Indoor tanning declines, but more melanoma prevention efforts urgently needed

Melanoma rates in the United States doubled between 1982 and 2011, according to a CDC report.

“The sobering news is that, in 2011, there were more than 65,000 cases of melanoma, and more than 9,000 people die from melanoma every year,” Gery P. Guy Jr., PhD, MPH,  health economist in the CDC’s Division of Cancer Prevention and Control, told HemOnc Today.

At its current pace, incidence of melanoma — the most deadly form of skin cancer in the United States — will continue to increase over the next 15 years, peaking at an estimated 112,000 new cases in 2030, the CDC projects.

This trend comes with a staggering price tag, as the annual cost of treating melanoma is expected to triple from $457 million in 2011 to $1.6 billion in 2030, Guy said.

However, there are some reasons for cautious optimism.

Widespread use of indoor tanning — considered by many experts to be a key contributor to skyrocketing melanoma incidence, particularly among women — declined during a recent 3-year period.

In addition, an estimated 230,000 melanoma diagnoses — or 20% of all new cases — projected to occur between 2020 and 2030 could be prevented through comprehensive skin cancer prevention programs, according to the CDC.

HemOnc Today spoke with experts about the factors that have led to increased incidence of melanoma, the efforts to reduce indoor tanning, and the urgent need for additional skin cancer prevention and education programs.

 

Melanoma incidence

An overview of melanoma incidence and mortality trends — written by Guy and colleagues, and published in the CDC’s Vital Signs report for June — indicated several factors are coming into play.

They highlighted a few examples:

• Despite rising incidence, melanoma mortality among Americans aged younger than 65 years has declined. This suggests melanomas are being detected earlier and that more effective treatments have become available.

•  Increased melanoma mortality among Americans aged 65 years and older, however, indicates cumulative overexposure to UV radiation continues to be a concern. Higher melanoma incidence among older non-Hispanic white men may be explained, at least in part, due to the fact they spent more time outdoors throughout their lives and are less likely to protect themselves from the sun.

• In the 15-to 49-year-old demographic, melanoma incidence was considerably higher among women than men. The report’s authors indicated this disparity could be due at least in part to “widespread use of indoor tanning among females.” Previous research showed about one-third of non-Hispanic white women aged 16 to 25 years tan indoors each year.

 

‘Temporal decrease’ in tanning

In a research letter published in July in JAMA, Guy and colleagues used data from the National Health Interview Survey — a nationally representative sample of the U.S. population aged 18 years and older (n = 59,145) — to assess changes in indoor tanning use between 2010 and 2013.

Researchers defined indoor tanning as use of an indoor tanning device at least once during the previous year. Survey response rates were 60.8% in 2010 and 61.2% in 2013.

Results showed indoor tanning rates declined overall during the study period (5.5% vs. 4.2%; P < .001). Researchers observed the decline among women (8.6% vs. 6.5%; P < .001) and men (2.2% vs. 1.7%; P = .03).

Among women who identified themselves as frequent tanners — defined as those who use indoor tanning devices at least 10 times per year — the rate declined from 4.8% to 3.6% (P < .001).

Among infrequent tanners — defined as those who tan one to nine times per year — indoor tanning rates declined from 1.4% to 1% (P < .05) among men, and from 3.7% to 2.8% (P < .01) among women.

“Our findings indicate a temporal decrease in the prevalence of indoor tanning across several demographic groups,” Guy and colleagues wrote. “For 2013, a total of 1.6 million fewer women and [400,000] fewer men engaged in indoor tanning compared with 2010.”

These data suggest an important sign of progress, according to Darren Mays, PhD, MPH, assistant professor of oncology at Georgetown University Medical Center and member of the cancer prevention and control program at Georgetown’s Lombardi Comprehensive Cancer Center.

“I would interpret the data as state and local governments are implementing policies that primarily target minors under the age of 18, but it is possible that they could also be indirectly affecting adults by raising awareness of the potential risk,” Mays said. “Some of this impact could also be attributable to broader efforts that raise awareness and deter people from indoor tanning.”

 

Stronger regulations needed

In a Viewpoint article published in June in JAMA, Mays and John David Kraemer, JD, MPH, assistant professor in the department of health systems administration at Georgetown University, aimed to stimulate discussion on the ways in which policy and regulation at the national level could be strengthened to reduce the use of indoor tanning, as well as the associated risks for melanoma and other forms of skin cancer.

Nearly 1 year ago, the FDA reclassified indoor tanning devices from low-risk class 1 medical devices — which includes those deemed to have minimal potential to cause harm — to moderate-risk class II medical devices, a designation that requires manufacturers to prove their products have met certain performance testing requirements. The FDA also issued black box warnings stating the tanning devices should not be utilized by those aged younger than 18 years.

However, Mays and Kraemer said this approach may be insufficient.

“[It] puts the agency in the unusual situation of balancing the safety and health benefits of a technology with very limited therapeutic benefit with commercial interests,” they wrote.

Instead, they advocated for “a broader public health approach” to the risks associated with indoor tanning.

“The FDA’s reclassification of tanning devices from class I to class II medical devices nearly 1 year ago is viewed by many as a step in the right direction, but it also was a missed opportunity to put stronger policies in place,” Mays told HemOnc Today. “There is a need for a comprehensive approach to the control of indoor tanning, much like other areas of cancer prevention and control have required.”

