State/National Statistics: Basic Epidemiology of Skin Cancer

1. State/National Statistics:Basic Epidemiology of Skin Cancer Presented by: Chris Johnson, MPH Epidemiologist, Cancer Data Registry of Idaho Cancer Awareness, Screening, and Prevention Alliance (CASPA) May 18th, 2010 7-8:30 a.m. Huckleberry Room Central District Health Department. 

2. Skin Skin Cancer SCC and BCC Melanoma Melanoma Risk Factors Incidence Stage Survival Mortality Lifetime Risks Prevention Outline

3. The Skin • The skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. It helps regulate body temperature, stores water and fat, and produces vitamin D. • The skin has two main layers: the outer epidermis and the inner dermis.

4. Skin Cancer • Cancer may develop in any of the cell types: • Squamous Cell Carcinoma (SCC) • Basal Cell Carcinoma (BCC) • Melanoma • Skin cancer is the most common form of cancer in the United States.

5. Squamous and Basal Cell Carcinomas • The American Cancer Society estimates that substantially more than 1 million unreported cases of basal cell and squamous cell cancers occur annually in the US. This number is roughly equivalent to the total of all other cancer sites. • Death rates from basal cell and squamous cell carcinomas are low. • When detected early, approximately 95% of these carcinomas can be cured. • However, these cancers can cause considerable damage and disfigurement if they are untreated. • Basal cell and squamous cell carcinomas are more than 10 times as common as melanoma but account for less morbidity and mortality. • SCC may account for 20% of all deaths from skin cancer. • SCC and BCC are not reportable to CDRI unless regional or distant stage or on a mucous membrane. • There were 5 reportable SCC and BCC skin cases in 2007 in Idaho. • We do not know how many total cases of SCC and BCC there are per year in Idaho, but estimate it to be over 5,000.

6. Melanoma of the Skin • Melanoma is one of the most common cancers and the most serious type of cancer of the skin. • Melanoma accounts for less than 5% of skin cancer cases but causes a large majority (about 75%) of skin cancer deaths. • The American Cancer Society estimates that about 68,720 new cases of malignant melanoma will be diagnosed in 2009, and 8,650 will die from the disease in the US. • In some parts of the world, especially among Western countries, melanoma incidence is on the rise. • In the United States, melanoma incidence has more than doubled in the past 30 years. • All in situ and invasive melanoma cases are reportable to CDRI.

7. Melanoma Risk Factors • Light skin color, hair color, or eye color. • Rates are more than 10 times higher in whites than in African Americans. • Family history of skin cancer. • Personal history of skin cancer. • Intermittent exposure of untanned skin to intense sunlight. • Severe (blistering/peeling) sunburns early in childhood. • Presence of atypical or numerous moles (greater than 50). • Freckles, which indicate sun sensitivity and sun damage.

8. Ultraviolet Radiation EARTH SURFACE

9. UV Radiation Wavelengths • Ultraviolet radiation (or UV radiation)— Electromagnetic radiation with wavelengths between 100 and 400 nanometers. These rays are emitted from the sun and are not visible. They inflict increasingly more damage upon a recipient as the wavelength decreases. Based on its effects, UV radiation is subdivided into three wavelength ranges named UV-A, UV-B and UV-C: • UV-A covers the wavelength range 320-400 nm. UV-A is not absorbed by the ozone layer. UV-A are present with relatively equal intensity during all daylight hours throughout the year, and can penetrate clouds and glass. Does not cause sunburn, does cause tanning. Recent research suggests its role in melanoma. • UV-B covers the wavelength range 280-320 nm. UV-B is more energetic than UV-A, and is partially absorbed by the ozone layer. UV-B rays cause sunburn, tanning, and have been shown to cause SCC and BCC. UV-B also has the beneficial effect of vitamin-D production. • UV-C covers the wavelength range 100-280 nm. UV-C is the most dangerous form of UV radiation, but is completely absorbed by the ozone layer. Artificial UV-C (for example emitted by electric discharges) is a threat for certain occupational group, like welders.

