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Melanoma

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The American Academy of Dermatology recommends sunscreen lotion with an SPF of 30 to be used daily by those who spend a lot of time in the sun.
Choose sunscreen and clothing as part of your sun protection regimen
Dr. David Dunaief

This holiday weekend, many headed to the beaches or fired up the outside barbecue for the first weekend of what’s shaping up to be a steamy summer. Long summer days spent outside conjure up pleasant images of friends and family relaxing together.

What could possibly be wrong with this picture? With all these benefits, you need to be cognizant of cutaneous (skin) melanoma. It is small in frequency, compared to basal cell and squamous cell carcinomas, responsible for only about 1 percent of skin cancers; however, it is much more deadly.

Statistics

Unfortunately, melanoma is on the rise. Over the last 40 years from 1970 to 2009, its incidence has increased by 800 percent in young women and by 400 percent in young men (1). These were patients diagnosed for the first time between 18 and 39 years old. Overall, the risk is greater in men, with 1 in 28 lifetime risk. The rate among women is 1 in 44. It is predicted that in 2017, there will have been over 87,000 new diagnoses, with over 11 percent resulting in death (2).

Melanoma risk involves genetic and environmental factors. These include sun exposure that is intense but intermittent, tanning beds, UVA radiation used for the treatment of psoriasis, the number of nevi (moles), Parkinson’s disease, prostate cancer, family history and personal history. Many of these risk factors are modifiable (3).

Presentation

Fortunately, melanoma is mostly preventable. What should you look for to detect melanoma at its earliest stages? In medicine, we use the mnemonic “ABCDE” to recall key factors to look for when examining moles. This stands for asymmetric borders (change in shape); border irregularities; color change; diameter increase (size change); and evolution or enlargement of diameter, color or symptoms, such as inflammation, bleeding and crustiness (4). Asymmetry, color and diameter are most important, according to guidelines developed in England (5).

It is important to look over your skin completely, not just partially, and have a dermatologist screen for potential melanoma. Screening skin for melanomas has shown a six-times greater chance of detecting them. Skin areas exposed to the sun have the highest probability of developing the disease. Men are more likely to have melanoma tumors on the back, while women are more likely to have melanoma on the lower legs, but they can develop anywhere (6).

In addition, most important to the physician, especially the dermatologist, is the thickness of melanoma. This may determine its probability to metastasize. In a retrospective (backward-looking) study, the results suggest that melanoma of >0.75 mm needs to not only be excised, or removed, but also have the sentinel lymph node (the closest node) biopsied to determine risk of metastases (7).

A positive sentinel node biopsy occurred in 6.23 percent of those with thickness >0.75 mm, which was significantly greater than in those with thinner melanomas. When the sentinel node biopsy is positive, there is a greater than twofold increase in the risk of metastases. On the plus side, having a negative sentinel node helps relieve the stress and anxiety that the melanoma tumor has spread. The two most valuable types of prevention are clothing and sunscreen. Let’s look at these in detail.

Clothing

Clothing can play a key role in reducing melanoma risk. The rating system for clothing protection is the ultraviolet protection factor (UPF). The Skin Cancer Foundation provides a list of which laundry additives, clothing and cosmetics that protect against the sun (8). Clothing that has a UPF rating between 15 and 24 is considered good, 25 and 39 is very good, and 40 and 50 is excellent. The ratings assess tightness of weave, color (the darker the better), type of yarn, finishing, response to moisture, stretch and condition. The most important of these is the weave tightness (9). There are many companies that produce fashionable and lightweight sun protective clothing lines. Gone are the days of needing to wear your jeans into the water while swimming to protect you from the sun.

Sunscreen

We have always known that sunscreen is valuable. But just how effective is it? In an Australian prospective (forward-looking) study, those who were instructed to use sun protective factor (SPF) 16 sunscreen lotion on a daily basis had significantly fewer incidences of melanoma compared to the control group members, who used their own sunscreen and were allowed to apply it at their discretion (10). The number of melanomas in the treatment group was half that of the control group’s over a 10-year period. But even more significant was a 73 percent reduction in the risk of advanced-stage melanoma in the treatment group. Daily application of sunscreen was critical.

