“If minors don’t tan, then they may never become adult tanners,” Jeffrey E. Gershenwald, MD, said in explaining the emphasis on teaching sun safety behaviors to young children as part of the Melanoma Moon Shot Program at The University of Texas MD Anderson Cancer Center, Houston. Dr. Gershenwald is Co-Leader of the Melanoma Moon Shot, Professor of Surgical Oncology and Medical Director of the Melanoma and Skin Center at MD Anderson. He is also Co-Leader of the MD Anderson Melanoma Moon Shot, part of a broad multidisciplinary institutional research effort that includes a multifaceted approach to foster prevent melanoma efforts.
Recognizing the obvious parallel with antismoking efforts—“those who never smoke cigarettes as kids would be much less likely to be adult cigarette smokers”—Dr. Gershenwald told The ASCO Post how early educational efforts and public policy can instill lifelong habits that reduce excessive exposure to ultraviolet radiation and help prevent skin cancer, including melanoma.
“As a researcher, I am well aware of the underlying causes of skin cancer, including melanoma, and remain frustrated that the vast majority of these cases could be prevented. As a parent, I do what I can to ensure my children practice sun-safe behaviors, and I urge others to do the same,” Dr. Gershenwald wrote in an opinion piece in Newsweek.1 That article generated positive feedback from professional colleagues and others, he noted. Some commented, “there needs to be more of this kind of education in the mainstream media that helps to communicate messages” about health promotion and cancer prevention.
Superheroes Drive Home Message
“We know that having a sunburn in childhood could double the lifetime risk of melanoma and having multiple blistering sunburns in older adolescence and younger adulthood is also associated with an increased risk of melanoma,” Dr. Gershenwald said. “Yet there is no real integrated intervention at the national level to promote ultraviolet (UV) protection.” In 2014, the U.S. Surgeon General issued a Call to Action to Prevent Skin Cancer,2 and Dr. Gershenwald pointed out the Centers for Disease Control and Prevention (CDC) “recommends that educational programs be put in place to teach children about sun safety and how to lower their risk of skin cancer.”
When you look at the mutational patterns in melanoma tumors, they are associated with a UV signature.— Jeffrey E. Gershenwald, MD
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The Melanoma Moon Shot Program has responded with a “continuum strategy” of educational programs starting with a curriculum to engage preschool, kindergarten, and first-grade students in activities that reinforce simple sunscreen behaviors and carrying through to a Campus Toolkit for college students and administrators. Developed by the Melanoma Moon Shot behavioral science team, led by Mary K. Tripp, PhD, the early education sun-safety program features five superheroes to help deliver sun-protection messages to children through songs, games, and other lessons, as well as educate their parents. The five superheroes are known as Ray and the Sunbeatables™ and represent the “superpowers” of shade, sunscreen, sunglasses, protective clothing, and protective hats.
In collaboration with the institution’s Cancer Prevention and Control Platform, the curriculum is being disseminated through a partnership with the CATCH (Coordinated Approach to Child Health) Global Foundation. CATCH educators also train teachers to deliver the program,” Dr. Gershenwald explained. “In collaboration with CATCH, the program, including teaching and training materials, is now available in digital format through CATCH’s online digital platform, and will immensely help with the dissemination.” (Information about Ray and the Sunbeatables is available at https://www.mdanderson.org/sunbeatables.)
Undercutting educational messages about sunscreen in some states are restrictions against bringing and applying sunscreen in schools, because it is considered an over-the-counter medication by the U.S. Food and Drug Administration (FDA); as a result, school-based policies may require a physician’s note or prescription before a student can bring and use sunscreen on campus. Several states, including Texas, California, Oregon, and New York, have countermanded this restriction by passing legislation to allow children to bring sunscreens to school and use them there. A recent article in The Wall Street Journal reported “a flurry of legislation” this year to allow sunscreens in schools.3
Multipronged Educational Approach
The MD Anderson Moon Shot Program, which includes 12 other cancer types in addition to melanoma, began in 2012 and, was mapped to the 50th anniversary of President Kennedy’s Moon Shot address at nearby Rice University stadium in 1962, Dr. Gershenwald explained. “The Moon Shot concept is to have a significant clinical impact,” he noted, “and while we have been successful at reaching 100,000 students to date, overall there are about 55 million school-aged children in the United States. We are looking now to establish much broader partnerships at the national level to promote sun safety, not only in preK, kindergarten, and first grade, but moving into the other formative childhood school years as well. Over the next year or so, led by our MD Anderson Cancer Prevention and Control Platform, we hope to rev this up as part of a multipronged approach to educate young children and educate their parents as well. So ultimately, as children become able to make their own informed decisions, they will be able to make good ones.”