10. UV Exposure • More than 90% of skin cancers in the US are attributed to UV-B exposure. • Other causes of skin cancer include arsenic, other chemical exposures. • Human exposure to UV-B depends upon an individual's • location (latitude and altitude) • the duration and timing of outdoor activities (time of day, season of the year = angle of the sun) • and precautionary behavior (use of sunscreen, sunglasses, or protective clothing).

11. UV Exposure

12. UV-B Exposure - Sunburn • 33.7% of U.S. adults report having had a sunburn in 2004 (BRFSS). • In Idaho, 48.4% of white adults reported having had a sunburn in 2008. • Parents or caregivers reported that 72% of adolescents aged 11--18 years have had at least one sunburn, and 43% of white children aged <11 years experienced a sunburn in the past year.

13. Sunburn

14. Sunburn

15. Synopsis of Melanoma in Idaho • In 2007, there were 341 invasive cases of melanoma and 43 melanoma deaths among Idaho residents. • Melanoma is the 5th most common cancer in Idaho in terms of incidence and 16th most common site for cancer deaths.

16. Melanoma Incidence 2007

17. Incidence by Race/Ethnicity

18. Incidence by Age

19. Incidence of Invasive Melanoma by Site on Body and Sex, United States, 2004—2006

22. SEER Summary Staging 2000 • Cancer staging is the process of describing the extent of the disease or the spread of the cancer from the site of origin. • In situ – noninvasive; basement membrane of epidermis is intact (Clark’s level I) • Localized – papillary/reticular dermis invaded (Clark’s level II-IV) • Regional – subcutaneous tissue invaded (Clark’s level V), satellite nodules <= 2 cm from primary tumor, regional lymph nodes involved • Distant – extension to underlying cartilage, bone, skeletal muscle, metastasis to skin or subcutaneous tissue beyond regional lymph nodes or visceral metastasis

23. Incident Cases by Stage

24. Melanoma Trends

25. Cancer Survival

26. Melanoma Survival by Stage

27. Melanoma Mortality 2004-2008

28. Leading Causes of Mortality and Melanoma - Males

29. Leading Causes of Mortality and Melanoma - Females

31. Mortality Trends

32. Risks of Developing and Dying from Melanoma

33. Risks of Developing and Dying from Melanoma

34. Preliminary Results from CDC Melanoma Monograph • Many papers, many authors • A few preliminary results: • Socio-economic status (SES) • Physician per county population • Relationship to incidence differs by stage at time of diagnosis

35. Melanoma & SES • SES measures contribute substantially to variation in cutaneous melanoma incidence and mortality. • Patients with higher SES measures are more likely to be diagnosed with melanoma. • However, patients with lower SES measures are more likely to have an advanced stage at diagnosis, and worse outcomes, including higher mortality. • Complex relationship between: • socioeconomic factors, environmental risk factors and sun exposure behavior, • awareness of melanoma prevention, access to primary care and melanoma screening, • potential variation in ultraviolet exposure related to differences in outdoor recreation and leisure, a product of SES itself.

36. Melanoma & SES

37. Melanoma & Physician Density

38. Prevention of Melanoma • Primary Prevention • Avoiding the disease in the first place • Secondary Prevention • Screening • Early diagnosis and treatment

39. Primary Prevention • Skin cancer is largely preventable when sun protection measures against UV rays are used consistently. • Preventing sunburn, especially in childhood, may reduce the lifetime risk for melanoma. Recommendations: • Avoid exposure to the midday sun (from 10 a.m. to 4 p.m.) whenever possible. When your shadow is shorter than you are, remember to protect yourself from the sun. • If you must be outside, wear long sleeves, long pants, and a hat with a wide brim. • Protect yourself from UV radiation that can penetrate light clothing, windshields, and windows. • Protect yourself from UV radiation reflected by sand, water, snow, and ice.

