12. 11th ROC: Ultraviolet Radiation Related Exposures. 27 January 2005. U.S. Department of Health & Human Services. 15 April 2008. http://ntp.niehs.nih.gov/ ntp/roc/eleventh/profiles/s183uvrr.pdf 13. Sunbed use as a melanoma time bomb? World Health Organization. www. who.int 24 march 2009. http://www.who.int/uv/faq/sunbeds/en/index5.html 14. El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens — Part D: radiation. WHO International Agency for Research on Cancer Monograph Working Group. The Lancet Oncology 10; August 2009, Special Report: Policy. IARC Monographs. 15. Pleasance ED, Cheetham RK, Stephens PJ, et al. A comprehensive catalogue of somatic mutations from a human cancer genome. Nature 16 December 2009. Advance online publication. http://www.nature.com/nature/journal/vaop/ncurrent/ full/nature08658.html. 16. 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Solarium ban for under-18s and fair-skinned people, New South Wales, Australia. Medical News Today, April 11, 2008. http://www.medicalnewstoday. com/articles/103748.php 28. Restrictions put on solarium users, from Australian Associated Press, May 11, 2009. 29. Stark J. Tanning salons are fading fast. theage.com.au THE AGE June 21 2009, http://www.theage.com.au/national/tanning-salons-are-fading-fast-20090620-crz0. html. 30. Cumberland S, Jurberg C. From Australia to Brazil: sun worshippers beware. Bulletin of the World Health Organization 2009 August; 87(8):574-575. doi: 10.2471/ BLT.09.030809. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2733274 74 31. Canada moves to ban indoor tanning in kids under 18. EmaxHealth. From Canadian Dermatology Association. http://www.emaxhealth.com/1275/66/35364/ canada-moves-ban-indoor-tanning-kids-under-18.html 32. Canadian Dermatology Association homepage. http://www.dermatology.ca/ indoortanning/index.html 33. Morton E, Wighton K. Dying for a tan: Live It campaigns for clampdown after teen sunbed ban in Wales. http://www.thesun.co.uk/sol/homepage/woman/health/ health/2662839/Dying-for-a-tan-Liv... 10/1/2009 34. Public wants ban on sunbeds for under 18s. Cancer Research UK Press Release. Cancer Research UK Thursday 16 July. 2009.http://info.cancerresearchuk.org/news/ archive/pressrelease/2009-07-16-public-want-ban-on-sunbeds-for-under-18s. CLARE’S LEGACY (p.66) 1.Oliver O. A tan to die for. Herald Sun August 23, 2007. http://www.news.com. au/national/a-tan-to-die-for/story-e6frfkx0-1111114248428 2. Solarium ban for under-18s and fair-skinned people, New South Wales, Australia. Medical News Today, April 11, 2008. http://www.medicalnewstoday. com/articles/103748.php 3. Restrictions put on solarium users, from Australian Associated Press, May 11, 2009. 4. Stark J. Tanning salons are fading fast. theage.com.au THE AGE June 21 2009, http://www.theage.com.au/national/tanning-salons-are-fading-fast-20090620-crz0. html. 5. Makin JK, Dobbinson SJ. Changes in solarium numbers in Australia following negative media and legislation. Australian and New Zealand Journal of Public Health 2009; 33:5. 6. Shepherd T. Cancer dangers shut solariums in South Australia. From: The Advertiser October 7, 2009. http://www.news.com.au/national/cancer-dangersshut-solariums-in-south-australia/story-e6frfkx9-1225783559095 7. Australians turn their backs on solariums, ABC News online, Wed. October 7, 2009, http://www.abc.net.au/news/stories/2009/10/07/2706889.htm 8. Shepherd T. Tough regulations for solariums come into force. The Advertiser January 7, 2009, updated March 11, 2010. http://www.adelaidenow.com.au/news/ south-australia/tanning-salons-put-people-at-risk/story-e6frea83-1111118516119. The Road to Group I (p.68) 1. International Agency for Research on Cancer (IARC). Solar and ultraviolet radiation. Monographs on the Evaluation of Carcinogenic Risks to Humans. No. 55. Lyon: International Agency for Research on Cancer; 1992. 2. Rünger TM, Kappes UP. Mechanisms of mutation formation with long-wave ultraviolet light (UVA). Photodermatology, Photoimmunology & Photomedicine 2008; 24:2–10. 3. Ridley AJ, Whiteside JR, McMillan TJ, et al. Cellular and sub-cellular responses to UVA in relation to carcinogenesis. Int J Radiat Biol 2009; 85:177-195. 4. International Agency for Research on Cancer (IARC). Exposure to artificial UV radiation and skin cancer. IARC Working Group Reports No 1. IARC, Lyon; 2006 (freely available at www.iarc.fr). 5. Gandini S, Sera F, Cattaruzza MS, et al. Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer 2005; 41:45–60. 6. International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer 2007; 120(5):1116-1122. Erratum in: Int J Cancer 2007; 120(11):2526. 7. Autier P, Boyle P. Artificial ultraviolet sources and skin cancers: rationale for restricting access to sunbed use before 18 years of age. Nat Clin Pract Oncol 2008; 5(4):178-179. 8. Vajdic CM, Kricker A, Giblin M, et al. Artificial ultraviolet radiation and ocular melanoma in Australia. Int J Cancer 2004; 112:896-900. PM:15386378. 9. El Ghissassi F, Bann R, Starif K, et al. A review of human carcinogens – Part D: radiation. Lancet Oncol 2009; 10(8):751-752. 10. Boniol M, Autier P, Doré JF. Re: A prospective study of pigmentation, sun exposure, and risk of cutaneous malignant melanoma in women. J Natl Cancer Inst 2004; 96(4):335-336. 11. Dal H, Boldemann C, Lindelöf B. Does relative melanoma distribution by body site 1960-2004 reflect changes in intermittent exposure and intentional tanning in the Swedish population? Eur J Dermatol 2007; 17(5):428-434. 12.Héry C, Tryggvadóttir L, Sigurdsson T. A melanoma epidemic in Iceland: possible influence of sunbed use. Am J Epidemiology (2010, in press). Melanoma and Sunny Vacations (p.71) 1. Gandini S, Sera F, Cattaruzza MS, Pasquini P, Picconi O, Boyle P, et al. Metaanalysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer 2005; 41(1):45-60. 2. Chang YM, Barrett JH, Bishop DT, Armstrong BK, Bataille V, Bergman W, et al. Sun exposure and melanoma risk at different latitudes: a pooled analysis of 5700 cases and 7216 controls. Int J Epidemiol 2009; 38(3):814-30. 3. Gudbjartsson DF, Sulem P, Stacey SN, Goldstein AM, Rafnar T, Sigurgeirsson B, et al. ASIP and TYR pigmentation variants associate with cutaneous melanoma and basal cell carcinoma. Nat Genet 2008; 40(7):886-91. 4. Bishop DT, Demenais F, Iles MM, Harland M, Taylor JC, Corda E, et al. Genomewide association study identifies three loci associated with melanoma risk. Nat Genet 2009; 41(8):920-5. 5. Wang TJ, Pencina MJ, Booth SL, Jacques PF, Ingelsson E, Lanier K, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation 2008;117(4):503-11. 6. Clemens TL, Adams JS, Henderson SL, Holick MF. Increased skin pigment reduces the capacity of skin to synthesise vitamin D3. Lancet 1982;1:74-6. N ews fr o m t h e I nternati o na l A D V I S O R Y C O U N C I L International Advisory Council The International Advisory Council, representing 26 countries, supports and guides the Foundation’s mission to implement prevention and detection programs for populations at high risk, to disseminate vital information in many languages, and to conduct and co-sponsor national and international conferences for the medical profession and the general public on this most common cancer. ARGENTINA Hugo Cabrera, MD Patricia Della Giovanna, MD Patricia Dermer, MD Leon Jaimovich, MD Fernando M. Stengel, MD AUSTRALIA Ross Barnetson, MD Robin Marks, MD Wm H. McCarthy, MD, AM., M.Ed AUSTRIA Hubert Pehamberger, MD Klaus Wolff, MD BELGIUM Diane I. Roseeuw, MD Bertrand Richert, MD BRAZIL Cleire Paniago-Pereira, MD CANADA Jason Rivers, MD COSTA RICA Rodolfo Núñez, MD ECUADOR Reuhollah Khozein, MD FRANCE Robert L. Baran, MD Jean-Pierre Cesarini, MD Brigitte Dréno, MD Caroline Robert, MD Nicole Basset-Séguin, MD GERMANY Alina Fratila, MD Claus Garbe, MD Irmtraud Günther-Klamke, MD Eckart Haneke, MD Harald zur Hausen, MD Gerhard Sattler, MD Wilhelm Stolz, MD Luitgard Wiest, MD GREECE Dimitra Dasiou-Plakida, MD Panagiota Emmanouil, MD Andreas Katsambas, MD George N. Sgouros, MD IRELAND Gillian M. Murphy, MD Brigid O’Connell, MD ISRAEL Joseph Alcalay, MD Alejandro Ginzburg, MD Isaac Zilinsky, MD Miriam Ziv, MD ITALY Giorgio Landi, MD Luigi Rusciani Scorza, MD Antonio Tulli, MD JORDAN Laith Akkash, MD SPAIN Francisco Camacho-Martinez, MD Alejandro Camps-Fresneda, MD Julian S. Conejo-Mir, MD Carlos Guillén Barona, MD Miguel Sanchez Viera, MD SWEDEN Ann-Marie Wennberg, MD SWITZERLAND Günter Burg, MD THAILAND Atchima Suwanchinda, MD UNITED KINGDOM Irene Leigh, MD Rona MacKie, MD Lesley E. Rhodes, MD John Hawk, MD Christopher Rowland Payne, MD KUWAIT Sahar Ghannam, MD MEXICO Jorge Ocampo-Canadiani, MD THE NETHERLANDS Rob C. Beljaards, MD Jan M. Werner Habets, MD Kai Munte, MD Hendrik A.M. Neumann, MD Bing Thio, MD PHILLIPINES Sylvia S. Jacinto-Jamora, MD PORTUGAL António Silva Picoto, MD Osvaldo Correia, MD ROMANIA Ana-Maria Forsea, MD 75 LEAdER IN ThE FIGhT The Foundation’s mission is to decrease the incidence of the disease by means of public and professional education, medical training, and research. The Skin Cancer Foundation: Leader in the Fight Against Skin Cancer Since its founding in 1979, The Skin Cancer Foundation has set the standard for educating the public and the medical profession about skin cancer, its prevention by means of sun protection, the need for early detection, and prompt, effective treatment. It is the only international organization devoted solely to combating the world’s most common cancer, now occurring at epidemic levels. Skin cancer is the most common cancer in the world, with more than 13 million cases diagnosed annually. one of every three cancers diagnosed is a skin cancer, and up to 65,161 people die every year from skin cancer. The incidence of melanoma continues to rise at a rate faster than that of any of the seven most common cancers. Each year in the U.S. there are more new cases of skin cancer than the combined incidence of cancers of the breast, prostate, lung and colon. Almost 9,000 people die from melanoma in the U.S. every year. Nonmelanoma cancers such as basal cell carcinoma and