He cited the example of tobacco control programs, which include tobacco-free policies, tax increases, and media campaigns with persuasive messages about not smoking or quitting smoking.

“Over several decades, the collective impact of these kinds of measures have helped to reduce smoking in the United States,” Mays said. “In order to make an impact on indoor tanning and to lower melanoma that is attributable to indoor tanning, a similar coordinated effort is needed that integrates interventions across these different types — from policy to taxation to public health messaging — in order to avoid these skin cancers that are completely preventable.”

 

Public messaging

More than 419,000 cases of skin cancer are associated with indoor tanning annually in the United States. This includes nearly 245,000 basal cell carcinomas, 168,000 squamous cell carcinomas and 6,200 melanomas, according to The Skin Cancer Foundation, a national organization that emphasizes public awareness and education campaigns.

One such effort, Go with Your Own Glow, is an anti-tanning PSA campaign that encourages women to love and protect their natural hue of skin. In addition, the foundation launched a letter-writing campaign that encourages colleges to stop allowing students to engage in indoor tanning behaviors on or near campus.

In a study published earlier this year in American Journal of Public Health, Mays and colleagues assessed the effect of indoor tanning device PSAs that communicate the risks associated with indoor tanning, as well as the benefits of avoiding indoor tanning.

The analysis included 682 non-Hispanic white women aged 18 to 30 years who reported tanning indoors at least once in the previous year. All women completed baseline measures and reported their indoor tanning intentions.

Participants also indicated their intentions to quit indoor tanning in response to five warning messages. These messages included a text-only control warning based upon the FDA’s black box warnings for indoor tanning devices, as well as experimental warnings that included graphic content that were either gain-framed (ie, they emphasized the benefits of avoiding indoor tanning) or loss-framed (ie, they communicated the risks associated with indoor tanning).

Results showed that gain-framed warnings and control warnings had similar effects on women’s intentions for indoor tanning; however, gain-framed warnings prompted stronger intentions to quit than control messages.

Further, loss-framed warnings significantly decreased participants’ intentions to tan indoors and increased their intentions to quit indoor tanning when compared with control and gain-framed warnings.

“We looked at ways to design public health messages that communicated the risks of indoor tanning, as well as tips for avoiding tanning,” Mays said. “One of the key findings was that these messages did have an impact in this cross-sectional, experimental study. Our study provides data in support of the different types of comprehensive intervention models that incorporate policy, regulation and public health messaging as a way to prevent melanoma and other forms of skin cancer associated with indoor tanning.”

 

CDC’s prevention strategies

The CDC’s Division of Cancer Prevention and Control provides data that inform policy.

It also informs and educates the public about the harms of overexposure to UV radiation and indoor tanning through cancer prevention efforts, such as The Surgeon General’s Call to Action to Prevent Skin Cancer, issued in 2014.

“The good news about melanoma, as well as other types of skin cancers, is that they are largely preventable,” Guy said. “More than 90% of melanoma cases are caused by too much exposure to UV rays from the sun or indoor tanning.”

The CDC’s recommendations for reducing the risk of melanoma by limiting UV exposure are categorized into individual and community efforts.

On the individual level, the CDC suggests:

• Avoiding indoor tanning;

• Staying in the shade;

• Wearing clothing that covers the arms and legs;

• Wearing a wide-brimmed hat;

• Wearing wraparound sunglasses that shield the eyes from UVA and UVB rays; and

• Using sunscreen with an SPF of 15 or higher that protects against both types of rays.

On the community level, the CDC recommends:

• Increasing the amount of shade at playgrounds, public pools and other public areas;

• Promoting sun protection in recreation areas, including the use or purchase of hats, sunscreen and sunglasses;

• Encouraging employers, child care centers, schools and colleges to educate employees and students about sun safety and skin protection; and

• Restricting the use of indoor tanning by those aged younger than 18 years.

“Based on our most recent data, we are encouraged by a decrease in the number of people who are indoor tanning,” Guy said. “From 2010 to 2013, 1.6 million fewer women and 400,000 fewer men tanned indoors. The bad news is that nearly 10 million adults are still using an indoor tanning device at least once per year. That is 10 million adults who are trading a tan for an increased risk for skin cancer — including melanoma — every year. What many people likely do not appreciate is that while the tan is temporary, the risk for skin cancer is permanent.” – by Jennifer Southall

References:

Guy GP, et al. JAMA Dermatol. 2015;doi:10.1001/jamadermatol.2015.1568.

Guy GP, et al. MMWR. 2015;64:591-596.

Mays D and Tercyak KP. Am J Public Health. 2015; doi:10.2105/AJPH.2015.302665.

Mays D and Kraemer JD. JAMA. 2015;doi:10.1001/jama.2015.5975.

Skin Cancer Foundation. Go With Your Own Glow. Available at: www.skincancer.org/glow. Accessed on July 16, 2015.

U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Skin Cancer. Available at: http://www.surgeongeneral.gov/library/calls/prevent-skin-cancer/index.html. Accessed on July 16, 2015.

 

For more information:

Gery P. Guy Jr., PhD, MPH, can be reached at Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop F76, Atlanta, GA 30341; email: irm2@cdc.gov.

Darren Mays, PhD, MPH, can be reached at Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, 3300 Whitehaven St. NW, Suite 4100, Washington, DC 20007; email: dmm239@georgetown.edu.