The recommendation after this study and others like it is that an SPF of 15 should be used daily by those who are consistently exposed to the sun and/or are at high risk for melanoma according to the American Academy of Dermatology (11). The amount used per application should be about one ounce. However, since people don’t use as much sunscreen as they should, the academy recommends an SPF of 30 or higher.

Note that SPF 30 is not double the protection of SPF 15. The UVB protection of SPFs 15, 30 and 50 are 93, 97 and 98 percent, respectively. The problem is that SPF is a number that registers mostly the blocking of UVB but not so much the blocking of UVA1 or UVA2 rays. However, 95 percent of the sun’s rays that reach sea level are UVA. So what to do?

Sunscreens come in a variety of UV filters, which are either organic filters (chemical sunscreens) or inorganic filters (physical sunscreens). The FDA now requires broad-spectrum sunscreens pass a test showing they block both UVB and UVA radiation. Broad-spectrum sunscreens must be at least SPF 15 to decrease the risk of skin cancer and prevent premature skin aging caused by the sun. Anything over the level of SPF 50 should be referred to as 50+ (3).

The FDA also has done away with the term “waterproof.” Instead, sunscreens can be either water resistant or very water resistant, if they provide 40 and 80 minutes of protection, respectively. This means you should reapply sunscreen if you are out in the sun for more than 80 minutes, even with the most protective sunscreen (3). Look for sunscreens that have zinc oxide, avobenzone or titanium oxide; these are the only ones that provide UVA1 protection, in addition to UVA2 and UVB protection.

In conclusion, to reduce the risk of melanoma, proper clothing with tight weaving and/or sunscreen should be used. The best sunscreens are broad spectrum, as defined by the FDA, and should contain zinc oxide, avobenzone or titanium oxide to make sure the formulation not only blocks UVA2 but also UVA1 rays. It is best to reapply sunscreen every 40 to 80 minutes, depending on its rating. We can reduce the risk of melanoma occurrence significantly with these very simple steps.

References: (1) Mayo Clin Proc. 2012; 87(4): 328–334. (2) cancer.org. (3) uptodate.com. (4) JAMA. 2004;292(22):2771. (5) Br J Dermatol. 1994;130(1):48. (6) Langley, RG et al. Clinical characteristics. In: Cutaneous melanoma, Quality Medical, St. Louis, 1998, p. 81. (7) J Clin Oncol. 201;31(35):4385-4386. (8) skincancer.org. (9) Photodermatol Photoimmunol Photomed. 2007;23(6):264. (10) J Clin Oncol. 2011;29(3):257. (11) aad.org.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Councilwoman uses personal experience with skin cancer as motivation to spread awareness

Councilwoman Susan Berland stands with the free sunscreen dispenser now at Crab Meadow Beach in Northport. File photo from A.J. Carter

For one Huntington Town councilwoman, warning residents about the dangers of the sun isn’t just a work obligation — it’s personal.

Councilwoman Susan Berland (D) has been dealing with the effects of spending summers under the sun’s rays for nearly a decade, and it has motivated her to host “Melanoma Prevention: Avoiding the Dangers of Tanning,” an event open to the public Tuesday, April 25, at 7 p.m. at Town Hall, 100 Main St.

“I think it’s important for any parent whose kid wants to tan to learn spending too much time out in the sun is dangerous,” Berland said in a phone interview. “Hopefully this sways people from making bad decisions.”

Berland said she had her first run-in with skin cancer seven or eight years ago, when she discovered she had an irregular mole on her lower back that was precancerous. These moles, also known as dysplastic nevi, increase the risk of a patient developing melanoma in a mole elsewhere on the body.

“When I was in high school, I was one of the girls wearing Hawaiian Tropic [sunscreen] zero [SPF] and using tinfoil at the beach getting fried,” Berland said. “I did a lot of damage. Nobody knew, you just always thought you looked so much better with a tan.”

When she had kids, she said she was focused on making sure her children were protected with sunscreen, and would often “run out of steam,” by the time it got to her skin.