squamous cell carcinoma have reached critical levels, with squamous cell carcinoma killing 2,500 people each year. Ninety percent of nonmelanoma skin cancers are associated with exposure to ultraviolet radiation from the sun. A person’s risk for skin cancer doubles if he or she has had five or more sunburns. Just one blistering sunburn in childhood more than doubles a Caucasian’s chances of developing melanoma later in life. however, the incidence of skin cancer can be dramatically 76 reduced through education, behavior modification, and early detection. Skin cancer is primarily a lifestyle disease which is why The Skin Cancer Foundation emphasizes public awareness and education campaigns. puBLIC EduCATION AROuNd ThE WORLd www.SkinCancer.org More than two million visits annually are made to the Foundation’s website. With a #1 ranking on major search engines, the site is the leading patient information resource on skin cancer for millions of people around the world. In addition, SkinCancer.org features skin cancer information in several languages and the Foundation recently launched SkinCancer.com.mx and SkinCancer.ar.com to bring life-saving sun protection and skin cancer information to people in Mexico and latin America. Public Information The Foundation’s educational materials are distributed by dermatologists and at screening clinics, health fairs, and at community wellness programs by nurses, educators and schools. Several retail chains also distribute our sun protection information; millions of brochures, posters, books, newsletters, manuals, public service announcements, and audiovisual materials are distributed annually. SK I N C A NCER FoU N DAT IoN JoU R NA l Media The Foundation is recognized as a major resource on skin cancer for print and electronic media and generates more than 600 million media impressions a year. Coverage of the Foundation and information about skin cancer has been generated on local and national news programs such as Good Morning America and Today, on websites, in magazines from Vogue to TIME, and in newspapers including The New York Times, USA Today and The Wall Street Journal. Coverage of the Foundation’s biannual World Congress on Cancers of the Skin has been secured in Spain, Greece, Argentina, Italy, Israel, and other countries. The Seal of Recommendation for Sun Protection Products As a valuable guide to consumers, the Foundation’s Seal of Recommendation is granted to sun protection products that meet the stringent criteria of an independent Photobiology Committee. One of the first programs offered by the Foundation, it quickly gained acceptance from consumers for setting the standard for effective sun protection with sunscreen products, sunglasses, specially treated auto and residential window film, umbrellas, clothing and laundry products that wash UV protection into clothing. Currently more than 800 products carry the Seal nationally and internationally. Grassroots Program The Foundation’s Road to Healthy Skin Tour is a travelling skin cancer screening and resource center that visits nearly 80 cities in the U.S. and reaches thousands of people annually. The Sunsational Guide to Smart Sun Safety / Fun in the Sun 101 initiative is a children’s education program comprised of both in-school and online components. The Foundation’s public service advertising campaign, Go With Your Own GlowTM, focuses on how tanning is no longer in fashion. The ads have been featured in more than 15 magazines. Research Funding is provided annually for basic research and clinical studies related to skin cancer. Over ninety research grants, totaling almost $1 million, have been awarded since 1981. Advocacy Historically, government funding for research on melanoma and the prevention of skin cancer has been disproportionately low. However, the Foundation, along with the National Council on Skin Cancer Prevention, was successful in securing $4 million for melanoma research from the Department of Defense in 2009. In 2010, the goal is $5 million. Recently, the Foundation has gotten very involved in anti-tanning bed advocacy on the federal level by urging the U.S. Food and Drug Administration to enact stricter tanning bed regulations. International Outreach The Skin Cancer Foundation is committed to stopping skin cancer on a global basis and has been a catalyst for the establishment of skin cancer organizations in many countries. Public education abroad is sponsored by the International Advisory Council, representing 26 countries. The Council supports and guides the Foundation’s mission to implement prevention and detection programs for high risk populations, to disseminate vital information in many languages, and to conduct and co-sponsor national and international conferences for the medical profession and the general public on this most common cancer. The Foundation’s World Congress on Cancers of the Skin has taken its message around the world, providing an opportunity for physicians from many countries to exchange ideas on the prevention, diagnosis, and treatment of skin cancer. The National Council on Skin Cancer Prevention The Council is a coordinating body that seeks to establish a national action agenda on skin cancer. The Skin Cancer Foundation serves as a core member along with the American Cancer Society, the American Academy of Dermatology, the Melanoma Research Foundation and the SHADE Foundation. Inside the Foundation President Perry Robins, MD Corporate Secretary Mitzi Moulds Senior Vice Presidents Rex A. Amonette, MD C. William Hanke, MD Elizabeth Robins, Esq. Deborah S. Sarnoff, MD The Dr. Rex and Johnnie Amonette Circle, formed in 2004 to mark the Foundation’s 25th anniversary, is comprised of physician members who are making a lifetime commitment of support to the Foundation. Professional Members: Members and other distinguished physicians form a network of close to 700 dermatologists, Mohs surgeons, plastic surgeons and residents who play a critical role in the organization’s educational outreach. Corporate Partners: The Corporate Leadership Council works in close partnership with Foundation management to help achieve its mission. The Corporate Council is a larger group of companies that support our mission and are eligible to apply for the Seal of Recommendation. The Skin Cancer Foundation has been honored with the American Academy of Dermatology’s Excellence in Education Award and fourteen Gold Triangle Awards for Community Service. 77 The Skin Cancer Foundation BOARD OF DIRECTORS PHOTOBIOLOGY COMMITTEE EXECUTIVE DIRECTOR President Perry Robins, MD Warwick L. Morison, MB, BS, MD Chairman John H. Epstein, MD Heidi Jacobe, MD Henry W. Lim, MD Steven Q. Wang, MD Mary Stine Senior Vice Presidents Rex A. Amonette, MD C. William Hanke, MD Elizabeth Robins, Esq. Deborah S. Sarnoff, MD Corporate Secretary Mitzi Moulds Vice Presidents Daniel C. Baker, MD Leonard H. Goldberg, MD Allan C. Halpern, MD Susan H. Weinkle, MD ADVISORY Board Anne Akers Mindy Gorman Anand Khubani Kenneth Kolker Anthony P. Leichter Dennis P. Lynch, Esq. Dr. Marcia Robbins-Wilf Axel Stawski Bennett Weiner, Esq. William Wiener PUBLICATIONS EDITORS The Skin Cancer Foundation Journal Pearon G. Lang, Jr., MD Medical Editor The Melanoma Letter Allan C. Halpern, MD Editor-in-Chief Ashfaq A. Marghoob, MD Associate Editor Alfred W. Kopf, MD Consulting Editor Sun & Skin News Ritu Saini, MD Medical Editor RESEARCH GRANTS COMMITTEE Jean-Claude Bystryn, MD Chairman Jeffrey Dover, MD, FRCPC Leonard H. Goldberg, MD David J. Leffell, MD Bijan Safai, MD, DSc DR. MARCIA ROBBINS-WILF AWARDS SOCIETY Clark A. Johnson Steve Laumas Leonard Mazur Dr. Marcia Robbins-Wilf Neil S. Sadick, MD FOUNDATION STAFF Veronica Barlow Assistant Manager of Sponsorship Administration Melissa Colvin Receptionist Steven Estrada Fulfillment Coordinator Susan Henry Web Associate Dan Latore Director of Corporate Partnerships Jo Ann Perrino Executive Assistant Paul Melia Director of New Media Pamela McLaughlin Manager of Corporate Partnerships Elizabeth Michaelson Associate Editor Victoria Moran Assistant Manager of Operations Erin Mulvey Stoeber Director of Communications Jessica Shaffer Director of Development Matt Sheehan Director of Programs Jamie Sylves Communications Manager Mark Teich Executive Editor Evan Watkins Development Associate Steven Q. Wang, MD Medical Editor 78 SK I N C A NCER FOU N DAT ION JOU R NA L Thanks to the efforts of our dedicated staff, board members, donors, and volunteers, 2009 was The Skin Cancer Foundation’s most successful year to date. The American Academy of Dermatology (AAD) acknowledged our fine work in educating the public about sun protection when it presented us with 5 Gold Triangle Awards, which set a record for the number of wins in one year in the Health Community Organization category. With the continued growth of our International Advisory Committee and expanded U.S.-based education programs, we will continue to make progress in combating the world’s most common cancer. PERRY ROBINS, MD President 2010 Research Grants Awarded by The Skin Cancer Foundation The Dr. Patricia Wexler Research Grant Award A one-year, $10,000 grant, for a research project, “DNA Damage-Mediated Sirtuin 1 Inhibition as Novel Survival Mechanism in Skin Cancer” Arianna L. Kim, PhD, Herbert Living Assistant Professor of Dermatology, Columbia University Medical Center, New York, NY. A one-year, $10,000 grant, for a research project, “The Utility of Src-kinase Inhibitors in Preventing the Formation of Precancerous Lesions and Squamous Cell Carcinomas” John T. Seykora, MD Assistant Professor, Department of Dermatology, University of Pennsylvania Medical School, Philadelphia, PA. Funding for these Awards was provided by the Brown Foundation. The Dr. Marcia Robbins-Wilf Research Award A one-year, $10,000 grant, for a research project, “Delivery of Topical siRNAs for the Prevention and Treatment of Squamous Cell Carcinomas and other Skin Cancers” Thanh-Nga Trinh Tran, MD, PhD, Graduate Assistant, Department of Dermatology, Massachusetts General Hospital, Charleston, MA. Funding for this Award was provided by the Dr. Marcia Robbins-Wilf Research Award Society. The Melissa K. Bambino Memorial Award A one-year, $10,000 grant, for a research project, “Determining Benign or Malignant Behavior of Spitzoid Neoplasms Through Deep Molecular Profiling” Arlo Miller, MD, PhD, Resident in Dermatology, Mayo Clinic Rochester, New York. Funding for this Award was provided by the Melissa K. Bambino Melanoma Foundation. The Dr. Alfred W. Kopf Research Grant Award A one-year, $10,000 grant, for a research project, “Role of Immune Modulation and Surveillance in Sentinel Lymph Node Positivity in Melanoma” Farbod Darvishian, MD, Assistant Professor of Pathology, New York University School of Medicine, New York, NY. Funding for this Award was provided by the donors of The Skin Cancer Foundation. The Live Love and Laugh Research Award A one-year, $10,000 grant, for a research project, “Proteomic Characterization of Benign Melanocytic Lesions and Melanoma: A Pilot Study” Adar Berghoff, MD, Chief Resident Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA. Funding for this Award was provided by Mindy Gorman. 