Restrictions on Indoor Tanning
“When our Moon Shot was launched, we recognized that with the clinical and scientific information to date known about the dangers of indoor tanning, we had an opportunity to partner clinical and behavioral science teams with our with our government relations team here, as well as other important agencies around the state of Texas, the American Cancer Society, and other melanoma advocacy groups and foundations,” Dr. -Gershenwald recollected. “As employees of the State of Texas, we are not allowed to advocate for any specific legislation, but we helped to educate legislators and other key stakeholders on the dangers of indoor tanning by serving as the primary clinical and scientific resource on the legislation.”
INDOOR TANNING: FAST FACTS
- About one-third of U.S. states ban the use of indoor-tanning devices for those under age 18.
- Even in states without such a ban, the FDA requires indoor-tanning devices to be labeled with a black-box warning that they should not be used by those under age 18.
- More than 20 organizations, including ASCO and the American Academy of Pediatrics, have endorsed legislation prohibiting the use of indoor-tanning devices by those under age 18.
When legislation to prohibit indoor tanning for those younger than age 18 was introduced in the Texas legislature in 2013, “only 2 states in the country had an under-18 prohibition, California and Vermont,” Dr. Gershenwald reported. “Texas become the fourth state,” he noted, and now about one-third of states, plus the District of Columbia, prohibit the use of indoor-tanning devices for those under age 18. He added: “And there are many other states that have some level of prohibition or restrictive policy.” Even in states with no outright ban on indoor tanning for those younger than age 18, the FDA requires indoor-tanning devices to be labeled with a black-box warning that they should not be used by those under 18. In 2015, the FDA proposed a rule that would not allow the use of tanning booth devices to those younger than 18,4 but a final rule has not been issued.
The 2016 Skin Cancer Prevention Progress Report issued this past year by the CDC includes a graph charting the results of the Youth Risk Behavior Survey; it showed a 15% decline between 2009 and 2015 in the use of indoor tanning devices among female high school students.5 The decline was greatest from 2013 to 2015, “years that overlap with some of the indoor-tanning legislative initiatives,” Dr. Gershenwald remarked. “So, we may be seeing the beginning of some behavioral changes that could lead to actual clinical impact.”
If you can try to moderate exposure and respect the sun and use tools of sun safety, that is a way to mitigate risk.— —Jeffrey E. Gershenwald, MD
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Another indication of the impact of the Texas ban on indoor tanning for minors came from a study led by Dr. Tripp and reported in a research letter this past year in JAMA Dermatology.6 For the study, female employees of a mystery shopping firm posed as 17-year-old high school girls and called indoor-tanning facilities to see if they could use a tanning bed. “Overall, 81% of facilities reportedly complied with the ban on tanning by minors,” the researchers reported.
A study of the potential impact of reducing indoor tanning in the United States used a Markov model to estimate health benefits and melanoma treatment cost savings over the lifetimes of the current cohort of 61.2 million people aged 14 or younger.7 If none of them used indoor tanning before age 18, 61,839 melanoma cases and 6,735 melanoma deaths could be prevented, resulting in a gain of 152,659 life years and a saving of $342.9 million in treatment costs, the researchers estimated.7 “If nobody in that age group ever indoor tanned, there would be just under a half-million life years gained,” Dr. -Gershenwald said. “At a population level, the potential impact is actually quite significant. And because the median age of melanoma diagnosis in the United States is in the early 50s, the potential impact in terms of life-years gained may be magnified.”
College Campus Toolkit
The Skin Cancer Prevention Toolkit for Institutions of Higher Education, designed to assist college and university leaders nationwide implement and enforce skin cancer prevention, was developed by MD Anderson’s Melanoma Moon Shot, Cancer Prevention and Control Platform, and Office of Health Policy “in response to our identified need to help across this entire continuum,” Dr. Gershenwald noted. The toolkit relied on experience at MD Anderson in developing a tobacco prevention toolkit a year prior. Part of the supporting rationale for the skin prevention toolkit was the prevalence of indoor-tanning facilities on campus or in off-campus housing and the use of campus cash cards to purchase indoor-tanning facilities at off-campus facilities.
The toolkit includes materials to support and explain the many benefits of a 100% Indoor Tanning Free Campus Policy. Also included are guidelines for developing policy statements and student health services for behavioral counseling to prevent skin cancer and for skin examinations, as well as suggestions and templates for increasing awareness of the dangers of UV radiation and protective measures. The toolkit was developed in partnership with the American Cancer Society Cancer Action Network.