Berland, like many other people, learned of a “base tan,” a once-popular idea to get before vacations, where the thought was getting a starter level for a tan on your skin would help protect it from getting burnt when on tropical vacations. Many science and health organizations, including medical research group Mayo Clinic, have come out against base tans in recent years, saying they do not protect skin anymore than sunscreen and can actually cause more damage long term.

“I didn’t get fried anymore, and I really thought I was doing the right thing and getting a healthy tan,” Berland said. “Turns out there’s really no such thing as that.”

The councilwoman said she’s had six procedures so far — the most recent in March — to remove dangerous parts of her skin, and she goes for full-body checks every three months.

“I always hope to leave the doctor’s office as I came in but that hasn’t been the case yet,” she said. “The pain is just not worth it — it’s just not.”

In some cases she said skin abnormalities had to be removed with liquid nitrogen. “On a scale from one to 10, that’s about a seven, but in some cases I had to have the procedure on my lip and that is like a 50,” she said of the pain associated with the treatment. “And that is why I am doing this. People are not paying close enough attention. I am a total convert now, I lay under an umbrella at the beach and wear SPF 50.”

Berland said she hopes people will realize how serious skin protection is during the event, where Meghan Rothschild, a cancer survivor and spokesperson for the Melanoma Foundation of New England will be speaking about her fight against cancer and how to prevent melanoma, the deadliest form of skin cancer and the second most-common cancer in children, teens and young adults aged 15-29. New York State Attorney General Eric Schneiderman (D) will also be attending the event, and echoed the dangers of tanning.

“To many people, indoor tanning seems like a harmless activity — it’s not,” Schneiderman said. “Each session increases your risk of skin cancer and contributes to premature aging, eye damage, allergic reactions and more. There are many myths and misconceptions concerning the safety of tanning, many of them perpetrated by the indoor tanning salon industry. If you engage in indoor tanning or are thinking about it, it’s important to make sure you know the significant associated health risks.”

Berland said she would tell young children considering going to a tanning booth to get their tan out of a bottle.

“Spray tans or makeup, if you don’t like it you can wash it off and start again,” she said. “But in a booth there is nothing you can do to reverse the damage. It’s just not worth it. The pain you go through, the anxiety of wondering when the next spot will be found on your body. You’re playing Russian roulette with your body.”

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Councilwoman Susan Berland stands with the free sunscreen dispenser now at Crab Meadow Beach in Northport. File photo from A.J. Carter

As residents try to soak up the last few weeks of the sun’s rays, Huntington officials introduced a new program to help make sure the skin of their residents is as protected as possible.

Councilwoman Susan Berland (D) is leading a free sunscreen pilot program that kicked off at Crab Meadow Beach in Northport last week. The beach is now equipped with a sunscreen dispenser from the Melanoma Foundation of New England, a nonprofit that works to promote protecting skin from the sun. The dispenser is easy to use, similar to antiseptic dispensers, and is filled with organic, SPF 30 sunscreen.

“I believe that by providing this service to our residents we are helping them guard themselves from the sun, educate themselves on better sun protection and ultimately help the fight against skin cancer,” Berland said in a statement. “The importance of sunscreen is crucial and I’m hopeful that residents will take advantage of the free sunscreen now offered by the town.”

Berland said in a phone interview that she learned about the work the MFNE did through a constituent visiting Boston and wanted to bring the program to Huntington.

After the 2014 “Surgeon General’s Call to Action to Prevent Skin Cancer,” the MFNE went to work providing free sunscreen in public recreation areas across New England.

According to the 2014 report, skin cancer is the most commonly diagnosed cancer in the United States, and most cases are preventable. Melanoma is responsible for the most deaths of all skin cancers, killing almost 9,000 people each year. It is also one of the most common types of cancer among U.S. adolescents and young adults.

Berland said she hopes the dispenser will help children enjoy a day at Crab Meadow Beach.

“A lot of time people damage their skin as children and teenagers, but it takes years for the damage to manifest,” she said. “I’d like to encourage people who don’t bring sunscreen to protect themselves for the future.”

