Anthony J. Alberg, PhD, MPH

The increasing incidence rates of skin cancer in the United States are staggering. It is the most common cancer diagnosed in the country, and current estimates show that about 9,500 Americans are diagnosed with skin cancer every day. Over the course of a year, more than 3 million people are diagnosed with nonmelanoma skin cancer, including basal cell and squamous cell carcinomas,¹ and another 100,350 individuals are diagnosed with melanoma, the deadliest type of skin cancer. According to American Cancer Society estimates, about 6,850 people are expected to die of melanoma this year.²

To reduce the skin cancer burden in the United States, earlier this year, ASCO published a policy statement examining the risk factors for the development of skin cancer and the public health challenges posed by the disease. The statement suggested recommendations in four key areas to prevent skin cancer.³ Those areas include the following:

Reducing exposure to indoor tanning: Because ultraviolet (UV) radiation–emitting tanning devices, such as tanning beds, sunlamp products, and UV lamps, are a strong determinant of skin cancer risk, ASCO is recommending strengthening laws and regulations against the use of UV radiation–emitting indoor tanning devices.

Increasing public efforts to promote sun protection: ASCO’s statement calls for expanding strategies to reduce harmful UV radiation from the sun. They include supporting school district policies that allow students to use sun-protection products without physician authorization, the development of improved sunscreen products, public education to prevent intentional sun exposure to increase vitamin D levels, and the development of educational efforts to change the social perceptions of tanned skin.

Community education and outreach: ASCO recommends that concurrent investments be made to define effective skin cancer prevention interventions and best practices for disseminating them through education, clinical services, and public policy. ASCO also encourages the development of evidence-based approaches for public health programs aimed at diverse segments of the population at risk for skin cancer, including sexual minority men, people with a lower socioeconomic status, and persons of color.

GUEST EDITOR

Jennifer A. Ligibel, MD

Prevention in Oncology is guest edited by Jennifer A. Ligibel, MD, Chair of ASCO’s Energy Balance Working Group and a member of ASCO’s Cancer Survivorship and Cancer Prevention Committees. Dr. Ligibel is Director of the Leonard P. Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute.

Each Prevention in Oncology column will address one of five areas in cancer prevention—alcohol use, obesity, tobacco use, vaccines to prevent cancer-causing infections, and germline genetics—with the goal of providing strategies to reduce the risk of cancer, as well as preventing cancer recurrence and second malignancy during cancer survivorship.

Defining the role of oncology providers: Research shows that cancer survivors do not adhere to skin-protective behaviors more than those who have not been diagnosed with cancer.⁴ ASCO’s recommendations in this area highlight ways oncology providers can enhance awareness about skin cancer with their patients and their communities. The recommendations include discussing skin cancer prevention as part of survivorship care planning; educating patients about their potential risk of secondary skin cancers from treatment and the importance of using sunscreen and protective clothing as well as the dangers of indoor tanning; and supporting primary care and other community providers in their skin cancer prevention strategies.

The ASCO Post talked with Anthony J. Alberg, PhD, MPH, Professor and Chair in the Department of Epidemiology and Biostatistics at the Arnold School of Public Health at the University of South Carolina, former Chair of ASCO’s Cancer Prevention Committee, and lead author of ASCO’s skin cancer prevention policy statement, about the danger of “tanning dependence” from the use of indoor tanning devices, the skin cancer risk for people of color, and how oncologists can promote cancer prevention strategies with their patients and in their communities.

Acknowledging Skin Cancer’s Impact on Society

Why did ASCO develop this policy statement on skin cancer prevention at this particular time?

What prompted the development of this statement and its recommendations was the realization that ASCO had not weighed in on this topic and that skin cancer has such a major impact on society. The trends in skin cancer rates are increasing at such an alarming level that I consider skin cancer rates to be at epidemic levels in the United States. The way to significantly reduce the risk of skin cancer is to reduce exposure to UV radiation from the sun and indoor tanning devices, but many people are not taking these precautions. In fact, ASCO’s 2019 National Cancer Opinion Survey found that only 49% of respondents reported using sunblock to prevent skin cancer,⁵ so we have to do a better job of educating the public about the dangers of UV radiation exposure.

Screening for ‘Tanning Dependence’

The policy statement mentions an emerging body of evidence showing the presence of “tanning dependence,” similar to substance use dependence, among individuals who engage in indoor tanning. What are the implications of such dependence in the clinical setting?

If the evidence regarding tanning dependence from the use of indoor tanning solidifies and becomes more pronounced, and tanning dependence is eventually classified as a medical disorder, the implications in the clinic could include the need to screen for the disorder and to treat it. Although, currently, this may be more of a concern for primary care physicians, we know that exposure to UV rays from the sun or from indoor tanning devices raises the risk of skin cancer, and that poses a problem for oncologists and their patients.

Proving Causality: UV Radiation Exposure and Skin Cancer

What is the skin cancer danger from tanning beds and other indoor tanning devices? Are there higher incidences of nonmelanoma skin cancers and melanoma as a result of the use of these devices?