80 SK I N C A NCER FOU N DAT ION JOU R NA L The Skin Cancer Foundation Professional Members in 2009 Medical Council Michelle Abadir, MD Rye Brook, NY Steven Franks, MD Weston, MA Richard Miller, MD Port Richey, FL Debra Abell, MD Wexford, PA Bernard Gasch, MD Portland, OR Robert Miller, MD Long Beach, CA Max Adler, MD Dallas, TX Roy G. Geronemus, MD New York, NY Gary D. Monheit, MD Birmingham, AL Kathy Anderson, DO Clearwater, FL Gervaise Gerstner, MD New York, NY Michael Mulvaney, MD Albany, NY Kathleen Behr, MD Fresno, CA Jordana Gilman, MD New York, NY Howard Murad, MD El Segundo, CA Robert S. Berger, MD White Plains, MD Kimberly Grande, MD Knoxville, TN Douglas Naversen, MD Medford, OR Diane Berson, MD New York, NY Dennis Gross, MD New York, NY Mark Nestor, MD, PhD Aventura, FL John Binhlam, MD Brentwood, TN Brian Harris, MD Fort Myers, FL David Orentreich, MD New York, NY Christine D. Brown, MD Dallas, TX Andrew Hendricks, MD Lumberton, NC Diamondis Papadopoulos, MD Atlanta, GA Vivian Bucay, MD San Antonio, TX Alysa R. Herman, MD Miami, FL Kurt Pickus, MD Torrance, CA Katarina Chiller, MD Atlanta, GA Terrance Hopkins, MD Bradenton, FL Gangaram Ragi, MD Teaneck, NJ Elvira Chiritescu, MD Apex, NC Julie Karen, MD New York, NY Heather Rogers, MD Seattle, WA Noel Chiu, MD Antioch, CA Andrew J. Kaufman, MD Thousand Oaks, CA Amy Ross, MD Palm Harbor, FL Anir Dhir, MD Lexington, KY Arielle Kauvar, MD New York, NY Beata Rydzik, MD Portland, OR Patricia A. Dickerson, MD Centerville, OH John Kayal, MD Marietta, GA Michael A. Scannon, MD Tampa, FL Jeanine B. Downie, MD Montclair, NJ Candace King, MD Pinehurst, NC Maral Kibarian Skelsey, MD Chevy Chase, MD N. Fred Eaglstein, DO Orange Park, FL Joseph Kolb, MD Richmond, IN James Spencer, MD St. Petersburg, FL Samuel Ejadi, MD Scottsdale, AZ Kent Krach, MD Clinton Township, MI Margaret Sutton, MD Lincoln, NE Craig Elmets, MD Birmingham, AL James G. Lahti, MD North Brook, IL Leonard J. Swinyer, MD Salt Lake City, UT James O. Ertle, MD Hinsdale, IL Larry Landsman, MD Vero Beach, FL Elizabeth Tanzi, MD Washington, DC John Exner, MD Sterling, IL David Lane, MD Rock Hill, SC Amy Taub, MD Lincolnshire, IL Jessica Fewkes, MD Boston, MA Mark Lebwohl, MD New York, NY Carl Thornfeldt, MD Fruitland, ID Theodore Fotopoulos, MD New Port Richey, FL Eugene Mandrea, MD Palos Heights, IL Michael Tomcik, MD San Ramon, CA Joshua L. Fox, MD Fresh Meadows, NY Michael Margolin, MD Palos Heights, IL Jennifer Walden, MD New York, NY E. William Frank, MD Nashua, NH Robert Marsico, MD Akron, OH Ingrid Warmuth, MD Elmer, NJ Ellen Frankel, MD Cranston, RI Flor Mayoral, MD Coral Gables, FL Scott Warren, MD Jacksonville, FL Linda Franks, MD New York, NY Madhavi Menon, MD Syracuse, NY Karen Weismantle, MD Islamorada, FL 81 The Skin Cancer Foundation Professional Members in 2009, Continued William Welborn, MD Sheffield, AL Jennifer Baron, MD Palo Alto, CA Howard Brooks, MD Washington, DC Gregory Wilmoth, MD Raleigh, NC Frank Barone, MD Toledo, OH Robert Brown, MD Jacksonville, FL Marc Zimbler, MD New York, NY William Baugh, MD Fullerton, CA Richard Brown, MD Medford, MA John Zitelli, MD Pittsburgh, PA David S. Becker, MD New York, NY Gerardo Brual, MD Apache Junction, AZ James H. Beckett, MD Soquel, CA Audrey Bruell, MD Livonia, MI Robert Beer, MD Brentwood, CA Enid Burnett, MD Daytona Beach, FL Frederick R. Behringer, Jr., MD Ocala, FL David Byrd, MD Rochester Hills, MI Daniel Behroozan, MD Santa Monica, CA Francis Caban, MD Brandon, FL Michael Bell, MD Murfreesboro, TN Paul Cabiran, MD Highlands, NC Betty Bellman, MD Miami Beach, FL Valerie Callender, MD Mitcheville, MD Laura Benedict, MD Atlanta, GA Sharon Camden, MD, PhD Glen Allen, VA Edward Benjamin, MD Enfield, CT Daniel Carrasco, MD Austin, TX Richard Berger, MD Somerset, NJ Albert Cattell, MD Ann Arbor, MI Allen Berliner, MD Norwood, MA Alix Charles, MD Hinsdale, IL David Berman, MD Palo Alto, CA Timothy Chartier, MD Farmington, CT Mindy Berstein, MD Plainview, NY Mark Chastain, MD Marietta, GA Judith Arluk, MD Forest Hills, PA Ashisha Bhatia, MD Naperville, IL Tommy Chen, MD Pasadena, CA Alan Arnold, MD Las Vegas, NV Rajiv Bhatnager, MD Redwood City, CA Thomas Chin, MD New York, NY Arash Asadi, MD Houston, TX Renuka Bhatt, MD Burr Ridge, IL Lisa Chipps, MD Los Angeles, CA Robert Ash, MD Dothan, AL Joseph Bikowski, MD Sewickley, PA Susan Chon, MD Houston, TX Anna Asher, MD Flowood, MS Carey Bligard, MD Fort Dodge, IA William Chow, MD San Leandro, CA Robin Ashinoff, MD Hackensack, NJ David Blum, MD Canton, MI Sabatino Ciatti, MD Westfield, NJ James Auerbach, MD Santa Fe, NM Jennifer Boldrick, MD Redwood City, CA C. Drew Claudel, MD Goodlettsville, TN Gary Augter, MD McAlester, OK Barbara Bopp, MD Metairie, LA Mark Cleveland, MD West Burlington, IA Robert Aylesworth, MD Rhinelander, WI John Boyer, MD Honolulu, HI Missy Clifton, MD Bentonville, AR Haleh Bakshandeh, MD Beverly Hills, CA Robert Breedlove, MD Stillwater, OK Joel L. Cohen, MD Englewood, CO Joseph P. Bark, MD Lexington, KY Mitchell Bressack, MD Crown Point, IN Kendra Cole, MD Duluth, GA Louis Barich, MD Hamilton, OH Gregory Bricca, MD El Dorado, CA Lewis Collins, Jr., MD Savannah, GA Walter Barkey, MD Flint, MI Bruce Brod, MD Lancaster, PA Coyle Connolly, DO Linwood, NJ Fellow Mark Abdelmalek, MD Philadelphia, PA Glynis Ablon, MD Manhattan Beach, CA Neera Agarwal-Antal, MD Hudson, OH Shino Bay Aguilera, DO Fort Lauderdale, FL Murad Alam, MD Chicago, IL Corie Alford, MD Atlanta, GA Dima Ali, MD Reston, VA Jeffrey Altman, MD Arlington Heights, IL David Amato, MD Harrisburg, PA Prapand Apisarnthanarax, MD Webster, TX 82 SK I N C A NCER FOU N DAT ION JOU R NA L Michael Contreras, MD Albuquerque, NM Adolfo Fernandez-Obregon, MD Hoboken, NJ Bruce Gordon, MD Hyannis, MA Gregory Cox, MD Atlanta, GA Edgar Fincher, MD Los Angeles, CA Annalisa Gorman, MD Seattle, WA Marguerite Critelli, MD Newport Beach, CA Helen Fincher, MD Los Angeles, CA Sanjiva Goyal, MD Ponte Vedra Beach, FL Lynora Curtis, MD Lake Worth, FL David Finkelstein, MD Vorhees, NJ Gloria Graham, MD Morehead City, NC Peter S.C. d’Aubermont, MD Atlanta, GA Steven Fishman, MD Monticello, NY James Graham, MD Pine Knoll Shores, NC Doris Day, MD New York, NY Diane Ford ,MD Frederick, MD Deetta Gray, MD Bellevue, WA James Del Rosso, DO Henderson, NV Peter Ford, MD Santa Barbara, CA Steven Greenbaum, MD Philadelphia, PA Gloria D’Hue, MD Atlanta, GA Rutledge Forney, MD Atlanta, GA H. L. Greenberg, MD Las Vegas, NV Anna Di Nardo, MD, PhD San Diego, CA Jayne Fortson, MD Anchorage, AK David Greenstein, MD Andover, MA Lynn Dimino, MD Newport Beach, CA John Fox, MD Austin, TX James M. Grichnik, MD Miami, FL Danya Diven, MD Austin, TX Joyce Fox, MD Beverly Hills, CA Ned Gross, MD Greensboro, NC Melissa Dixon, MD Hazlet, NJ Kathryn Frew, MD New York, NY Esti Gumpertz, MD Mayfield Heights, OH Glenn Dobecki, MD South Weymouth, MA Bruce E. Fuller, MD Newport News, VA Richard Gunning, MD Beltsville, MD J. Lawrence Dohan, MD Hudson, MA Bruce W. Fuller, MD Bradenton, FL Christopher Ha, MD Roseville, CA Susan Dozier, MD Austin, TX Mark Garcia, MD New Braunfels, TX Monica Halem, MD New York, NY Kristina Duffin, MD Salt Lake City, UT Jorge Garcia-Zuazaga, MD Cleveland, OH Russel Harris, MD Atlanta, GA H. Michael Duke, MD Dayton, OH Sharon Gardepe, MD Huntsville, AL Nicole Hartsough, MD Loves Park, IL Deason Dunagan, MD Huntsville, AL Claudia Gaughf, MD Savannah, GA Karen Hastings, MD, PhD Phoenix, AZ Jeff Eaton, MD San Diego, CA Bryon Gaul, MD Spencer, IA Patrick Hatfield, MD Batesville, AR Michael Ebertz, MD Burnsville, MN Susanne L. Gee, MD Seattle, WA Adrianne Haughton, MD Long Beach, NY Christine Egan, MD Media, PA Shelly Gibbs, MD Houston, TX Sarah Haydel, MD Houma, LA Khaled El-Hoshy, MD Livonia, MI Erik Gilbertson, MD La Mesa, CA Benjamin Hayes, MD Spring Hill, TN Merrick Elias, MD Hollywood, FL Scott Glazer, MD Buffalo Grove, IL Laura Haygood, MD Tyler, TX Darrel Ellis, MD Nashville, TN Ronald Glick, MD Mesa, AZ Harley Haynes, MD Boston, MA Jeffrey Ellis, MD Jericho, NY Hugh Gloster, Jr., MD Cincinnati, OH Adelaide Herbert, MD Houston, TX Rebecca Euwer, MD Dallas, TX Mona Gohara, MD Woodbridge, CT James Herndon, Jr., MD Dallas, TX Jeffrey Evanson, MD Duluth, MN Roger Golomb, MD Clearwater, FL Howard Hines, MD Salisbury, MD Adrienne Feasel, MD Austin, TX Virnalisis Gonzalez, MD San Antonio, TX Lisa Hitchens, MD Houston, TX Lori Fedoronko, MD Troy, MI Susan Goodlerner, MD Torrance, CA Pamela Hite, MD Newport Beach, CA Brian Feinstein, DO Delray Beach, FL Anita Goodrich-Licata, MD South Burlington, VT Alfred Hockley, MD Live Oak, TX 83 The Skin Cancer Foundation Professional Members in 2009, Continued Sharon Hrabovsky, MD McMurray, PA Lynn Klein, MD Wynnewood, PA Emmanuel Loucas, MD New York, NY Jeffrey Hsu, MD Naperville, IL Jay Klemme, MD Strongsville, OH Mary Lupo, MD New Orleans, LA Larry Hudson, MD Johnson City, TN Todd Knapp, MD Springfield, OR Frederick A. Lupton, MD