Sunshine Laws: Diminish Your Risks for Skin Cancer

By Roberta Nubile

Skin is our body’s largest organ. It is also the only organ with direct exposure to the sun, and therefore at risk for a type of cancer that forms in the epidermis, or outer layer of the skin. Skin cancer is primarily caused by exposure to ultraviolet (UVA or UVB) rays, either from the sun or tanning beds. Sunscreens which block one or both of these types of rays can help protect against skin cancer, but are not officially recommended by regulating agencies, which remain concerned about chemicals in the sunscreens, as well as potential deficiencies in Vitamin D.

The Epidemic of Skin Cancer

Though once more common in people over 50, skin cancer is now showing up in younger people. According to the Environmental Protection Agency (EPA), melanoma is the second most common form of cancer in adolescents and young adults (15-29 years old). Dr. Mitchell Schwartz of Dorset Street Dermatology in South Burlington says he is “seeing it in children even in the single digits.” And in July 2008 a National Institutes of Health study found that melanoma rates among young women in the United States almost tripled between 1973 and 2004. In the last 15 years, there has been a 350 percent increase in the incidence of skin cancer in the U.S., and it is the leading cancer in the U.S., according to the Skin Cancer Foundation.

While the increase in skin cancer is not understood, dermatologists have warned for years that the cause is our obsession with the tan, whose advent as a mark of beauty was relatively recent. “Tans used to be for those who were workers and laborers,” says Schwartz. “Then the fashion shifted to ‘I have leisure time, I can tan’.” This shift may have started as early as the 1920s when fashion designer Coco Chanel started a trend when she returned sunburnt after a vacation. By the 1950s, with the advent of the bikini and the iconic ad campaign of the Coppertone Girl, tanned skin was decidedly in.

What is needed, Schwartz says, is a cultural shift. “People need to change the way they look at beauty. We need to get people thinking the other way, back to parasols and pale skin as the beauty ideal.”

According to Schwartz, the message to protect from excessive sun exposure may be most effective when people are shown the damage sun can do. “Some people come to see me to fix wrinkles which are caused by sun damage – but it’s hard to reverse,” he says. “Looking older is a risk of sun damage, so maybe using that approach is the best one to get people to protect from the sun.” Schwartz uses an article from the journal Plastic and Reconstructive Surgery, about 59-year-old twins who had different amounts of sun exposure and the remarkable differences in the appearance of their skin to illustrate his point.

Beyond the damage to the surface look of our skin lies the risk of cancer.

Precancerous Skin Lesions

A precancerous lesion is a change in some areas of your skin that carries the risk of turning into skin cancer. Two of the most common types are actinic keratosis, and dysplastic nevus, also known as an atypical mole. They are called precancerous because without treatment they can develop into squamous cell carcinoma.

Precancerous lesions are treated similarly to cancerous lesions. The first step is biopsy, and then removal, either by chemical or surgical means. Erin O’Brien (not her real name), 62, has seen a dermatologist regularly since the ’80s when her actinic keratoses – dry, scaly, calloused lesions caused by ultraviolet exposure – were first detected. “I had lesions on my skin that would peel and not heal,” says O’Brien. “I am an Irish American with fair skin who would go to the beach as a child. There was no sunscreen then, and multiple times I would get so badly burned I would need to be carried from the car to the house.”

O’Brien’s lesions are monitored twice a year for any changes, and when cells are have mutated, she receives cryofreeze treatments, or the application of liquid nitrogen, which removes the lesion. “It’s a balance and a continuous judgment call,” says O’Brien, referring to the vigilance she and her doctor must assume. “I hope for the best, and keep my ears open for nutritional ways to support my skin. I also protect myself from the sun between 10 a.m. and 4 p.m. If I am out then, I wear a hat and long sleeves.”

Types of Skin Cancer

The three types of skin cancer are basal cell carcinoma, squamous cell carcinoma (nonmelanoma skin cancers), and malignant melanoma.

Basal cell carcinoma (BCC) is the most common and can appear as a small reddish or translucent fleshy bump on the head, neck or hands. It can be easily detected by biopsy, and if found to be cancerous, will be removed. If detected early, basal cell carcinomas are mostly treatable and will not spread, but they can be disfiguring. Risk factors for BCC include fair skin, age (the highest incidence occurs in people over age 50: BCC is assumed to be a cumulative effect of life-long exposure), living in a sunnier climate, or exposure to tanning beds. The number of people in their 20s and 30s who develop BCC has risen sharply in recent years.

