Safe Sun : Medical Experts Are Doing a Slow Burn Over Deep Tans as the Incidence of Skin Cancers Continues to Increase
Dr. Richard Strick has come to expect the calls from parents of his daughter’s friends.
The message is always more or less the same. Debby, 8, has been an overnight guest. Did Strick know his daughter arose early in the morning, washed her face and immediately applied 15 sunblock to her head and neck?
Calmly, the UCLA dermatologist tells the parent he knows Debby does this--because he suggested it and, in fact, he starts his days the same way. And if Strick and a growing number of dermatologists, cancer specialists and other doctors have their way, this morning routine will become a part of the way of life for Californians and anyone else who lives in a generally sunny climate.
It is part of what these physicians hope is the beginning of a large-scale response to an epidemic whose breadth and ramifications are increasingly disquieting.
Epidemic Reaching Younger People
It is an epidemic of skin cancer. Once a disease afflicting primarily the old, skin cancer has been seen increasingly in people in their 20s and 30s, and specialists now are starting to report serious skin cancers and even deaths among teen-agers.
According to statistics of both the American Academy of Dermatology and the American Cancer Society, there may be as many as 500,000 new cases of skin cancer this year in the United States, including between 26,000 and 27,000 new malignant melanomas--the most serious kind. The outbreak also includes two less serious--but far more numerous--cancers: squamous cell and basal cell carcinoma.
Just as Americans began a decade ago to monitor their blood pressures and change their eating habits accordingly and are now beginning to exhibit similar concerns over cholesterol levels, dermatologists hope a public awareness of skin cancer and sun damage to the skin will change American life styles so much that one day the catch phrase safe sun will as meaningful as safe sex is today.
A lot more will change, specialists hope:
--Outdoor habits, of Californians in particular, will be significantly affected. Mid-day hours--from 10:30 or 11 a.m. to 2:30 to 4 p.m.--traditionally identified as the time of the sun’s best tanning rays, will be recognized instead as the most dangerous. Children will be taught to think of the peak tanning hours as, instead, the protect time. Beaches will not be populated by sunbathers devoted to basting themselves, according to Dr. Faye Arundell, a Menlo Park dermatologist and spokeswoman for the American Academy of Dermatology.
--Cool, opaque cotton shirts will be pulled on during the peak mid-day hours and floppy, full-brimmed hats and visors will be commonly worn. Instead of turning their beach chairs toward the sun, beach-goers will maneuver their chairs to face away , and avoid sun burn at all costs, since the burning of the skin is the most significant harmful effect of sun. Runners and tennis players will avoid scheduling exercise periods during the middle of the day.
--Sunblocks rated at least 15 will be applied to faces, heads and arms as part of the morning routine, just like shaving and applying makeup. Construction companies, police agencies and even baseball teams will start providing high-number sunblocks for their workers.
--Parents of infants will take care to keep their babies covered--with clothing, retractable tops on strollers and umbrellas, as well as by taking advantage of natural shade--since some skin cancer experts believe that by controlling sun exposure in babies 1 or younger, as much as 95% of skin cancer could be prevented later in life, according to some research estimates.
--More important, though, said Dr. Richard Odom of UC San Francisco and UCLA’s Dr. Ronald Reisner, the social acceptability of the deep tan will disappear. Someone with a deep tan might be perceived in a decade the same way someone who can’t quit smoking is now.
Part of this futurism has already emerged. Beauty magazines and cosmetic companies have begun to back away from emphasis on the deep tan as a fashion statement. Models are appearing paler in many advertising campaigns, and women’s magazines have begun to focus on the idea that tan is not necessarily hip.
Dermatology experts agree that about 80% of the sun-induced basis for premature deterioration of the skin--a process called photoaging and characterized by wrinkling, sagging and other aging of the skin--is laid before a person turns 20. Reaching young people with this message is seen as crucially important.
“We used to think that the best we could do was hold the line (after age 20) and not add to it,” Arundell said. “But there are laboratory investigations now that show if a 15 sunblock is used daily, the skin does actually start to repair itself. If you’re 25, you have at least twice as long (in terms of natural life expectancy) to repair that damage as you did to get it in the first place.”