Greensboro, NC Allison Hughes, MD Mercer Island, WA Brett Kockentiet, MD Dublin, OH Frederick F. Lykes, MD Victoria, TX Kimberly Hurvitz, MD Santa Barbara, CA Robert Kolbusz, MD Downers Grove, IL Megan Machuzak, MD Paradise Valley, AZ Edward Hurwitz, MD Houston, TX Stephen Kovacs, MD Brighton, MA Albert MacKenzie, MD Encino, CA William James, MD Philadelphia, PA Avery Kuflik, MD Toms River, NJ Stephanie A. Mackey, MD Lancaster, PA Farhana Jan, MD Boston, MA Ann LaFond, MD Canton, MI Diane C. Madfes, MD New York, NY Anthony Janiga, MD Naperville, IL Kathy Laing, MD Ann Arbor, MI Erick Mafong, MD Chula Vista, CA Shang I. Brian Jiang, MD La Jolla, CA David Lambert, MD Columbus, OH Diane Maiwald, MD Huntington Station, NY Kay Johnston, MD San Angelo, TX Maeran Landers, MD Tualatin, OR Heidi Mangelsdorf, MD Cary, NC Kastas Jucas, MD Chicago, IL Richard Lanthrope, MD Warren, NJ Christine Marcuson, MD Newport News, VA Karen Kade, MD Miami, FL Christine Law, MD Marietta, GA Kenneth Mark, MD Southampton, NY Ralph M. Kamell, MD Thousand Oaks, CA Deirdre Leake, MD St. Augustine, FL Donna Bilu Martin, MD Miami Beach, FL Sherri Kaplan, MD Ardsley, NY Stanton Lebouitz, MD York, PA Louise Martin, MD Warren, MI Gary Karakanishan, MD Sea Girt, NJ Brian Lee, MD New Orleans, LA Sandy Martin, MD Boca Raton, FL Cheryl Karcher, MD New York, NY Meeyoung Lee, MD Boston, MA Marlene Mash, MD Plymouth, PA Brian Katz, MD Miami, FL Eyal Levit, MD Brooklyn, NY D. Neal Mastruserio, MD Columbus, OH Mandeep Kaur, MD, MS Greensboro, NC Stephan Levitt, MD St. Petersburg, FL Patricia McCormack, MD Staten Island, NY Mary Kegel, MD Lancaster, PA Elie Levy, MD Seattle, WA Michael McCracken, MD Denver, CO Sharon Kelly, MD Bellevue, WA Michelle Lewis, MD Pawtuchet, RI Mark McCune, MD Overland Park, KS Daniel Kenady, MD Lexington, KY Wennie Liao, MD Soquel, CA William McDaniel, MD Lexington, KY Holly Kerr, MD Troy, MI Katherine Lim, MD Chandler, AZ Harrison McDonald, MD Encinitas, CA ViKram Khanna, MD Woodstock, IL Allison Linquist, MD Elkridge, MD Caren Mikesh, MD Naples, FL Amy Kim, MD Atlanta, GA Judith Lipinski, MD Grosse Point, MI Indira Misra-Higgins, DO Beverly Hills, MI Caroline Kim, MD Boston, MA Keith Llewellyn, MD Santa Barbara, CA Christopher Moeller, MD Wichita, KS Don King, MD Whittier, CA Jason Lockridge, MD Bessemer, AL Brent Moody, MD Nashville, TN John Kinney, MD West Palm Beach, FL Norman Lockshin, MD Silver Spring, MD Meena Moosavi, MD Livonia, MI Paul Klas, MD Tualatin, OR Gwyn Londeree, MD Columbus, OH Janice F. Moranz, MD Albuquerque, NM 84 SK I N C A NCER FOU N DAT ION JOU R NA L Kelli Morgan, MD Bardstown, KY Harvey Penzinger, MD Boca Raton, FL Heather Roberts, MD Los Angeles, CA Kevin Mott, MD Honolulu, HI Jose E. Peraza, MD Claremont, NH Timothy Rodgers, MD Frisco, TX Kurt Mueller, MD La Crosse, WI Marina Peredo, MD Smithtown, NY Ana Rodriguez, MD San Marcos, TX Mark Naylor, MD Live Oaks, TX Charles Perniciaro, MD Jacksonville, FL Cynthia Rogers, MD Stuart, FL Kishwer Nehal, MD New York, NY Angela Peterman, MD Annapolis, MD Michael J. Rogers, MD Sebring, FL Christopher Nelson, Sr., MD St. Petersburg, FL Gerald Peters, MD Bend, OR Timothy Rosio, MD El Dorado, CA Kelly Nelson, MD Durham, NC James Petrin, MD Woodinville, WA Amy Ross, MD Palm Harbor, FL Ronald Nelson, MD Murfreesboro, TN John Pfenninger, MD Midland, MI Richard Rudnicki, MD Mesquite, TX Jessica Newman, MD, MPH New York, NY Kevin Pinski, MD Chicago, IL Bruce M. Saal, MD Los Gatos, CA Hank Nichamin, MD Schaumburg, IL George Poggioli, MD Centennial, CO Julia Sabetta, MD Greenwich, CT Thomas D. Nichols, MD Houston, TX Robert Polisky, MD Elk Grove Village, IL Ritu Saini, MD New York, NY Robert Norman, DO Tampa, FL Jeffrey Pollak, MD Huntingdon Valley, PA F. Paul Sajben, MD Chico, CA Christopher Norwood, MD New Britain, CT Leah Press, MD Fresno, CA Stacy Salob, MD New York, NY Janna Nunez-Gussman, MD Beaumont, TX Mark A. Price, MD Houston, TX Anita Saluja, MD Melbourne, FL Peter Odland, MD Seattle, WA Emily Prosise, MD Austin, TX Harry Saperstein, MD Beverly Hills, CA Michael O’Donoghue, MD Boulder, CO Janet H. Prystowsky, MD New York, NY Kathleen Sawada, MD Lakewood, CO David C. Olansky, MD Atlanta, GA Irene Questra, MD Miami, FL Dwight Scarborough, MD Dublin, OH Jesse Olmedo, MD Scottsdale, AZ Daniel Rabb, MD Gainesville, GA Jennifer Sceppa, MD Lancaster, PA Richard Ort, MD Lone Tree, CO Vicki Rappaport, MD Beverly Hills, CA Lori Schaen, MD Atlanta, GA Rebekah Oyler, MD Raleigh, NC Ronald Reece, MD Redding, CA Brent Schillinger, MD Boca Raton, FL Dimitry Palceski, MD Orlando, FL Charles Reed, MD Hickory, NC Erin Schoor, MD Huntington Station, NY Susan Pardee, MD Chandler, AZ Louis C. Rehlen, MD Santa Ana, CA Neal B. Schultz, MD New York, NY Anna Pare, MD Atlanta, GA Andrew Ress, MD Boca Raton, FL Keith Schulze, MD Sugarland, TX Kimberly Parham, MD Texarkana, TX Blas Reyes, MD Miami, FL Donald Scott, MD Palm Springs, CA William Parsons, MD Live Oak, TX Melissa Reyes-Merin, MD Sacramento, CA Riddell Scott, MD Memphis, TN Steven Partilo, MD South Burlington, VT Donald Richey, MD Chico, CA Alan Alexander Semion, MD Roseville, CA Carolyn Pass, MD Baltimore, MD Jennifer Ridge, MD Middletown, OH Charles Sevadjian, MD San Diego, CA Vikas Patel, MD Raleigh, NC Hal Ridgeway, MD West Palm Beach, FL Jessica Severson, MD Batavia, NY David Pegouski, MD Livonia, MI Christopher Robb, MD Spring Hill, TN Pramod Sharma, MD Salt Lake City, UT Michelle Pelle, MD San Diego, CA Elisa M. Roberts, MD Asheville, NC Toby Shawe, MD Wyndmoor, PA 85 The Skin Cancer Foundation Professional Members in 2009, Continued Richard H. Shereff, MD Fayetteville, NC Yardy Tse, MD Encinitas, CA George Woodbury, Jr., MD Cordova, TN Sherry Shieh, MD New York, NY Felix Urman, MD Brooklyn, NY Courtney Woodmansee, MD Memphis, TN Elisabeth Shim, MD Santa Monica, CA J. Nicholas Vandermoer, MD Hyannis, MA David Sire, MD Fullerton, CA Frank Victor, MD Manasquan, NJ Diedre Woods, MD Philadelphia, PA Boyd Skinner, MD Pensacola, FL Kimberly Dawn Vincent, MD Nashville, TN Steven Skinner, MD Cullman, AL John Vine, MD Princeton, NJ David Smack, MD Chestertown, MD Peter Vitulli, DO Jupiter, FL Cameron Smith, MD Greenville, NC Mark Waldman, MD Louisville, KY Sam Smith, DO Mesa, AZ Michael Warner, MD Frederick, MD Sidney Smith, MD Kennewick, WA Carl Washington, Jr., MD Atlanta, GA Kimberly Soderberg, MD Newport News, VA John Watson, MD Hollis, NH Vipal Soni, MD Fountain Valley, CA Debra Wattenberg, MD New York, NY Kerrie Spoonemore, MD Seattle, WA Bill Way, DO Duncanville, TX Karen Sra, MD Webster, TX Jeffrey Weaver, DO Monroeville, PA Jon Starr, MD Palo Alto, CA Amy Wechsler, MD New York, NY Jennifer Stein, MD New York, NY James Weintraub, MD Westlake Village, CA Daniel Stewart, MD Parma, OH Margaret Weiss, MD Hunt Valley, MD Robert Strimling, MD Las Vegas, NV Robert Weiss, MD Hunt Valley, MD Tina Suneja, MD Centennial, CO John Werber, MD Brooklyn, NY William Engstrom, PA High Point, NC W. Patrick Teer, MD Jackson, TN Morris Westfried, MD Brooklyn, NY Jodi Logerfo, NP New York, NY John A. Thompson, Jr., MD Charlotte, NC Jeffrey Whitworth, MD West Patterson, NJ Alison Pruim, PA-C Puyallup, WA Sidney Thompson, MD Fayetteville, NC Scott Wilhelmus, MD Bloomington, IN Sheri Rolewski, NP Washington, PA Stacy Thurber, MD Fullerton, CA Marlene D. Willen, MD Cleveland, OH William Ting, MD San Ramon, CA Andrea Willey, MD Sacramento, CA Huntley Sanders, PA-C Macon, GA Michael Todd, MD Lansdowne, VA John Williams, MD Summit, NJ Carol Trakimas, MD Raleigh, NC Mark Willoughby, MD San Diego, CA Linh Tran, MD Atlanta, GA B. Dale Wilson, MD Hamburg, NY Robin Travers, MD Chestnut Hill, MA Isabelle Wilson, MD New York, NY Leonid Trost, MD Jupiter, FL Diedre Wood, MD Philadelphia, PA 86 Carol Woody, MD Greensboro, NC Douglas Woseth, MD Salt Lake City, UT Robert Wright, MD Wheat Ridge, CO Elisa Yoo, MD Los Alamitos, CA Joseph Zaladonis, MD Bethlehem, PA Larissa Zaulyanov-Scanlan, MD Delray Beach, FL Ibrahim Zayneh, MD Portsmouth, OH Nathalie Zeitouni, MD Buffalo, NY Kathryn Zeoli, MD Pembroke Pines, FL Jay Zimmerman, MD Palo Alto, CA AFILIATE Joan Csaposs, NP Albany, NY Graciette Da Silva, PA Bristol, RI Susan Schooler, PA-C West Des Moines, IA Brenda Wieseler Kansas City, MO SK I N C A NCER FOU N DAT ION JOU R NA L ® The Skin Cancer Foundation would like to thank these companies for supporting The Skin Cancer Foundation Journal. 87 The Skin Cancer Foundation Honors The Dr. Rex and Johnnie Amonette Circle The Dr. Rex and Johnnie Amonette Circle is a lifetime membership group comprised of physicians who make an outstanding commitment to The Skin Cancer Foundation’s mission and programs. Indicates new member Rex Amonette, MD Johnnie Amonette Dale M. Abadir, MD Shawn Allen, MD Darrick Antell, MD Daniel C. Baker, MD David E. Bank, MD Jay Barnett, MD Leonard Dzubow, MD Robin Friedman, MD Francesca Fusco, MD Pierre M. George, MD Michael H. Gold, MD David J. Goldberg, MD Leonard H. Goldberg, MD Robert H. Gotkin, MD Bruce E. Katz, MD Leon H. Kircik, MD David J. Leffell, MD Albert M. Lefkovits, MD Jennifer L. Linder, MD Joseph Masessa, MD Ronald L. Moy, MD Margaret E. Olsen, MD Daniel M. Siegel, MD Ronald J. Siegle, MD Stephen N. Snow, MD John R. Steinbaugh, MD Michael W. Steppie, MD Domenico Valente, MD Susan H. Weinkle, MD William A. Steele, MD Amonette Circle members pledge a minimum of $25,000 to the Foundation. Benefits of membership in this prominent group are: • Local and national media opportunities • Exclusive opportunity to serve as the expert in the “Ask the Expert” column on the homepage of the Foundation’s website and in the Sun & Skin News newsletter • Premier recognition in the annual Skin Cancer Foundation Journal 88 • Special recognition on the Foundation’s website and on the Physician Finder service with photo, biography, and link to practice website • One complimentary ticket to The Skin Sense Award Gala • Listing on the Foundation’s official letterhead • 1,000 free patient education brochures SK I N C A NCER FOU N DAT ION JOU R NA L Craig S. Birkby, MD Michele S. Green, MD Norman A. Brooks, MD Forrest C. Brown, MD Karen E. Burke, MD Roger I. Ceilley, MD Maribeth Chitkara, MD Brian Cook, MD Robert Durst, Jr., MD Elizabeth K. Hale, MD Allan C. Halpern, MD C. William Hanke, MD William Heimer, MD Amy Huber, MD John Huber, MD Evelyn Jones, MD Perry Robins, MD Steven M. Rotter, MD Neil S. Sadick, MD Deborah S. Sarnoff, MD Ariel Ostad, MD Maritza I. Perez, MD Harold S. Rabinovitz, MD William P. Werschler, MD Patricia Wexler, MD Ronald G. Wheeland, MD Bryan C. Schultz, MD Please keep in mind that patient donations and/or foundation grants made in your honor can be credited towards your Amonette Circle pledge. For more information on the Amonette Circle, please contact the Development Office by phone at 212-725-5176, or by email at [email protected]. 