The councilwoman said she wants to bring this program back next year and expand it by providing stations at more beaches and other recreational places. However, she needs to find the funding first.

Each dispenser costs approximately $665, $400 for the dispenser, $200 for the refill package and $65 for shipping. The first dispenser was purchased through the town, but Berland said any future dispensers would need to be sponsored and purchased by a business, organization or resident. Berland said she is hoping to get several sponsors between now and the beginning of summer 2017.

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People should go through several bottles of sunscreen in one season. Using an ounce of sunscreen is ideal, as companies measure the SPF of a sunscreen by applying that amount of sunscreen to the body. Photo by Giselle Barkley

A little dab here and a little dab there. That’s usually how people apply sunscreen to their skin, according to Dr. Michael Dannenberg of Dermatology Associates of Huntington, chief of dermatology at Huntington Hospital. But with around one in five people developing skin cancer on their scalp, a dab of sunscreen isn’t enough.

Skin cancer is one of the most prevalent cancers in America, and cases for scalp cancer have increased in the past several years. While those who don’t have hair may be more prone to getting scalp cancer in comparison to those with hair, anyone can develop any form of skin cancer on this area of their body.

Squamous cell and basal cell carcinoma are common for those who are frequently exposed to the sun and those who are losing hair. Melanoma can also develop on the scalp. In 1935, one in 1,500 people developed melanoma, but the rate has since increased. Now, one in 50 people have a lifetime risk of developing melanoma.

According to Dr. Tara Huston, a surgeon in the Melanoma Management Team for Stony Brook Medicine, there will be 74,000 new cases this year of melanoma in the United States alone. Huston also said that this form of skin cancer usually requires a surgeon’s attention, as it calls for “a larger excision margin than either basal or squamous cell skin cancer.”

Huston and her team help patients with various forms of skin cancer. While dermatologists treat skin cancers like melanoma if caught early, people with more advanced stages of skin cancer may need surgery and additional treatment to recover. A patient’s lymph nodes are also examined. Lymph nodes are responsible for the drainage of certain parts of the skin. Doctors can further repair issues found from examining the nodes associated with the cancer in that area.

Sunburns, above, and increased sun exposure increase an individual’s risk of getting skin cancer like Melanoma, which accounts for four percent of cases, but 75 percent of skin cancer-related deaths according to Dr. Huston. Photo from Alexandra Zendrian
Sunburns, above, and increased sun exposure increase an individual’s risk of getting skin cancer like Melanoma, which accounts for four percent of cases, but 75 percent of skin cancer-related deaths according to Dr. Huston. Photo from Alexandra Zendrian

Although skin cancer of the scalp is not difficult to detect, Dr. Dannenberg says it can be missed because it is on the head. Lesions can vary based on the form of skin cancer on the scalp. Yet, it is easy to detect, especially when people receive frequent haircuts. According to Dannenberg, his office receives countless referrals from barbers and hairstylists who may find a cancerous lesion on their client’s heads.

Huston agreed with Dannenberg regarding the role of barbers and hairstylists, as a number of skin cancer lesions are identified by these professionals.

Squamous cell carcinoma appears in dull, red, rough and scaly lesions, while basal cell carcinoma appears as raised, pink and wax-like bumps that can bleed. Melanoma on the scalp appears as it would on any other part of the body — irregularly shaped, dark-colored lesions.

While sunscreen is more often associated with skin protection, dermatologists like Dannenberg also recommend protective clothing and hats. Cloth hats allow the wearer’s head to breathe while protecting the scalp. Hats with a three and a half inch or more rim offer the best protection, as they cover the head while protecting the ears and other parts of the face or neck. While people can also use straw hats, the hats should be densely woven and not allow sun to penetrate. Hats as well as sunscreen and protective clothing should be used together to provide people with the best form of sun protection.

“Nobody is completely compulsive about putting on that hat every moment they walk out the door,” Dannenberg said. “Likewise, even for people [who] are using sunscreens, people tend not to use enough of it and they don’t reapply it as often as necessary.”