“I think that there is a certain, basic practical philosophical issue that people ought to settle in their minds,” Reisner said. “That is: How concerned are they about the risk of premature aging of their skin and the risk of skin cancer or melanoma?
Some Want Protection
“Some people are going to come down on the side that they want to be protected in the same way some people 10 years ago said they were going to eat a low-fat diet, high in carbohydrates, to lower serum cholesterol and reduce the risk of a heart attack.
“Other people said, ‘I don’t care. I’m going to eat my steak every night.’ It’s the same story as with smoking. People need to make these kinds of decisions. They’re just not as dramatic in regard to the issue of sun exposure yet, because it (the importance of controlling sun damage to the body) has not yet penetrated the consciousnesses of most people. It is not a popular item with the public--yet.”
No one thinks this sun revolution will be easily accomplished. UC Riverside psychologist Howard Friedman led a study published last year in which interviewers fanned out on beaches in five south Orange County communities and administered detailed questionnaires to 120 beach-goers in an attempt to find out how they view themselves and their behavior.
Traits of Sun Worshipers
The most devoted sun worshipers, Friedman and co-researcher Barbara Keesling found, have a higher need for aggression than achievement, rank avoiding harmful behavior low on a priority list, tend to be weight-conscious and health-conscious, are preoccupied with their appearance, engage in active sports and are disinclined to use seat belts regularly. Women were more likely to use sunscreens than men.
The tanning culture, Friedman and Keesling found, has as one of its central bases the need to maintain the appearance of being active, healthy and attractive. So in a follow-up study now under way, Friedman said researchers have begun to find that educational programs focusing on the harm of skin cancer may be able to change sun behavior.
“We want people to say: ‘I brush my teeth in the morning. I shave or I put on my makeup. I put my sunscreen on every morning. And that’s how I lead my life,” Reisner said. “I think that’s going to happen with the kids who are now growing up. This information is becoming increasingly available to the general public. I think it is possible for behavioral change to take place, but it takes place very slowly.”
Doctors, Odom and Reisner readily admit, are late--perhaps very late--converts to this faith. The science on which today’s developing programs encouraging caution in sun exposure is built is not new; in fact, the gospel dermatologists preach was largely written by researchers at least a decade ago.
Odom said he thinks dermatologists, in particular, embraced the developing campaign not only because of its scientific merit but also because of market forces introduced by a glut of doctors and increased competition for patients among physicians and hospitals.
Reisner and Odom concede that the revolutionary changes in behavior they now espouse may be impractical to expect among today’s adults and even teen-agers.
Preventing Skin Cancers
“There is no question that there are a lot of skin cancers now, but the thing about it is it is preventable,” Odom said. “That’s the reason we’re making people a little bit paranoid. We’re maybe scaring them, giving them a lot of information. Most people are not going to live (a life style organized around optimal sun avoidance).
“Hopefully, though, the fallout will be that people adopt a middle-of-the-road approach. We can go down to Laguna Beach and Huntington Beach and tell them (adolescents and young adults) to put their shirts on and wear sunscreen and they’ll just . . . say, ‘No way, Jose.’ ”
“It’s very difficult to convince teen-agers that they should be using sunscreens when all their peers think a tan is healthy and has the appearance of wealth,” said Dr. Sidney Hurvitz, a Yale University pediatrician and medical adviser to the New York-based Skin Cancer Foundation.
“I tell every one of them, ‘You have to use sunscreen.’ Most listen. But not always,” Hurvitz said. “We have to get them to realize they are damaging their skin every time they get a tan. We are now seeing bad skin cancers in younger and younger individuals.
“It used to be a problem of older people. But we’re now seeing basal cell carcinomas and malignant melanomas in individuals in their 20s and in teen-agers. I’m about to report a 16-year-old who died. It’s no longer fun and games.”
Campaign in Australia
Doctors agreed that one of their objectives in the United States is to approach the success of a public awareness program in Australia in which, over the last five to 10 years, skin cancer specialists have urged people to adopt safe-sun behavior. The campaign has had little effect on the degree to which Australians expose themselves to the sun, Odom said, but it has markedly increased the awareness of the signs of skin cancer among the population and significantly reduced death rates because cancers are detected early.
Odom emphasized that treatment is most effective when lesions are found when they are small. In most cases, skin cancers that have just begun to develop can be cured by minor surgery under local anesthetic, with only a small area of skin removed.