89 The Skin Cancer Foundation 2009 Donors Founders $100,000+ Beiersdorf, Inc. AVEENO® Lita Annenberg Hazen Foundation Rite Aid Corporation Sephora USA, Inc. Leaders: $50,000 - $99,999 Columbia Sportswear Company DUSA Pharmaceuticals Johnson & Johnson Beauty Care Kao Brands Company The Procter & Gamble Company Schering-Plough HealthCare Products, Inc. Vision-Ease Lens Benefactors: $25,000 - $49,999 Bare Escentuals Bekaert Specialty Films Clinique Inc. Dowell Group Elizabeth Arden F. M. Kirby Foundation, Inc. Garnier Nutritioniste Graceway Pharmaceuticals Jafra Cosmetics Intl. Kenneth and Anne Griffin Foundation Mary Kay Niadyne, Inc. The Rona Jaffe Foundation Shiseido Cosmetics America Ltd. 90 Patrons: $10,000 - $24,999 3M Company Allergan, Inc. Allure Arizona Sunwash, LLC Atico International USA The Brown Foundation, Inc. Coca Cola Colorescience Condé Nast Cosmo International CPFilms Ellis Family Foundation Energizer Personal Care Estée Lauder Companies, Inc. Excito Ltd. Fischer Pharmaceuticals Frito-Lay Galderma USA Glen Raven Custom Fabrics Mindy Gorman Gotham, Inc. Groupe Clarins The Hain Celestial Group Hearst Iredale Mineral Cosmetics JGR Copa, LLC Kimberly-Clark Kenneth Kolker Foundation Lancôme LensCrafters L’Oreal Paris Dermo-Expertise L’Oreal USA, Inc. Mana Robert & Lauren Manning MD Formulations Meredith Corporation Murad Nissan Soap Co., Ltd. Obagi Medical Products Pearle Vision Pharma Cosmetix Research Phoenix Brands LLC Publicis NY Dr. Marcia Robbins-Wilf Rohto Pharmaceuticals Sears Optical Skin Effects by Dr. Jeffrey Dover SunSetter Products Time, Inc. Valeant Pharmaceuticals Vichy International SK I N C A NCER FOU N DAT ION JOU R NA L Sponsors: $5,000 - $9,999 American Greetings Avon Products, Inc. DDF - Doctors Dermatologic Formula DSM Nutritional Products, Inc. ECRM I Hate Cancer Foundation, Inc. La Roche-Posay The Litwin Foundation, Inc. Macy’s, Inc. Majestic Drug Company, Inc. Marc USA Melissa K. Bambino Foundation MerchSource, LLC Roger Michaels NACDS Foundation Pierre Fabre Dermo-Cosmetique USA Robin and Bob Paulson Charitable Fund The Sadie & Louis Roth Foundation, Inc. Sanofi-Aventis Dermatology/Dermik Maxine Shegog Todd Nagel Open / Linda Nagel Wallaroo Hat Company Woodbourne Foundation, Inc. Contributors: $2,000 - $4,999 Alberto Culver Dr. and Mrs. Rex Amonette BASF Corporation Beth Israel Deaconess Medical Center The Bobby McCann Memorial Golf Tournament BTC Innovations LLC Conair Corporation Elle Frederick Loewe Foundation, Inc. Fusion Brands Inc. Glaceau Gordon Flournoy Charitable Lead Annuity Trust Arnold Greenberg The Hershey Company Aurelia Lewis LVMH Perfumes & Cosmetics William Matteson Michael Moffett PCA SKIN Redbook Magazine William Scroggie Simon & Eve Colin Foundation, Inc. Spectrum Printing and Lithography Co. Star Magazine StoreBoard Media, LLC Tyco International, Ltd. Vertra, Inc. Vix Swimwear Friends: $500 - $1,999 Abby & George O’Neill Trust Anne Akers AMA Laboratories, Inc. Mr. & Mrs. James Averill Daniel C. Baker, MD Belair Instrument Company, Inc. Birdie Day Spa Boehringer Ingelheim USA Corporation Centex Materials, LLC Norma Cohen The Craig R. and Julie N. Oechsel Charitable Fund Daymon Worldwide Inc. DBA South Side The Dennis Neely Memorial Fund The Detleff Bolthoff Memorial Fund The Diamondston Foundation, Inc. Jeanine B. Downie, MD Drug Store News Audrey Gerson John Gleason, MD Daniel Green Mr. & Mrs. Leonard Gryn John & Elaine Hayes Laurie Jacoby Jean & Henry Pollak Foundation The Jewish Communal Fund Kevin Johnson The Juliet Rosenthal Foundation, Inc. Frank Keane Latina Media Ventures MillerCoors Mirabel Promotions, Ltd. Sheila Natbony O, The Oprah Magazine Office Automation System Sean O’Halloran Karen Oliver John O’Malley Kathy O’Malley Optima Sun Lab Ltd. David Orentreich, MD The Patricia Ann & Robert D. English Fund Peck Family Foundation Pharmavite, LLC Pierre Fabre Dermo-Cosmetique USA Diane Riley Perry Robins, MD Ronald & Lillie Ades Foundation Inc. Sacramento Area Mustang Club Paul & Christine Scheele Shape Magazine Roderick M. Sherwood, III Skinfo, LLC Students With a Purpose Swap Robert I. Toussie James M. Webster Westwood College Online Marc Zimbler, MD 91 Corporate Leadership Council The Skin Cancer Foundation gratefully acknowledges the leadership role of AVEENO® Beiersdorf Inc. Garnier Nutritioniste Limited Brands P&G Beauty Rite Aid Corporation Schering-Plough HealthCare Products, Inc. Sephora USA Inc. Their support and counsel will enable the Foundation to develop strategies with a powerful and effective impact on reducing the incidence of skin cancer, a disease that has reached epidemic proportions. 92 SK I N C A NCER FOU N DAT ION JOU R NA L U.S. Corporate Council International Corporate Council 3M Company Allergan Skin Care AMBI AVEENO Banana Boat Bare Escentuals Bath & Body Works Beiersdorf, Inc. Bekaert Specialty Films, LLC BTC Innovations Clinique Colorescience Columbia Sportswear Company Coolibar, LLC Coppertone Lenses CPFilms, Inc. DDF (Doctor’s Dermatologic Formula) Eagle Vision Sun Defense Elizabeth Arden Galderma Laboratories Garnier Nutritioniste Glen Raven, Inc. Groupe Clarins Guardian Industries Corp. Hain Celestial Group Hawaiian Tropic Iredale Mineral Cosmetics Jafra Cosmetics International Jergens JGR Copa, LLC Johnson’s Baby La Roche-Posay Lancôme USA Lubriderm L’Oréal Paris Dermo-Expertise Mary Kay Inc. MD formulations NIA24 NO-AD Obagi Medical Products Ocean Potion PCA Skin Phoenix Brands, LLC Physicians Formula, Inc. Priori The Procter & Gamble Company PURPOSE Rio Brands Rite Aid Corporation Schering-Plough HealthCare Products, Inc. Sephora USA Shiseido Cosmetics America Ltd. Skin Effects by Dr. Jeffrey Dover Solar Protective Factory SunSetter Products L.P. Therapeutix by dr luftman Valeant Pharmaceuticals International Vertra, Inc. Vichy Laboratoires Vision-Ease Lens 3M Company Bare Escentulas Banana Boat Bel Star Columbia Sportswear Company Elizabeth Arden Fischer Pharmaceuticals, Ltd. Glen Raven, Inc. Hawaiian Tropic Iredale Mineral Cosmetics Jafra Cosmetics International, Inc. Labo Cosprophar AG Lacer S.A. Mary Kay Inc. Nissan Soap Co., Ltd. Obagi Medical Products O’Neill Wetsuits Perrigo Israel Procter & Gamble ANZ Rohto Pharmaceuticals Yanbal (Unique) 93 Seal of Recommendation U.S. Sunscreens/Moisturizers/Cosmetics Alba Botanical AMBI American Girl AVEENO Banana Boat Bare Escentuals Cetaphil Clarins Clinique C.O. Bigelow Colorescience Coppertone DDF (Doctors Dermatologic Formula) Elizabeth Arden Eucerin Garnier Nutritioniste Hawaiian Tropic Iredale Mineral Cosmetics Jafra Cosmetics Jergens Johnson’s Baby Kinerase Lancôme La Roche-Posay L’Oréal Paris Dermo-Expertise Lubriderm Mary Kay MD Formulations MD Forte/Allergan Skin Care NIA24 NO-AD Obagi Medical Products Ocean Potion Olay PCA SKIN Physicians Formula Priori Pure Simplicity 94 PURPOSE Rite Aid Shiseido Cosmetics Skin Effects by Dr. Jeffrey Dover Therapeutix by Dr. Luftman True Blue Spa Vertra Victoria’s Secret UV Fabric Protection Sun Guard UV Fabric/Umbrellas/ Awnings Coolibar JGR Copa Rio Brands Sunbrella Brand Fabrics Sunsetter Sun Protective Clothing Boy Scouts of America BTC Innovations Coolibar Columbia Sportswear O’Neill Wetsuits Solar Protective Factory SPF Sunglasses Coolibar Coppertone Lenses Eagle Vision Sun Defense UV Film 3M UV Films CPFilms SolarGard and Panorama UV Glass ClimaGuard SPF – Guardian Industries INTERNATIONAL Sunscreens/Moisturizers/Cosmetics Banana Boat Bare Escentuals Bel Star Careline Skingard Dr. Fischer Elizabeth Arden Hawaiian Tropic Iredale Mineral Cosmetics Jafra Cosmetics Labo Lacer Mary Kay Obagi Medical Products Orezo – Rohto Pharmaceuticals Olay Vichy Yanbal (Unique) UV Fabric Protection Nissan Soap Co, Ltd UV Fabric/Umbrellas/Awnings Sunbrella Brand Fabrics Sun Protective Clothing Columbia Sportswear O’Neill Wetsuits UV Film 3M UV Films To view a complete list of products that currently carry the Seal of Recommendation, please visit www.SkinCancer.org/seal SK I N C A NCER FOU N DAT ION JOU R NA L Highlights from The Skin Cancer Foundation’s 2009 Events 1 2 4 5 7 6 8 1 CELEBRATING OUR MEMBERS… The Dr. Rex and Johnnie Amonette Circle members: Ronald L. Moy, MD; Leonard H. Goldberg, MD; Deborah S. Sarnoff, MD; Perry Robins, MD, Johnnie Amonette, Rex A. Amonette, MD; Albert M. Lefkovits, MD; Karen E. Burke, MD; Neil S. Sadick, MD; Michael H. Gold, MD; Robert H. Gotkin, MD; Shawn Allen, MD. Back row from left to right: Allan C. Halpern, MD; Jay Barnett, MD; Steven M. Rotter, MD; Robert Durst, MD; Jennifer L. Linder, MD; William Heimer, MD; Amy Huber, MD and John Huber, MD. 3 FUNDING RESEARCH… 9 5 Perry Robins, MD, speaks at the Foundation’s Skin Cancer in Skin of Color press event. 6 The Skin Cancer Foundation’s Diversity Task Force: Mona A. Gohara, MD, Perry Robins, MD, Ivis Febus-Sampayo, and Maritza I. Perez, MD. FUNDRAISING… 7 Maribeth Bambino Chitkara, MD, Founder of the Melissa Fund, kicks off the 5th Annual Sun Run benefitting The Skin Cancer Foundation. 