Bad News

One in five Americans will develop skin cancer in their lifetime.

• This translates into over 55 million Americans.
  
• One in 75 will develop melanoma, the often-fatal form of skin cancer, and if the current trends hold true, the percentage will be higher still.
  
• Melanoma incidence has increased by 1200% since the 1930s.
  
• In teenagers it has increased by 100% in the past 10 years alone.
  
• It is the most common cancer in women under 30.
  
• Deaths from melanoma continue to rise despite newer treatment modalitites.

Good News

The good news is that you can actively change the above statistics for yourself or your children through relatively easy steps.

• Prevention
  
• Early recognition and treatment

This discussion will focus on melanoma rather than the other two skin cancers, basal cell and squamous cell carcinomas, because melanoma does routinely kill people, while the other two do so only rarely.

• Causes of Skin Cancer
• Prevention
• Signs of Melanoma
• Protecting Yourself
• Myths vs. Facts

Sunlight and The Damage It Can Cause

Causes of Skin Cancer

Melanoma rates are increasing exponentially and faster than those of any other cancer. The cause of this is still somewhat of a puzzle, but appears to be directly linked to:

• Our populations increasing sun exposure. Many blame the designer Coco Chanel for first introducing tan models and making tan skin fashionable.
  
  
• The rest of the fashion industry has further contributed by doing away with clothing as a form of sun protection; hem lines have gone up, swim wear has shrunk, and parasols and gloves have gone out of style.
  
  
• Henry Ford and the automobile are also at fault. As more and more people drove, the wearing of hats was abandoned, and the current popularity of motorized transportation has led to ozone depletion and global warming.
  
  
• Holes in the ozone layer allow more cancer-causing rays to reach the earths surface, and global warming has led to sunnier days.
  
  
• Our country's increasing leisure time spent in the sun has also played a role, as well as the fact that more light-skinned people are living in more tropical climates.
  
  
• Lastly, the possibility has been raised that perhaps the increasing length of sun exposure enabled by sunscreen use has allowed more tumors to form.

Other Risk Factors That May Contribute to Melanoma Development

• Skin color, are indirectly related to sun exposure, i.e., because lighter skin has less intrinsic protection against the sun, it allows more sun to penetrate the skin surface. Interestingly, very dark-skinned people often develop melanoma in less pigmented locations, such as the palms or soles.
  
  
• Family history of melanoma; it is unclear whether this is simply due to similar skin color and similar sun exposure, or rather due to some inherent genetic defect.
  
  
• People with more than a hundred moles are at an increased risk as well, especially if many of these moles appear atypical.

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Prevention

So, in light of the above grim statistics, what can you do to avoid getting melanoma?

The most critical tactic is prevention.

Since more than 80% of all sun damage occurs before the age of 18, the most effective time for this is during childhood. Unfortunately, children are not sovereign and cannot do this on their own. Unless the parent takes serious responsibility for sun safety, the child will enter adulthood with irreversible damage already done.

The Environmental Protection Agency (EPA) is concerned enough about the lack of sun safety during childhood that it has developed a program to use in elementary schools. Over the next few years, children will begin learning about sun safety as part of their required curriculum, but until then, nothing is being taught. In fact, our schools are often the worst offenders regarding skin protection: most schoolyards lack shade, many schools have banned the use of hats, and there is no opportunity given to reapply sunscreen.

This is in contrast to Australia, a country with similar melanoma rates as ours, where skin safety instruction begins at the kindergarten level and national policy requires children to put on hats and sunscreen prior to going outside. Moreover, lunch and recess have been moved to avoid noontime sun when the ultraviolet rays are particularly damaging.

Similar strategies will undoubtedly become mandated policy in this country, but since bureaucracy moves slowly, this will come too late for this generation of children. If you are already an adult, all is not lost and you can still reduce your chances of skin cancer somewhat by starting with safe sun practices now.

If you're an adult who fried their skin during childhood and have done irreversible damage already, you need to perform routine self-exams and learn to recognize melanoma early, so that it can be treated before it has a chance to metastasize.
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Signs of Melanoma

Recognizing melanoma is not difficult.

Since melanoma is now common in our population and can develop in young people, even teenagers, all Americans need to learn to recognize its warning signs. Melanoma can look like a mole, which is why we are often told to "watch our moles."

However, it differs from ordinary moles in five ways, which can be remembered using an ABCDE algorithm:

A stands for asymmetry; melanoma can be asymmetric, whereas ordinary moles are usually round and fairly symmetric.

B stands for border irregularity; melanomas can have irregular or jagged borders, whereas benign lesions tend to have smooth borders.

C stands for color, which is usually black or has variations of different colors, including brown, black, or red; harmless moles are usually all one color.

D stands for diameter, which is usually larger than six millimeters, or the size of a pencil eraser; harmless moles are usually smaller.

E is for expansion; even if melanoma starts out small, it usually enlarges.

Another clue that a spot may be dangerous is if it looks different from all your other moles. Melanoma can be completely flat and not give you any symptoms, therefore, you have to look for it.

It is recommended that you do a quick skin exam once a month.