The problem may even be worsened, a team of Dutch researchers reported this week, by the chronic inability of people to accurately judge how easily they sunburn or tan--which, in turn, may affect behaviors like total sun exposure and ultimate skin damage.
Researchers in Oss, The Netherlands, found in a study of 790 white students aged 17 to 30 that there was no discernible relationship between the students’ own perception of their tanning ability and what would be expected using a measuring system in which sunburn susceptibility is divided into four skin type groups among light-skinned Caucasians.
People, the researchers reported in the journal Archives of Dermatology, consistently underrated their own ability to tan and burn. Dark-skinned Caucasians, Asians and blacks are grouped in two separate categories in terms of tanning and skin cancer risk--each one signifying far lower risk than fairer-skinned whites. All types of skin cancer are far more common in pale-skinned people.
To detect skin cancers, dermatologists recommend self-examination at least monthly. Basal cell and squamous cell carcinomas generally occur on the head, neck or hands. Basal cell carcinoma often appears as a small, fleshy bump, while squamous cell carcinoma has the appearance of a scaly, red patch.
Four Danger Signs
The far more serious melanomas can be recognized by any of four common danger signs. Many begin as dark blotches on the skin. They can be identified because:
--They are asymmetrical, with one half of the spot distinctly unlike the other half.
--They have irregular or poorly defined edges.
--They have color variations between areas of the spot, with shades of black, tan, brown, white, red or blue often mixed together.
--They are larger than the diameter of a common pencil eraser.
Melanomas can also appear as moles on the skin surface, and any change in an existing mole should be viewed with suspicion. Moles first noticed in early childhood may remain dormant for years but turn into melanomas in adulthood. Melanomas are more common in women on the legs and in men on the back, but they can occur on many parts of the body. A melanoma may not necessarily appear on a part of the body that is heavily exposed to the sun.
It is this tendency of melanoma that has made most experts reluctant to say unequivocally that melanoma is strictly caused by exposure to the sun. While basal cell and squamous cell carcinomas are seen as sun-induced almost unanimously by cancer experts, questions still surround the role of sun in melanoma.
In just 50 years, the incidence of melanoma has increased from one chance in 1,500 that the average person will get it in his or her lifetime to one in 250 today and is projected to be one in 90 to 150 by the turn of the century, according to the American Academy of Dermatology. Of the melanoma victims, there are expected to be 7,000 deaths this year. (Another 2,000 people are expected to die from it because they had advanced cases of the two less serious cancers varieties that were not detected in time.)
‘Sun Plays a Role in Melanoma’
“I think most people agree that sun plays a role in melanoma, although all of the evidence for that is circumstantial,” said UCLA’s Strick. “As you go closer to the Equator, the incidence rises. The hooker is that melanomas don’t necessarily occur on areas (of the body) that are sun-exposed and that makes you wonder.”
The American fascination with the sun is a comparatively recent social development. Friedman, Arundell and other experts noted that, before the turn of the century, having a tan was identified with blue-collar occupations since only lower-class workers toiled outdoors. But in the early 1900s, a health craze called heliotherapy took root in Europe and arrived in the United States just before World War I.
Gradually, having a tan came to be associated with health. As the Industrial Revolution matured, indoor work became less the exclusive province of the rich. In the 1930s, heliotherapy and a fascination with nudity joined, and health officials began to urge mothers to make sure their children sunbathed daily. The sun was thought to afford health properties.
The first warnings about skin cancer were sounded as early as the 1940s, but it was not until about 20 years ago that scientists focused on the problem with precision.
Today, according to Arundell, while some exposure to the sun is necessary to maintain health, experts unanimously agree there is nothing but risk in overexposure. Even among teen-agers, who may believe being in the sun can minimize the effects of acne, the health mystique has disappeared, Arundell said. Most modern acne medications do a far better job of treating the condition than sunlight.
“There definitely is a trend,” Arundell said. “There is enhanced awareness, even in teen-agers who are the greatest risk-takers in the population. They have the feeling that they’re invulnerable, that it (aging or skin cancer) is not going to happen to them.
“Now, teen-agers talk to me spontaneously about what kind of sunblock to use. Those things indicate that the message is getting through, but we still have a lot to do.”