Convergence on Melanoma
“Roughly 40 tumor types have been explored as part of the National Institutes of Health initiative of The Cancer Genome Atlas project over the past several years, and melanoma has the highest mutational burden among all the tumors studied. That may be one of the reasons why melanoma has been responsive to immunotherapy,” noted Dr. Gershenwald, who in addition to the many roles he has is the Co-Leader of The Cancer Genome Atlas project for melanoma.
“If you look under the hood a little bit at the types of mutations, there is a very strong UV radiation signature for the type of mutations that are observed. The majority of the mutations that we see in the melanoma tumors actually have this signature. When you look at the mutational patterns, they are associated with a UV signature.”
In the past 5 or so years, there have been “amazing advances with immunotherapy and targeted therapy” in the treatment of melanoma, and now there is an opportunity, Dr. Gershenwald said, to “complement” these advances with greater emphasis on prevention. “Melanoma hasn’t yet decreased or stabilized in incidence like many other cancers,” he added, and “melanoma is arguably the most common cancer in women in their 20s.” “These are all things that converge,” he said, to highlight the importance of focused efforts on melanoma.
Noteworthy Abstracts From ASCO
Asked about potentially practice-changing studies presented at the 2017 ASCO Annual Meeting, Dr. Gershenwald cited updates on targeted immunotherapy for patients with melanoma and brain metastases. “Often those patients have been excluded from clinical trials,” he admitted. “Brain metastases are one of the untapped areas. We learned that we probably can use these therapies in ways that may have been out of some practitioners’ comfort zone.”
Two studies reported that the combination of nivolumab (Opdivo) and ipilimumab (Yervoy) was active in patients with melanoma and brain metastases,8,9 with one study concluding the combination therapy “may represent a new treatment paradigm” for patients with asymptomatic brain metastases and “could change practice to avoid or delay whole-brain radiotherapy or stereotactic radiotherapy.”9
A phase II trial found encouraging intracranial response and disease control rates with a combination of dabrafenib (Taflinar) and trametinib (Mekinist) in patients with BRAF V600–mutant melanoma brain metastases, “but responses appear less durable” than for patients with metastatic melanoma without brain metastases, noted Dr. Gershenwald.10 ■
DISCLOSURE: Dr. Gershenwald is an advisor for Castle Biosciences and Merck.
REFERENCES
1. Gershenwald J: Skin cancer is on the rise, focus on -prevention. Newsweek, May 18. 2017. Available at http://www.newsweek.com/skin-cancer-rise-focus-prevention-jeffrey-gershenwald-md-611780. Accessed July 7, 2017.
2. U.S. Department of Health and Human Services: The Surgeon General’s Call to Action to Prevent Skin Cancer. Washington, DC. U.S. Department of Health and Human Services, Office of the Surgeon General, 2014.
3. Reddy S: Where kids aren’t allowed to put on sunscreen: in school. The Wall Street Journal, May 15, 2017. Available at https://www.wsj.com/articles/where-kids-arent-allowed-to-put-on-sunscreen-in-school-1494863143. Accessed July 7, 2017.
4. FDA proposes new safety measures for indoor tanning devices: The facts. FDA Consumer Updates page, updated July 22, 2016.
5. Skin Cancer Prevention Progress Report 2016: Atlanta, GA: Centers for Disease Control and Prevention, U.S. Departmentt of Health and Human Services; 2016.
6. Tripp MK, Gershenwald JE, Davies MA, et al: Assessment of compliance with Texas legislation banning indoor UV tanning by minors. JAMA Dermatol. November 9, 2016 (early release online).
7. Guy GP Jr, Zhang Y, Ekwueme DU, et al: The potential impact of reducing indoor tanning on melanoma prevention and treatment costs in the United States: An economic analysis. J Am Acad Dermatol 76:226-233, 2017.
8. Long GV, Atkinson V, Menzies AM, et al: A randomized phase II study of nivolumab or nivolumab combined with ipilimumab in patients with melanoma brain metastases: The Anti-PD1 Brain Collaboration. 2017 ASCO Annual Meeting. Abstract 9508. June 4, 2017.
9. Tawbi H A-H, Forsyth PA, Algazi AP, et al: Efficacy and safety of nivolumab plus ipilimumab in patients with melanoma metastatic to the brain: Results of the phase II study CheckMate 204. 2017 ASCO Annual Meeting. Abstract 9507. June 4, 2017.
10. Davies MA, Robert C, Long GV, et al: COMBI-MB: A phase II study of combination dabrafenib and trametinib in patients with BRAF V600–mutant melanoma brain metastases. 2017 ASCO Annual Meeting. Abstract 9506. June 4, 2017.