Squamous cell carcinoma (SCC) is the second most common skin cancer. This type is twice as common in men as in women, and often associated with outdoor occupations or any chronic sun exposure, including tanning beds. The majority of skin cancers in African-Americans are squamous cell carcinomas; other risk groups are fair-skinned people and those older than 50. SCC occurs on all areas of the body, including the mucous membranes and genitals, but is most common in areas frequently exposed to the sun, such as the rim of the ear, lower lip, face, bald scalp, neck, hands, arms and legs. This type of cancer is also associated with skin injuries such as burns, chronic skin infections, sores and ulcers and sites on the body exposed to radiation. There is also a hereditary factor in SCC, which in part explains why it can arise spontaneously in previously health skin.

The third type is malignant melanoma, which accounts for about three percent of skin cancer cases, but causes more than 75 percent of skin cancer deaths. Melanoma can metastasize, or spread, to other parts of the body and be fatal if left untreated. It affects cells that produce melanin and is more common among city-dwellers than people who have constant exposure to sun (some studies have demonstrated a stronger link between developing melanoma and exposure to electromagnetic waves from FM radio transmitter towers, for example, than that of exposure to ultraviolet radiation). It does not only occur on sun-exposed areas of the body, and is thought to be caused by brief, intense periods of sun exposure and a history of severe sunburn in childhood or adolescence.

Marcelle Leahy’s Story

Marcelle Leahy, wife of Senator Patrick Leahy, was diagnosed with melanoma in 2003. Fortunately, it was melanoma in situ – meaning it didn’t spread – but Leahy has a cautionary tale to tell about how long it took for her to be diagnosed correctly and treated.

For several years, Leahy had a discolored area on her left lower cheek. Her dermatologist followed the spot for years and, as Leahy puts it, believed “it wasn’t cancer by looking at it.” Leahy saw other dermatologists when her own wasn’t available, and no one caught it. A couple of times she had the discoloration cosmetically frozen off, but it would come right back. “What should have been done,” says Leahy, “is biopsy. It is the only sure way to diagnose skin cancer. I had an atypical form, which didn’t conform to the pictures in textbooks.”

It wasn’t until after her dermatologist retired and Leahy saw a new one that her cancer was finally diagnosed. “At the end of the exam when he asked if I had any questions, I mentioned the area on my cheek. The doctor took a closer look and said, ‘Well, I do want to biopsy it.’ Within days it came back – it was melanoma in situ.”

Leahy first underwent two surgical procedures which left her face disfigured and did not completely remove the cancer. She then traveled to Johns Hopkins Hospital in Baltimore to have her melanoma removed through Mohs surgery. The procedure, also called chemosurgery, is performed under microscope and is the current gold standard for full removal of basal, squamous, and melanoma in situ cancers, with high success rates.

Leahy underwent multiple procedures before it was completely removed. The pain was not physical, she says: “It only hurt psychologically. No one likes to think they have cancer.” Leahy reports the scar went from her temple to her jaw line, and jokes, “My skin was so tight on my left side that my nose pointed to the left. But after all, I am a Democrat.” Since then, however, her skin has stretched and “now my nose points straight ahead.”

Leahy, who is a retired registered nurse, now speaks publicly about her experience so others will learn from it. Her story is even featured on the Environmental Protection Agency’s Sunwise Web site, an educational site aimed at teaching children to protect themselves from the sun.

“I tell people that I hope they can apply what I say to all their health care,” says Leahy. “Prevention is key; there are cancers – like colon and melanoma – that are preventable and curable if detected early enough. You need to be able trust your doctor to answer any question until it is fully explained. If it isn’t, find someone who will work with you. I have had people telling me, ‘Because of you, I went back to my doctor and insisted I be sent to a dermatologist for an exam, and we found my melanoma or basal cell cancer.’”

Through her experience, Leahy has learned much about skin cancer. “That only those with fair skin get skin cancer is a fallacy. People think if they have brown eyes and a lot of pigment they are immune. It is true they are not as apt, but they still get it. The unfortunate part is too often their cancer has progressed more or further and mortality rate is higher because it is discovered later.

“There are such simple ways we can take care of our skin,” Leahy continues. “It took us a long time to understand how harmful the UVA and UVB rays are to our skin. It’s as simple as wearing sunscreen and reapplying frequently, staying out of sun, and seeking shade between the hours of 10 and 4. Don’t abuse the sun.”

Skin Cancer in Vermont on the Rise

Leahy points out that Vermont is not immune to the effects of the sun. “We think of Vermont as not being sunny. When the sun does come out people are so happy to see it they don’t protect themselves. Skin cancer is almost epidemic up and down eastern seaboard. The medical establishment doesn’t even understand it at this point.”

Skin cancer facts about Vermont listed on the Sunwise Web site are unsettling. Vermont had the highest rate of new melanoma diagnoses in the U.S. from 2001 to 2005 – 63 percent higher than the national average.