One ounce of sunscreen might be hard to hold without dripping down the side of someone’s hand, but it is the amount of sunscreen people should use on their entire body. Dannenberg also says that sunscreens usually last for about three hours before people need to reapply.

Since few people follow the directions when applying sunscreen, Dannenberg as well as the American Academy of Dermatology recommend people use sunscreens with at least SPF 30. Using sunscreens with higher SPF counts means that people can under apply and still get some degree of sun and ultraviolet radiation protection.

Huston said individuals who don’t want to wear sunscreen or those with a history of tanning should seek a dermatologist and schedule appointments at least once a year to conduct a full body skin examination.

According to Huston, operating on areas of the head like the ears, nose, eyelids, lips and scalp is difficult because of the surrounding tissue.

“Reconstruction of a 2 cm defect on the nose may require multiple stages/surgeries in order to optimize the aesthetic result,” Huston said in an e-mail interview.

While some patients need skin grafts upon the removal of a cancerous lesion, Huston said, “incisions on the scalp can lead to alopecia, or hair loss along the incision line, if it stretches, and can be very upsetting to patients.”

Both Huston and Dannenberg emphasized the importance of protecting the skin and skin cancer education. Dannenberg hopes that the rates of skin cancer will decrease if people are more consistent about protecting their skin with protective attire, sunscreen and hats.

“We’ve been talking to people for years about wearing hats…telling them that as fashion always seems to follow need, that these hats are going to be coming in style,” Dannenberg said. “We’re hoping that over the next 10 or 15 years, we’ll be able to get a drop in the incidences of skin cancer.”

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Longer days are here again, and you can feel the jubilance of people coming out of hibernation after a long, hard winter. Summer weather will be here before you know it, and millions will be heading to the beaches.

What could possibly be wrong with this picture? With all these benefits, you need to be cognizant of cutaneous (skin) melanoma. It is small in frequency, compared to basal cell and squamous cell carcinomas, responsible for only about 5 percent of skin cancers; however, it is much more deadly.

STATISTICS
Unfortunately, melanoma is on the rise. Over the last 40 years from 1970 to 2009, its incidence has increased by 800 percent in young women and by 400 percent in young men (1). These were patients diagnosed for the first time between 18 and 39 years old. Overall, the risk is greater in men, with 1 in 37 afflicted by this disease in his lifetime. The rate among women is 1 in 56. It is predicted that in 2014, there will have been over 76,000 cases, with over 12 percent resulting in death (2).
Melanoma risk involves genetic and environmental factors. These include sun exposure that is intense but intermittent, tanning beds, UVA radiation used for the treatment of psoriasis, the number of nevi (moles), Parkinson’s disease, prostate cancer, family history and personal history. Many of these risk factors are modifiable (3).

PRESENTATION
Fortunately, melanoma is mostly preventable. What should you look for to detect melanoma at its earliest stages? In medicine, we use the mnemonic “ABCDE” to recall key factors to look for when examining moles. This stands for asymmetric borders (change in shape); border irregularities; color change; diameter increase (size change); and evolution or enlargement of diameter, color or symptoms, such as inflammation, bleeding and crustiness (4). Asymmetry, color and diameter are most important, according to guidelines developed in England (5).
It is important to look over your skin completely, not just partially, and have a dermatologist screen for potential melanoma. Screening skin for melanomas has shown a six-times greater chance of detecting them. Skin areas exposed to the sun have the highest probability of developing the disease. Men are more likely to have melanoma tumors on the back, while women are more likely to have melanoma on the lower legs, but they can develop anywhere (6).
In addition, most important to the physician, especially the dermatologist, is the thickness of melanoma. This may determine its probability to metastasize. In a recent retrospective (backward-looking) study, the results suggest that melanoma of >0.75 mm needs to not only be excised, or removed, but also have the sentinel lymph node (the closest node) biopsied to determine risk of metastases (7). A positive sentinel node biopsy occurred in 6.23 percent of those with thickness >0.75 mm, which was significantly greater than in those with thinner melanomas. When the sentinel node biopsy is positive, there is a greater than twofold increase in the risk of metastases. On the plus side, having a negative sentinel node helps relieve the stress and anxiety that the melanoma tumor has spread.