2 The Skin Cancer Foundation’s Executive Director, Mary Stine and Research Grants Committee Chairman, Jean-Claude Bystryn, MD. 8 The start of the 5th Annual Melissa Fund Sun Run in New York City’s Riverside Park. 3 Dr. Marcia Robbins-Wilf presents a $10,000 research grant to James E. Cleaver, PhD. 9 Dear friend and supporter of The Skin Cancer Foundation, Johnnie Amonette toasts Perry Robins, MD, at the Foundation’s 30th anniversary celebration. MEDIA OUTREACH… 4 Allison Slater, VP of Sephora Retail Marketing, welcomes top health and beauty editors to the Foundation’s “Your Skin — All Day, Everyday” press event. THIRTY YEARS OF ACHIEVEMENTS… 95 References Melanoma Screening Saves Lives (p.23) 1. American Cancer Society: Cancer facts & figures 2009. American Cancer Society Atlanta, GA. 2009. 2. Wolff T, Tai E, Miller T. Screening for skin cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 150:194-8. 3. Brady MS, Oliveria SA, Christos PJ, et al: Patterns of detection in patients with cutaneous melanoma. Cancer 2000; 89:342-347. 4. McPherson M, Elwood M, English DR, et al: Presentation and detection of invasive melanoma in a high-risk population. J Am Acad Dermatol 2006; 54:783-792. 5. Carli P, De Giorgi V, Palli D, et al: Dermatologist detection and skin self-examination are associated with thinner melanomas: results from a survey of the Italian Multidisciplinary Group on Melanoma. Arch Dermatol 2003; 139:607-612. 6. Berwick M, Begg CB, Fine JA, et al: Screening for cutaneous melanoma by skin self-examination. J Natl Cancer Inst 1996; 88:17-23. 7. Carli P, De Giorgi V, Palli D, et al: Self-detected cutaneous melanomas in Italian patients. Clin Exp Dermatol 2004; 29:593-596. 8. Arnold MR, DeJong W: Skin self-examination practices in a convenience sample of US university students. Prev Med 2005; 40:268-273. 9. Kantor J, Kantor E. Routine dermatologist-performed full-body skin examination and early melanoma detection. Arch Dermatol 2009; 145(8):873-876. 10.Epstein DS, Lange JR, Gruber SB, et al: Is physician detection associated with thinner melanomas? JAMA 1999; 281:640-643. 11. Swetter SM, Johnson TM, Miller DR, et al. Melanoma in middle-aged and older men: a multi-institutional survey study of factors related to tumor thickness. Arch Dermatol 2009; 145(4):397-404. 12.Aitken JF, Elwood M, Baade PD, Youl P, English D. Clinical whole-body skin examination reduces the incidence of thick melanomas. Int J Canc 2009 July 16 [Epub ahead of print]. TANNING ADDICTION: the new form of substance abuse (p.28) 1. American Cancer Society. 2009 Cancer Facts and Figures. www.cancer.org/ downloads/STT/500809web.pdf 2. Swerdlow AJ, Weinstock MA. Do tanning lamps cause melanoma? An epidemiologic assessment. J Am Acad Dermatol 1998; 38:89–98. 3. Council of Scientific Affairs. Harmful effects of ultra- violet radiation. JAMA 1989; 262:380–4. 4. Knight JM, Kirincich AN, Farmer ER, et al. Awareness of the risks of tanning lamps does not influence behavior among college students. Arch Dermatol 2002; 138:1311–5. 5. Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol 2007; 56:375–9. 6. Donovan DM, Dennis M. Assessment of Addictive Behaviors. New York: Guilford Press; 2005. 7. Kaur M, Liguori A, Land W, et al. Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockage in frequent tanners. J Am Acad Dermatol 2006; 54:709–11. 8. Feldman SR, Liguori A, Kucenic M, et al. Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol 2004; 51:45–51. 9. Kaur M, Feldman SR, Liguori A, et al. Indoor tanning relieves pain. Photodermatol Photoimmunol Photomed 2005; 21:278. 10.Zeller S, Lazovich D, Forester J, et al. Do adolescent tanners exhibit dependency? J Am Acad Dermatol 2006; 54:589–96. 11. American Psychiatric Association, Task Force on DSM-IV. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Publishing; 2000. 12.Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984; 252:1905–7. 13.Warthan MM, Ichida T, Wagner RF Jr. UV light tanning as a type of substance-related disorder. Arch Dermatol 2005; 141:963–6. 14.O’Riordan DL, Field AE, Geller AC, et al. Frequent tanning bed use, weight concerns, and other health risk behaviors in adolescent females (United States). Cancer Causes Control 2006;17(5):679–86. 15.Richmond JB, Kotelchuck M. Personal health maintenance for children. Western J of Med 1984;141:816-23. 16.National Conference of State Legislatures. Tanning Restrictions for Minors. http:// www.ncsl.org/default.aspx?tabid=14394#statelws 17. DiClemente CC. Readiness and Stages of Change in Addiction Treatment. Am J Addict. 2004;13(2):103-19. Appearance Trumps Health as an Anti-Tanning Argument (p.30) 1. Hillhouse J, Turrisi R. Examination of the efficacy of an appearance focused intervention to reduce UV exposure. Journal of Behavioral Medicine 2002; 25:395–409. 2. Hillhouse J, Turrisi R, Stapleton J, Robinson J. A randomized controlled trial 96 of an appearance-focused intervention to prevent skin cancer. Cancer 2008; 113(11):3257-3266. 3. Gibbons FX, Gerrard M, Lane DJ, Mahler HI, Kulik JA. Using UV photography to reduce use of tanning booths: a test of cognitive mediation. Health Psychol Jul 2005; 24(4):358-363. 4. Greene K, Brinn LS. Messages influencing college women’s tanning bed use: Statistical versus narrative evidence format and a self-assessment to increase perceived susceptibility. Journal of Health Communication Sep-Oct 2003; 8(5):443-461. 5. Jackson KM, Aiken LS. Evaluation of a multicomponent appearance-based sunprotective intervention for young women: uncovering the mechanisms of program efficacy. Health Psychol Jan 2006; 25(1):34-46. 6. Mahler H, Kulik J, Gibbons F, Gerrard M, Harrell J. Effects of appearance-based interventions on sun protection intentions and self-reported behaviors. Health Psychol Mar 2003; 22(2):199-209. From bardot to BECKHAM: the decline of celebrity tanning (p.42) 1. Sonnby-Borgstrom M, Jonsson P, Svensson 0. Gender differences in facial imitation and verbally reported emotional contagion from spontaneous to emotionally regulated processing levels. Scandinavian Journal of Psychology 2008; 49(2):111-122. 2. Armstrong BK and Kricker A. The epidemiology of solar radiation and skin cancer. In: Sun Protection in Man. P.U. Giacomoni, Ed., 2001, pp. 131-153. Elsevier Science: Amsterdam. 3. Diepgen TL, Mahler V. The epidemiology of skin cancer. British Journal of Dermatology 2002; 146(s61):1-6. 4. Leiter U, Garbe C. Epidemiology of melanoma and nonmelanoma skin cancer — The role of sunlight. Advances in Experimental Medicine and Biology 2008. 624:89-103. 5. Australian Institute of Health and Welfare, Health System Expenditures on Cancer and Other Neoplasms in Australia, 2000-01. Health and Welfare Expenditure Series No. 22. 2005, Canberra, Australia: Australian Institute of Health and Welfare. 6. Montague M, Borland R, Sinclair C. Slip! Slop! Slap! and SunSmart, 1980-2000: Skin cancer control and 20 years of population-based campaigning. Health Education & Behavior 2001; 28(3):290-305. 7. Feldman SR, Liguori A, Kucenic M,et al. Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. Journal of the American Academy of Dermatology 2004; 51(1): 45-51. 8. Pagoto SL, Hillhouse J. Not all tanners are created equal: Implications of tanning subtypes for skin cancer prevention. Archives of Dermatology 2008; 144(11):1505-1508. 9. Tadros E. Elle of a Thing to Say. Sydney Morning Herald 2008: Sydney, Australia, Jan 4, 2008. 10.Warrington R. End of the Bronze Age. The Sunday Times 2008: London. p.44, Nov 30, 2008. 11. Dixon H, et al. Portrayal of tanning, clothing fashion and shade use in Australian women’s magazines, 1987-2005. Health Education Research 2008; 23(5):791-802. Sun Safety AT SCHOOL (p. 46) 1. World Health Organization. (2003). Sun protection and schools: How to make a difference [Electronic version]. Retrieved on 11/25/09, from http://www.who.int/uv/ publications/en/sunprotschools.pdf 2. Young, JC (2000). Sun safety survey of preschools and day care centers. American Journal of Health Studies; 16(2):71. 3. Gilchrest, BA, Eller MS, Geller AC, and Yaar M. New England Journal of Medicine 1999 (April 29). 340(17);1341-1348. 4. Centers for Disease Control and Prevention. (2002). Shade planning for America’s schools. Retrieved from the internet on 11/23/09, from http://www.cdc.gov/cancer/ skin/pdf/shade_planning.pdf 5. Giles-Corti B, English DR, Costa C, Milne E, Cross D, and Johnston R. Creating SunSmart schools. Health Education Research 2004; 19(1):98-109. 6. Glanz K, Saraiya M, and Wechsler H. Guidelines for school programs to prevent skin cancer. Morbidity and Mortality Weekly Report 2002 (April 26); 51(RR04); 1-16. 7. Dadlani C and Orlow SJ. Planning for a brighter future: A review of sun protection and barriers to behavioral change in children and adolescents. Dermatology Online Journal (2008 Sept.); 14(9). Retrieved from the internet on 11/16/09 from http:// dermatology.cdlib.org/149/commentaries/sunprotection/dadlani.html 8. Centers for Disease Control and Prevention. (n.d). Sun safety at schools: What you can do. Retrieved from the internet on 11/23/09, from http://www.cdc.gov/cancer/ skin/pdf/sunsafety_v0908.pdf Under the Sun, Everything You Wear Matters (p.48) 1. American Cancer Society. Cancer Facts & Figures 2009. Atlanta: American Cancer Society; 2009. 2. Armstrong, BK and Kricker, A. How much melanoma is caused by sun exposure, Melanoma Research, 1993: 3:395-401. Lip Cancer: Not Uncommon, Often Overlooked (p. 51) 1. Cancer Facts & Figures 2009. In: Society AC, ed. Atlanta; 2009. SK I N C A NCER FOU N DAT ION JOU R NA L 2. Robinson JK. Sun exposure, sun protection, and vitamin D. JAMA 2005; 294:1541-3. 3. Young JL, Jr., Percy CL, Asire AJ, et al. Cancer incidence and mortality in the United States, 1973-77. Natl Cancer Inst Monogr 1981:1-187. 4. Abreu L, Kruger E, Tennant M. Lip cancer in Western Australia, 1982-2006: a 25-year retrospective epidemiological study. Aust Dent J 2009; 54:130-5. 5. Molnar L, Ronay P, Tapolcsanyi L. Carcinoma of the lip. Analysis of the material of 25 years. Oncology 1974; 29:101-21. 6. Veness M. Lip cancer: important management issues. Australas J Dermatol 2001; 42:30-2. 7. Mohs FE, Snow SN. Microscopically controlled surgical treatment for squamous cell carcinoma of the lower lip. Surg Gynecol Obstet 1985; 160:37-41. 8. Zitsch RP, 3rd, Park CW, Renner GJ, Rea JL. Outcome analysis for lip carcinoma. Otolaryngol Head Neck Surg 1995; 113:589-96. 