Approximately 20 people in Vermont die of melanoma every year. And Vermont had the 13^th highest death rate nationally between 2001 and 2005: 11.1 percent higher than the U.S average.

But how do we get the sun we need without burning or tanning?

Sunscreens – Are They Helping or Hurting?

Both the Food and Drug Administration (FDA) and the International Agency for Research on Cancer (IARC), a special research group of the World Health Organization, do not actively endorse use of sunscreen to prevent skin cancer. The FDA has yet to finalize its recommendations as to the safety and efficacy of sunscreens, as first promised in 1978. But in May 2010, under growing pressure from Congress and consumer protection groups, the agency announced it would finally publish its mandatory standards in the fall of 2010. Ideally, these standards will hold sunscreen manufacturers accountable and prevent exaggerated claims of UV protection. However, it may take up to a year after the report comes out for companies to comply with the new rules.

The IARC recommends clothing, hats, and shade as primary barriers to UV radiation and cautions in its ‘Handbook of Cancer Prevention’ that “sunscreens should not be the first choice for skin cancer prevention and should not be used as the sole agent for protection against the sun.”

Some studies have shown an increased risk of melanoma among sunscreen users, perhaps related to improper use of sunscreens or inadequate UVA coverage. But while major organizations such as the Skin Cancer Foundation, American Cancer Society, and the Melanoma Foundation all recommend the use of sunscreens, they also stress the importance of shade, sun-protective clothing, and timing.

The Environmental Working Group (EWG), a non-profit research organization dedicated to consumer safety that publishes a guide to sunscreen safety, ultimately concludes, “No ingredient is without concern. The best sunscreen is a hat and a shirt. No chemicals to absorb through the skin, no questions about whether they work.”

Sunscreen 101

There are two main types of sunscreens in the way they protect the skin: physical and chemical. Physical, or mineral sunscreens, literally block the sun – with zinc oxide or titanium dioxide, but not both. Of these ingredients, zinc oxide is considered the safest. Titanium dioxide is a group 2B carcinogen, according to the IARC (group 2B carcinogens are labeled as possibly carcinogenic, as there is limited evidence in human studies). These physical sunscreens are also chalkier substances, which leave a film and are not absorbed as the chemical substances are, but provide excellent protection against UVA and UVB rays. Currently, research continues as to whether these microparticles reach the bloodstream and are toxic.

The chemical, or non-mineral, sunscreens contain ingredients that the skin readily absorbs – and therein lies the problem. Several of the ingredients have come under scrutiny by the FDA, including Vitamin A (retinyl palmitate) and oxybenzone. Vitamin A has photocarcinogenic properties and may result in cancerous tumors when used on skin exposed to sunlight. Oxybenzone, a derivative of Benzophenone-3, has been linked to allergies and hormone disruption, making it especially questionable for use on children.

The EWG released a report this year that found only eight percent of 500 sunscreens they tested contain no suspect chemicals. All eight were physical blocks containing either zinc or titanium.

Skin Cancer Treatments

Standard treatments for localized basal cell and squamous cell carcinomas may range from surgical excision of small tumors to removal with a scraping tool (curette), after which the area is cauterized, frozen with liquid nitrogen, or treated with low-dose radiation. Applying an ointment containing a chemotherapeutic agent called 5-fluorouracil to a superficial tumor for several weeks may also work. Larger localized tumors are removed surgically.

In rare cases where basal cell or squamous cell carcinoma has begun to spread beyond the skin, tumors are removed surgically and patients are treated with chemotherapy and radiation.

Melanoma tumors must be removed surgically, preferably before they spread beyond the skin into other organs. The surgeon removes the tumor fully, along with a safe margin of surrounding tissue. Nearby lymph nodes may also be removed in certain cases, though this practice is controversial. Neither radiation nor chemotherapy will cure advanced melanoma, but either treatment may slow the disease and relieve symptoms. Chemotherapy, sometimes in combination with immunotherapy, is generally preferred. If melanoma spreads to the brain, radiation is used to slow the growth and control symptoms.

Currently, alternative and complementary treatments related to skin cancer are focused on prevention and healing. Molly Fleming, a naturopathic medicine specialist with Health Resolutions in Burlington, advises, “Don’t mess around with skin cancer. When in doubt, get a biopsy. While we don’t have treatments for skin cancer in our practice, we will support the body’s whole immune system – for example, what kind of antioxidant and nutritional support can aid in healing the long-term damage to the skin. Your body’s ability to heal is dependent on all systems working.”

Alternative medicine can also be effective in combating the nausea, vomiting, fatigue, and headaches caused by chemotherapy, radiation, or immunotherapy treatments of advanced skin cancer.

Roberta Nubile is a Vermont registered nurse and freelance writer in Shelburne.