40. Sunscreen • Sunscreen's role in preventing skin cancer has been demonstrated to be complex. • Using sunscreen has been shown to prevent squamous cell and basal cell skin cancers. • Sunscreens May Not Reduce the Risk of Cutaneous Melanoma • The evidence for the effect of sunscreen use in preventing melanoma is mixed. • The conflicting results may reflect the fact that sunscreen use is more common among fair-skinned people, who are at higher risk for melanoma; • or, this finding may reflect the fact that sunscreen use could be harmful if it encourages longer stays in the sun without protecting completely against cancer-causing radiation. • Some sunscreens only protect against UVB radiation. • Sunscreen also blocks vitamin D formation in the skin, a process that some researchers believe also promotes cancer. • To date, no criteria exist in the U.S. for measuring and labeling the amount of UVA defense a sunscreen provides. However, the FDA plans to introduce UVA standards within the next few years.

41. Recent Sunscreen Research • A recent meta-analysis found consistently that sunscreen users above 40 degrees latitude are at a higher risk of melanoma than people who don't use sunscreen, even when differences in skin color are taken into account. • Wearing sunscreen decreased melanoma risk in studies closer to the equator. • In the Northern hemisphere, 40 degrees draws a line between New York city and Beijing. • The UV light that reaches the Earth's surface is composed of UVA (longer) and UVB (shorter) wavelengths. UVB causes sunburn, while they both cause tanning. Sunscreen blocks UVB, preventing burns, but most brands only weakly block UVA. Sunscreen allows a person to spend more time in the sun than they would otherwise, and attenuates tanning. Tanning is a protective response (among several) by the skin that protects it against both UVA and UVB. Burning is a protective response that tells you to get out of the sun. The result of diminishing both is that sunblock tends to increase a person's exposure to UVA rays. • It turns out that UVA rays are more closely associated with melanoma than UVB rays, and typical sunscreen fails to prevent melanoma in laboratory animals.

42. Ultraviolet-B (UVB)-vitamin D-cancer hypothesis • UVB-induced vitamin-D may decrease the rates of some cancers. • Several ecological and observational studies have examined the hypothesis, in addition to one good randomized, controlled trial. • Results for breast and colorectal cancer satisfy the criteria best, but there is also good evidence that other cancers do as well, including bladder, esophageal, gallbladder, gastric, ovarian, rectal, renal and uterine corpus cancer, as well as Hodgkin's and non-Hodgkin's lymphoma. • Several cancers have mixed findings with respect to UVB and/or vitamin D, including pancreatic and prostate cancer and melanoma. Even for these, the benefit of vitamin D seems reasonably strong. • The action spectrum of ultraviolet radiation mainly responsible for melanoma induction is unknown, but evidence suggests it could be ultraviolet A (UVA), which has a different geographic distribution than ultraviolet B (UVB).

43. Sun Exposure: UV-B • A number of public health organizations state that there needs to be a balance between having the risks of having too much (skin cancer) and the risks of having too little sunlight (vitamin-D deficiency). • There is a general consensus that sunburn should always be avoided. • However, not all physicians agree with the assertion that there is an optimal level of sun exposure, with some arguing that it is better to minimize sun exposure at all times and to obtain vitamin D from other sources. • Serum levels of 25(OH) D3 are below the recommended levels for a large portion of the general adult population and in most minorities, indicating that Vitamin D deficiency is a common problem in the United States.

44. Tanning Beds • Tanning beds primarily emit UVA. The lamps used in tanning salons emit doses of UVA as much as 12 times that of the sun. • Use of sunbeds (with deeply penetrating UVA rays) has been linked to the development of skin cancers, including melanoma. • In July 2009, the IARC released a report that categorized tanning beds as “carcinogenic to humans.” The agency, which is part of the World Health Organization (WHO), previously classified tanning beds as “probably carcinogenic.” The change comes after an analysis of more than 20 epidemiological studies indicating that people who begin using tanning devices before age 30 are 75% more likely to develop melanoma. • The World Health Organization recommends that no person under 18 should use a sunbed.

45. Secondary Prevention • Self Skin Examinations • Medical Skin Examinations

46. Cost-Effectiveness of Screening for Malignant Melanoma • Journal of the American Academy of Dermatology. 41(5, Part 1):738-745, November 1999. • The cost-effectiveness ratio for a screening program of adults older than age 20 who were at high risk for skin cancer was about $30,000 per year of life saved. • This is reasonably cost-effective compared with other accepted cancer screening strategies.