PREVENTION
The two most valuable types of prevention are clothing and sunscreen. Let’s look at these in more detail.

Clothing
Clothing can play a key role in reducing melanoma risk. The rating system for clothing protection is the ultraviolet protection factor (UPF). The Skin Cancer Foundation provides a list of which laundry additives, clothing and cosmetics protect against the sun (8). Clothing that has a UPF rating between 15 and 24 is considered good, 25 and 39 is very good, and 40 and 50 is excellent. The ratings assess tightness of weave, color (the darker the better), type of yarn, finishing, response to moisture, stretch and condition. The most important of these is the weave tightness (9).
Interestingly, the New York Times wrote about how major companies are producing sun protective clothing lines that are fashionable and lighter in weight. The article is entitled “Fashionable Options Reshape Sun-Protective Clothing,” published on July 17, 2013 (10).

Sunscreen
We have always known that sunscreen is valuable. But just how effective is it? In an Australian prospective (forward-looking) study, those who were instructed to use sun protective factor (SPF) 16 sunscreen lotion on a daily basis had significantly fewer incidences of melanoma compared to the control group members, who used their own sunscreen and were allowed to apply it at their discretion (11). The number of melanomas in the treatment group was half that of the control group’s over a 10-year period. But even more significant was a 73 percent reduction in the risk of advanced-stage melanoma in the treatment group. Daily application of sunscreen was critical.
The recommendation after this study and others like it is that an SPF of 15 should be used daily by those who are consistently exposed to the sun and/or are at high risk for melanoma according to the American Academy of Dermatology (12). The amount used per application should be about one ounce. However, since people don’t use as much sunscreen as they should, the academy recommends an SPF of 30 or higher. Note that SPF 30 is not double the protection of SPF 15. The UVB protection of SPFs 15, 30 and 50 are 93, 97 and 98 percent, respectively.
The problem is that SPF is a number that registers mostly the blocking of UVB but not so much the blocking of UVA1 or UVA2 rays. However, 95 percent of the sun’s rays that reach sea level are UVA. So what to do?
Sunscreens come in a variety of UV filters, which are either organic filters (chemical sunscreens) or inorganic filters (physical sunscreens). The FDA now requires broad-spectrum sunscreens pass a test showing they block both UVB and UVA radiation. Broad-spectrum sunscreens must be at least SPF 15 to decrease the risk of skin cancer and prevent premature skin aging caused by the sun. Anything over the level of SPF 50 should be referred to as 50+ (3).
The FDA also has done away with the term “waterproof.” Instead, sunscreens can be either water resistant or very water resistant, if they provide 40 and 80 minutes of protection, respectively. This means you should reapply sunscreen if you are out in the sun for more than 80 minutes, even with the most protective sunscreen (3). Look for sunscreens that have zinc oxide, avobenezene or titanium oxide; these are the only ones that provide UVA1 protection, in addition to UVA2 and UVB protection.
In conclusion, to reduce the risk of melanoma, proper clothing with tight weaving and/or sunscreen should be used. The best sunscreens are broad spectrum, as defined by the FDA, and should contain zinc oxide, avobenezene or titanium oxide to make sure the formulation not only blocks UVA2 but also UVA1 rays. It is best to reapply sunscreen every 40 to 80 minutes, depending on its rating. We can reduce the risk of melanoma occurrence significantly with these very simple steps.

REFERENCES:
(1) Mayo Clin Proc. 2012; 87(4): 328–334. (2) CA Cancer J Clin. 2014;64(1):9. (3) uptodate.com. (4) JAMA. 2004;292(22):2771. (5) Br J Dermatol. 1994;130(1):48. (6) Langley, RG et al. Clinical characteristics. In: Cutaneous melanoma, Quality Medical Publishing, Inc, St. Louis, 1998, p. 81. (7) J Clin Oncol. 201;31(35):4385-4386. (8) skincancer.org. (9) Photodermatol Photoimmunol Photomed. 2007;23(6):264. (10) nytimes.com. (11) J Clin Oncol. 2011;29(3):257. (12) aad.org.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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