9. Armstrong BK, Kricker A. How much melanoma is caused by sun exposure? Melanoma Res 1993; 3:395-401. 10.Fincham SM, Hanson J, Berkel J. Patterns and risks of cancer in farmers in Alberta. Cancer 1992; 69:1276-85. 11. van Leeuwen MT, Grulich AE, McDonald SP, et al. Immunosuppression and other risk factors for lip cancer after kidney transplantation. Cancer Epidemiol Biomarkers Prev 2009; 18:561-9. 12.Dantal J, Hourmant M, Cantarovich D, et al. Effect of long-term immunosuppression in kidney-graft recipients on cancer incidence: randomised comparison of two cyclosporin regimens. Lancet 1998; 351:623-8. 13.Grulich AE, van Leeuwen MT, Falster MO, Vajdic CM. Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis. Lancet 2007; 370:59-67. 14.Holmkvist KA, Roenigk RK. Squamous cell carcinoma of the lip treated with Mohs micrographic surgery: outcome at 5 years. J Am Acad Dermatol 1998; 38:960-6. 15.Pogoda JM, Preston-Martin S. Solar radiation, lip protection, and lip cancer risk in Los Angeles County women (California, United States). Cancer Causes Control 1996; 7:458-63. 16.Busick TL, Uchida T, Wagner RF, Jr. Preventing ultraviolet light lip injury: beachgoer awareness about lip cancer risk factors and lip protection behavior. Dermatol Surg 2005; 31:173-6. 17. Maier H, Schauberger G, Brunnhofer K, Honigsmann H. Assessment of thickness of photoprotective lipsticks and frequency of reapplication: results from a laboratory test and a field experiment. Br J Dermatol 2003; 148:763-9. 18.Maier H, Schauberger G, Martincigh BS, Brunnhofer K, Honigsmann H. Ultraviolet protective performance of photoprotective lipsticks: change of spectral transmittance because of ultraviolet exposure. Photodermatol Photoimmunol Photomed 2005; 21:84-92. The Right Way to Treat Seasonal Depression (p. 56) 1. Lam RW, Buchanan A, Mador JA, Corral MR, Remick RA. The effects of ultraviolet-A wavelengths in light therapy for seasonal depression. J Affect Disord 1992; 24:237-43. 2. Hillhouse J, Stapleton J, Turrisi R. Association of frequent indoor UV tanning with seasonal affective disorder. Arch Dermatology 2005; 141:1465. 3. Roberts D. Artificial lighting and the blue light hazard. Accessible at http://www. mdsupport.org/library/hazard.html, 2008. 4. Terman M, Remé CE, Rafferty B, Gallin PF, Terman JS. Bright light therapy for winter depression: Potential ocular effects and theoretical implications. Photochem Photobiol 1990; 51:781-793. 5. DeLeo VA, Remé CE. Bright light exposure risks. Accessible in the Therapy section at http://www.cet.org, 2008. 6. Terman M, Terman JS. Controlled trial of naturalistic dawn simulation and negative air ionization for seasonal affective disorder. Am J Psychiatry 2006; 163:2126-2133. 7. Wirz-Justice A, Benedetti F, Terman M. Chronotherapeutics for Affective Disorders: a Clinician’s Manual for Light and Wake Therapy. Basel, Karger, 2009. Information at www.chronotherapeutics.org. PROTECT YOUR EYES: EVERYDAY STEPS TO SUN SAFETY (p.58) 1. Implications of the blue light hazard and (ROS) in the pathogenesis of age-related macular degeneration, Dr. George Banyas, OD. 2. HEV Light and Macular Degeneration, Midwest Monthly, Vol. 5, Issue 3, March, 2008, http://mwlabs.cc/pdf/MMMarch2008.pdf. 3. National Eye Institute, National Institutes of Health, Age-Related Macular Degeneration, www.nei.nih.gov/health/maculardegen/armd_facts.asp 4. Rene S. Rodriguez-Sains, MD, The sun, the eyelids, and the eye, The Skin Cancer Foundation Journal, Vol. 23, 2005, pp. 36-7. 5. Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome, Hamada S, Kersey T, Thaller VT, Br J Ophthalmol, August 2005; 89(8): 992-994. 6. EyecareAmerica, The Foundation of the American Academy of Ophthalmalogy, Eyelid and Orbital Tumors. http://www.eyecareamerica.org/eyecare/conditions/eye-tumors/ index.cfm 7. Emily Tierney, MD, and C. William Hanke, MD, MPH, The Eyelid: A High Risk Area for Skin Cancer, Skin Cancer Foundation Journal, 2009; 27:53-54. 8. Intraocular (Eye) Melanoma Treatment—National Cancer Institute. http://www. cancer.gov/cancertopics/pdq/treatment/intraocularmelanoma/patient/allpages/print] 9. Guo-Pei Yi, MD, Dan-Nin Hu, MD, Steven McCormick, MD, and Paul T. Finger, MD, Conjunctival Melanoma: Is It Increasing in the United States? American Journal of Ophthalmology, June 2003; 135:800-806. Elsevier, Inc. 10.Gies PH, Roy CR, Toomey S, McLennan A. Protection against solar ultraviolet radiation. Mutat Res 1998; 422:15-22. 11. Tucker MA, Shields JA, Hartge P, et al. Sunlight exposure as a risk factor for intraocular malignant melanoma. N Eng J Med 1985; 313:789-792. 12. American Cancer Society booklet, Eye Cancer – Intraocular Melanoma, page 5. 13.Sunlight exposure and risk of lens opacities in a population-based study, The Salisbury Eye Evaluation Project, West SK, Duncan, DD, Munoz B, Rubin GS, et al. JAMA Aug. 26, 1998, Vol. 280, No. 8, 714-718. 14.The content and cost of cataract surgery, Steinberg EP, Javitt JC, Sharkey PD, Zuckerman A, Legro MW, Anderson GF, Bass EB, O’Day D, Arch Derm 1993; Aug; 111:1041-9. 15.FDA: Saving Your Sight—Early Detection is Critical, by Michelle Meadows. cites NEI for over 1.5 million surgeries a year. http://www.fda.gov/fdac/features/2002/202_eyes. html] 16.Blue Light and Macular Degeneration, from The Complete Guide to Saving and Maximizing Your Sight, by Lylas G. Mogk, MD, and Marja Mogk, at Macular Degeneration Support online, www.mdsupport.org/library/blulight.html 17. What are the effects of UV on the eye? World Health Organization: http://www. who.int/uv/faq/uvhealtfac/en/index3.html. 18.CDC: Excite: Skin Cancer Module: Practice Exercises. Module 6: Ultraviolet Radiation. http://www.cdc.gov/excite/skincancer/mod06.htm] Breast Cancer and Melanoma (p.60) 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin Mar-Apr 2008; 58(2):71-96. 2. Ho WL, Comber H, Hill ADK, Murphy GM. Malignant melanoma and breast carcinoma: a bidirectional correlation. Ir J Med Sci Mar 2009:10.1007/s11845-0090297-5. 3. Schoenberg BS, Christine BW. Malignant melanoma associated with breast cancer. South Med J Nov 1980; 73(11):1493-1497. 4. Goggins W, Gao W, Tsao H. Association between female breast cancer and cutaneous melanoma. Int J Cancer Sep 20 2004; 111(5):792-794. 5. Levi F, Te VC, Randimbison L, La Vecchia C. Cancer risk in women with previous breast cancer. Ann Oncol Jan 2003; 14(1):71-73. 6. Rubino C, de Vathaire F, Diallo I, Shamsaldin A, Le MG. Increased risk of second cancers following breast cancer: role of the initial treatment. Breast Cancer Res Treat Jun 2000; 61(3):183-195. 7. Mellemkjaer L, Friis S, Olsen JH, et al. Risk of second cancer among women with breast cancer. Int J Cancer May 1 2006; 118(9):2285-2292. 8. Galper S, Gelman R, Recht A, et al. Second nonbreast malignancies after conservative surgery and radiation therapy for early-stage breast cancer. Int J Radiat Oncol Biol Phys Feb 1 2002; 52(2):406-414. 9. Bhatia S, Estrada-Batres L, Maryon T, Bogue M, Chu D. Second primary tumors in patients with cutaneous malignant melanoma. Cancer Nov 15 1999; 86(10):2014-2020. 10.Schmid-Wendtner MH, Baumert J, Wendtner CM, Plewig G, Volkenandt M. Risk of second primary malignancies in patients with cutaneous melanoma. Br J Dermatol Dec 2001; 145(6):981-985. 11. Borg A, Sandberg T, Nilsson K, et al. High frequency of multiple melanomas and breast and pancreas carcinomas in CDKN2A mutation-positive melanoma families. J Natl Cancer Inst Aug 2 2000; 92 (15):1260-1266. 12.Nagore E, Montoro A, Garcia-Casado Z, et al. Germline mutations in CDKN2A are infrequent in female patients with melanoma and breast cancer. Melanoma Res Aug 2009; 19(4):211-214. 13.Monnerat C, Chompret A, Kannengiesser C, et al. BRCA1, BRCA2, TP53, and CDKN2A germline mutations in patients with breast cancer and cutaneous melanoma. Fam Cancer 2007; 6(4):453-461. 14.Cancer risks in BRCA2 mutation carriers. The Breast Cancer Linkage Consortium. J Natl Cancer Inst Aug 4 1999; 91(15):1310-1316. 15.Debniak T, Scott RJ, Huzarski T, et al. XPD common variants and their association with melanoma and breast cancer risk. Breast Cancer Res Treat Jul 2006; 98(2):209-215. 16.Driscoll MS, Grant-Kels JM. Hormones, nevi, and melanoma: an approach to the patient. J Am Acad Dermatol Dec 2007; 57(6):919-931; quiz 932-916. 97 Skin Cancer Foundation Catalog The Skin Cancer Foundation produces a wide range of brochures, posters, books and clothing to educate and protect the public. Many of our materials are found in doctors’ offices. Clothing, books and more can be ordered from The Skin Cancer Foundation by visiting our web store at www.SkinCancer.org or by calling (212) 725-5176 ext. 102. BR-14 Skin Cancer In People Of Color Skin cancer can affect anyone. Learn about the most common skin cancers, and how they affect African Americans, Asians, Asian Indians, Latinos, and Middle Easterners. Includes information on the warning signs of different skin cancers, including acral lentiginous melanoma, and a special section on the importance of vitamin D. 6 pages, full color. LIFESTYLE BROCHURES BR-2 Preventing Skin Cancer Presents general information about skin cancer warning signs, treatment and preventive measures, including proper use of sunscreens. 6 panels, full color. BR-13 Skin Cancer: If You Can Spot It, You Can Stop It Step-by-step, illustrated instructions for complete selfexamination of the skin. Includes advice on where, how and when to check yourself, and how to recognize skin cancer warning signs. Body maps provided so that users can conveniently record changes in skin marks; detachable measurement guide included. 10 pages, 3 panels, full color. BR-6 SunSmart Kids Teaches children smart sun habits that will protect them all their lives. Offers tips on sun safety at school, during sports, and more. Perfect for pediatricians, family and general practitioners, parents and child care professionals. 6 panels, full color. Also available in Spanish and Italian. BR-17 SunSmart Women Addresses issues of interest to women; specifically rates of melanoma and the effects of seeking a tan, both in terms of skin cancer risk and photoaging. Appropriate for dermatologists, general practitioners, ob/gyn practices. 