Check all your skin, because melanoma can develop on any part of the skin, even that which is never exposed to sun. Moreover, melanoma can develop on normal skin and not necessarily from a mole. The monthly skin exam is perhaps more important than an annual skin check by a physician, because if you develop a melanoma, you need to find it long before your routine physical exam.

The role of sunscreens has recently been questioned by postulating that sunscreen use actually leads to more melanoma by allowing its user to stay in the sun longer and, therefore, cause more sun damage that way. It is argued that without sunscreen, a person would be forced to seek shade earlier because of burning and discomfort of the skin. It is difficult to prove or disprove this theory. Those advocating sunscreen use point out that Australia, where sunscreen use is prevalent, is the only country where melanoma rates have fallen, rather than increased. However, some attribute this decline of skin cancer to the influx of darker-skinned people into Australia rather than the increase in sunscreen use.

The American Academy of Dermatology (AAD) has come out in support of sunscreen use and those advocating against its use are certainly in the minority. The take home message here is that sunscreens are not perfect and their protection from the sun is not complete.
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Protecting Yourself

1. Sunscreen Use Guidelines

• Apply 30 minutes before exposure. It is only after it has time to bind to the skin that it becomes effective.
  
  
• Apply enough. Studies show that the average person applies only half the amount necessary for sun protection. By decreasing the thickness of application, you can decrease an SPF (sun protection factor) of 50 to 2.7.
  
  
• Apply even on cloudy days. 80% of the suns harmful rays still get to the earths surface despite a cloud cover.
  
  
• Reapply every two hours. The effectiveness of sunscreen declines rapidly. Don't be fooled by claims of "all day" or "8 hour" sunscreens; in fact, the FDA (Food and Drug Administration) has recently banned such advertising.
  
  
• Use a sunscreen with both UVA as well as UVB protection. The suns harmful rays are divided into UV (ultraviolet) A and B. Currently there are only two ingredients in US sunscreens that do an adequate job of UVA coverage: 1) microfine zinc oxide and 2) Parsol or avobenzone. Sunscreens lacking these two ingredients will only protect you against a very small part of the UVA spectrum. Since the SPF number only rates UVB light, you can buy a sunscreen with an SPF of 50 and still have almost no UVA protection.
  
  
• Do not use sunscreens made specifically for children. Most of these do not have adequate UVA protection and other than the packaging, are not much different from regular sunscreens.

2. Other Measures To Protect Yourself

• Encourage the use of hats and sunglasses. This is an important adjunct to sunscreens, as no sunscreen currently on the market blocks the sun completely.
  
  
• Avoid the sun between the hours of 10-2. This is when the suns rays are amplified and cause damage to the skin in a much shorter time.
  
  
• Wear sun-protective clothing. In general, this does a better job of protecting the skin than does sunscreen, and keeps you cooler on a sunny day. The clothing needs to have tightly woven material and usually states an SPF number. There are also sun-protective swimsuits available which look like wetsuits and come in many different styles (kids love them!).

3. What can you do at school?

• Have your child bring sunscreen to keep at school. Have the teachers encourage kids to apply this 1/2 hour before going outside. Remember, the more children who do this, the more routine this will become. This should be as routine to a child's safety as putting on seatbelts.
  
  
• Have your child bring a hat and sunglasses to wear outside. There are many styles the kids can get excited about wearing. Try to incorporate hats into P.E. wear in your school.
  
  
• Encourage your child to eat their lunch or snack in the shade. Several schools have funded table umbrellas and shade trellises for this purpose through fund raising drives.
  
  
• Plant shade trees. Encourage sun safety teaching as part of your child's curriculum. Materials can be obtained from the EPA or the AAD.

4. Think globally and act locally

• Do your part to decrease pollution and therefore slow global warming. Simplify your life. Drive less and walk more. Reduce your consumer spending; more cars, larger homes, more material possessions all contribute to global pollution. Support preservation of the worlds rain forests.
  
  
• Help stop ozone depletion. Avoid aerosol sprays, and make sure your appliances are ozone safe.

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Myths vs. Facts

Myth	Fact
If a mole is flat, it cant be dangerous.	Most melanomas start out flat and spread peripherally before becoming more bumpy.
If I don't feel anything, I don't have melanoma there.	Most melanomas don't give you any symptoms. They can become quite large without bleeding, hurting, or itching. Unless you look for it, you will miss it.
I've never had sun on this part of my skin, therefore I don't need to check it.	For reasons unknown, melanoma can sometimes develop in sun-protected skin, including the scalp and genital areas.
I always lather on the sunscreen, therefore I wont get skin cancer.	As mentioned above, sunscreens do not block 100% of the suns rays.
I'm not really that light-skinned.	Unless you have skin that never burns, no matter how long you stay in the sun, you're not considered dark-skinned.
I don't need to use sunscreen if I wear a hat.	You can sunburn from ultraviolet rays reflecting from the ground up.
If I have moles cut out, I don't have to worry about developing melanoma there.	You can develop melanoma in normal skin just as easily as in a mole.

References:

• Skin Cancer Foundation. Accessed January 2008.
  
• Skin Cancer, National Cancer Institute. Accessed January 2008

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