International health organizations have reviewed the evidence regarding the risk of skin cancer from indoor tanning devices and concluded that there is a causal association with these devices and an increase in the risk of malignant melanoma, so that is well established. The same conclusions have not been reached yet for nonmelanoma skin cancers, but the preliminary evidence is all pointing in that direction.

“Conversations about the risks of skin cancer from UV radiation should be part of patients’ survivorship care planning.”

— Anthony J. Alberg, PhD, MPH

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In my opinion, from the data I’ve seen, the body of evidence is strong enough to say that indoor tanning devices cause both squamous cell and basal cell carcinomas of the skin, but that has not been officially confirmed at this point by organizations such as the International Agency for Research on Cancer. However, we know that solar UV radiation is the leading cause of both major types of nonmelanoma skin cancer.

Although the incidence of melanoma is more common among non-Hispanic Whites than Hispanics and non-Whites, non-White racial/ethnic groups are more likely to be diagnosed with advanced-stage melanoma and die of the cancer.⁶ Do you believe a lack of awareness of the risk of cancer among people of color, less access to health care, and delayed diagnosis may be responsible?

This needs more study, but, yes, the thinking is that Black and Latinx individuals may be less aware of their skin cancer risks and, therefore, may be less likely to have it detected.

There is also a suspicion that physicians, even dermatologists, are more attuned to looking for skin cancers in their fair-skinned patients than in their darker-skinned patients. In addition, the issues of socioeconomic status and access to high-quality health care come into play.

This is why educating the public, including people of color, about the danger of UV radiation exposure and skin cancer risk is important. Then everyone can take protective measures, including the use of broad-spectrum sunscreen and protective clothing, to reduce the risk of skin cancer and have suspicious skin lesions checked by a physician, so melanoma can be detected in its early, most curable stages.

Increasing Legal Restrictions on Indoor Tanning

Among ASCO’s recommendations on skin cancer prevention is strengthening laws and regulations against the use of UV radiation–emitting indoor tanning devices and increasing public awareness of the benefits of sun protection. How effective are these suggestions in real-world settings?

I can’t speak for every state, but I know that in South Carolina, having ASCO release these recommendations has been very helpful in alerting legislators about the dangers of indoor tanning. For example, South Carolina does not currently have legislation prohibiting people aged 18 years and younger from using indoor tanning beds, but a bill is pending in the South Carolina Senate.

I recently testified before our state legislators about the skin cancer risks from tanning beds. And it was very helpful to have ASCO’s policy statement on skin cancer prevention as evidence of the risks these devices pose to people, especially young people.

Curtailing the Skin Cancer Epidemic

ASCO’s skin cancer prevention policy statement details the critical role oncology providers play in promoting skin-protective behaviors in their patients. Please talk about how oncologists can raise awareness of the risks posed by solar UV radiation exposure with their patients.

The first step that would be very valuable is just getting the risks of skin cancer from UV radiation on patients’ radar, including their patients of color, and making the conversation part of patients’ survivorship care planning. Oncologists can talk with their patients about the benefits of regularly using broad-spectrum sunscreen and wearing hats, long sleeves, and long pants during the strongest hours of the sun, between 10:00 AM and 4:00 PM, and avoiding artificial tanning devices.

Oncologists are also leaders in their communities, both their professional and personal communities, and are highly respected. Supporting the efforts of primary care providers and local legislators in the promotion of sun protection and in the engagement of the multifaceted strategies outlined in ASCO’s policy statement will have a major impact on curtailing the skin cancer epidemic in this country. 

DISCLOSURE: Dr. Alberg reported no conflicts of interest.

REFERENCES

1. American Academy of Dermatology Association. Skin cancer: Incidence rates. Available at www.aad.org/media/stats-skin-cancer. Accessed October 8, 2020.

2. American Cancer Society: Key statistics for melanoma skin cancer. Available at www.cancer.org/cancer/melanoma-skin-cancer/about/key-statistics.html. Accessed October 8, 2020.

3. Alberg AJ, LoConte NK, Foxhall L, et al: American Society of Clinical Oncology policy statement on skin cancer prevention. JCO Oncol Pract 16:490-499, 2020.

4. Lau SCM, Chen L, Cheung WY: Protective skin care behaviors in cancer survivors. Curr Oncol 21:e531-e540, 2014.

5. The Harris Poll, Harris Insights & Analytics LLC: ASCO 2019 cancer opinions survey, September 2019. Available at www.asco.org/sites/new-www.asco.org/files/content-files/blog-release/pdf/2019-ASCO-Cancer-Opinion-Survey-Final-Report.pdf. Accessed October 8, 2020.

6. Noone AM, Howlader N, Krapcho M, et al: SEER cancer statistics review, 1975–2015. Available at https://seer.cancer.gov/archive/csr/1975_2015/. Accessed October 8, 2020.