8 pages, full color. Also available in Spanish and Italian. CLINICAL BROCHURES BR-16 Understanding UVA and UVB Offers the latest information on ultraviolet radiation, which is emitted by the sun (and tanning lamps) and is the main cause of about 90 percent of all skin cancers. The brochure covers topics such as UVA and UVB radiation and sunscreens, including the difference between UVA and UVB-blocking ingredients. 10 pages, 8 photos and illustrations, full color. BR-4 The ABCDEs of Melanoma Identifies the most important differences between common moles and malignant melanomas: Asymmetry, Border, Color, Diameter and Evolving. 6 panels, 10 photos, full color. Also available in Spanish. BR-15 Actinic Keratosis An important new guide to the appearance, causes and latest treatments of this common precancer. Tells who is most at risk for the disease, what its dangers are, and how to prevent it. 6 pages, 10 photos, full color. Also available in Spanish, French, German and Italian. BR-7 Basal Cell Carcinoma A concise guide to the most prevalent skin cancer (and most common of all cancers). Contains vital information on risk factors, prevention, early detection and current treatment methods. 6 pages, 10 photos, full color. Also available in Spanish, French, German and Italian. BR-8 Dysplastic Nevi & Risk of Melanoma Compares normal and atypical moles (dysplastic nevi), shows how some moles can develop into melanomas, and illustrates the early warnings signs. Suggests preventive measures for people with atypical moles. 10 pages, 12 photos, full color. Also available in Spanish, French, German and Italian. BR-19 A Guide To Skin Cancers & Precancers This brochure explores actinic keratosis in detail and presents a concise introduction to the most common skin cancers - squamous cell carcinoma, basal cell carcinoma, and melanoma. It includes indispensable information on causes, hereditary risk factors, warning signs, treatment, prevention, and self-examination of the skin. 14 pages, 19 photos, full color. BR-5 The Many Faces of Melanoma This brochure features 24 full color 1-7/8”x3” photos of melanomas of varying thickness, representing different stages of the disease. This invaluable guide will help both doctors and patients identify suspicious moles. The text offers melanoma warning signs; information about those at high risk, and the all-important ABCDEs. 6 panels, 24 photos, full color. BR-3 Spotlight on Skin Cancer A quick guide to skin cancer that provides definitions and photos of actinic keratoses, basal cell carcinomas, squamous cell carcinomas, and melanoma. 6 panels, 9 photos, full color. BR-9 Squamous Cell Carcinoma Covers the causes, prevention and treatment of the second most common skin cancer. The photos serve as a diagnostic tool for physicians and an early detection aid for the general public. 10 pages, 6 photos, full color. Also available in Spanish, French, German and Italian. 98 SK I N C A NCER FOU N DAT ION JOU R NA L CLOTHING BOOKS BY PERRY ROBINS, MD TS-1 Long Sleeve Sun Protective Shirt with The Skin Cancer Foundation logo The Skin Cancer Foundation offers durable sun-protective shirts that block 97 percent of the sun`s ultraviolet rays (UVR). Offers a UPF rating of 40-50+. Made of premium 100% cotton, these tees are pre-shrunk for a perfect fit. The machine-washable tops are double-stitched for extra strength. The shirts are UV finished in the US and feature a 1/2” ribbed collar. The SCF logo appears just below the collar on the back of the shirt and is 2” square. M-5 Understanding Melanoma, What You Need to Know (3rd Edition) Newly updated and now in its third edition, this handbook is written for melanoma patients, their families and friends, health professionals, and every person with an interest in the disease. This valuable book, written by two eminent dermatologists, covers melanoma from the moment of diagnosis through state-of-the-art treatments. Honest and straightforward, but reassuring in tone. Contrary to what many people fear, there is an excellent chance for a long and healthy life after diagnosis. Early warning signs and a step-by-step illustrated guide to self-examination of the skin are presented along with answers to the 25 most frequently asked questions about melanoma. There are specially-complied listing of information sources and support groups, a glossary, and color photographs and drawings depicting typical melanomas. 72 pages. HT-1 Sun Protective Hat The Skin Cancer Foundation`s microfiber hat with fishing cap trim boasts a removable Velcro backstrap providing extra protection to the often-exposed back of the neck. The khaki cap comes with a Velcro Sunshield; one size fits most (from 20 3/4” up to 24 1/4”). POSTERS M-7 Understanding Basal Cell Carcinoma: What You Need To Know This valuable handbook provides comprehensive, up-to-date information for patients, their families, friends, and everybody else interested in BCC. Includes four-color illustrations, FAQ, a glossary of medical terms and more. 73 pages. All posters available in 11”x17”; 20”x28” posters available as indicated. M-6 Understanding Squamous Cell Carcinoma: What You Need To Know This new book, perfect for patients, friends and family of people with SCC, covers all stages of the disease, from diagnosis to the latest treatments. Important information on prevention and sun protection is included, along with full-color photos, a FAQ, a glossary of medical terms and more. 74 pages. Go With Your Own GlowTM is the rallying cry of The Skin Cancer Foundation’s public awareness campaign. Developed to encourage women to love and protect their skin, whatever its natural hue, the campaign is relying not just on health and safety information, but also on fashion. These stylish, fashion illustration-inspired posters catch the eye and inform the mind. These artworks are perfect for any office, workplace, school or spa. Available in 20”x28” Available in 20”x28” Available in 20”x28” PS-6 Can You Spot a Killer (20” x 28”) The five large color photos on this poster will familiarize the layperson with the warning signs of melanoma. The poster urges frequent skin self-examination and describes mole changes that could be cancer warning signs. Useful in any health care setting. 11”x17” Spanish version available. PS-2 If You Worship the Sun (20” x 28”) Reveals that tanning is the main cause of skin cancer. 11”x17” Spanish version available. PS-4 People Who Need the Most Sun Protection (20” x 28”) Emphasizes that parents must take responsibility for keeping vulnerable children from being harmed by the sun`s rays. Urges parents to start sun protection early to avoid skin cancer later. 11”x17” Spanish and Italian versions available. PS-3 One Blistering Sunburn In Childhood (20” x 28”) Informative poster with clear instructions for parents for establishing early and lifelong sun safety habits. 11”x17” Spanish and Italian versions available. PS-11 Learn the Body Language (20” x 28”) Features attractive close-up photos of the body areas where skin cancer is most likely to develop. Describes the warning signs, stresses the need for regular, complete skin self-examination and the lifesaving importance of early detection. For doctors’ waiting rooms, clinics, schools and health fairs. PS-10 Skin Cancer: If You Can Spot It You Can Stop It (20” x 28”) An 8-step illustrated guide to self-examination of the skin, designed for doctors` offices, clinics and health fairs. Explains the importance of early detection and describes the major warnings signs. 11”x17” Spanish version available. NL-1 Sun & Skin News A quarterly newsletter for consumers written in everyday language, providing information on a broad range of topics related to skin health. Subjects include prevention and treatment of skin cancers and other forms of skin damage, sunscreen, and the danger of tanning parlors. Also available as a subscription. JL-1 The Skin Cancer Foundation Journal An annual publication covering beauty, lifestyles, health and more. Written in an accessible, easy to understand style, The Skin Cancer Foundation Journal is an award-winning publication bringing the best information on skin cancer prevention, advances in treatment and tips from a wide range of experts to both doctors and patients. Periodicals NL-2 The Melanoma Letter A quarterly newsletter for doctors, featuring articles by prominent medical authorities. Designed to keep clinicians, scientists and other health professionals up-to-date on advances in diagnosis and treatment, as well as research breakthroughs. Also available as a subscription. 99 Advertisers’ Index 2010 ADVERTISER PAGE Darrick Antell, MD 62 www.antell-md.com Archives of Dermatology 53 www.archdermatol.com AVEENO® 19 www.aveeno.com Banana Boat 29 www.bananaboat.com Bath and Body Works 55 www.bathandbodyworks.com Clarins 27 www.clarins.com Clinique Inside Front Cover-1 www.clinique.com Coppertone 36 www.coppertone.com DSM Nutritional Products 6 www.dsmnutritionalproducts.com Eucerin Back Cover www.eucerinus.com Galderma 22 www.cetaphil.com Garnier Nutritioniste 2-3 www.garnier.com Hawaiian Tropic 16 www.hawaiiantropic.com Jane Iredale 14 www.janeiredale.com L'Oreal Paris 4-5 www.loreal.com Perry Robins, MD 79 Revision Skincare Inside Back Cover www.intellishadespf45.com Sephora 9 www.sephora.com Shiseido 10 www.sca.shiseido.com Skinmedica 50 www.skinmedica.com Solise 31 www.solise.com 100 SK I N C A NCER FOU N DAT ION JOU R NA L YOU CAN’T ALWAYS AVOID THE SUN, BUT YOU CAN BE READY FOR IT. PUT THE HEALTH OF YOUR SKIN FIRST with daily moisturizer + daily SPF protection. A healthy relationship with the sun means protecting your skin from incidental exposure. That’s why there’s Eucerin EVERY DAY PROTECTION SPF 15 body lotion and SPF 30 face lotion. Both protect your skin from harmful UVA & UVB rays, yet feel light and non-greasy for daily use. Feel great about a sunny day with Eucerin, the brand dermatologists recommend. EucerinUS.com/SKINFIRST Skin science that shows.
