V ery few dermatologists were surprised when the Journal of the National Cancer Institute published a study recently that reported that the use of tanning salons resulted in a 55% increase in melanoma in a group of Scandinavian women. Most people, including most doctors, accept the link between ultraviolet (UV) radiation and skin cancer, and many saw this study as verification of what they considered obvious. “In my practice, I am seeing an increase in the number of young patients who present with multiple irregular nevi and at least one nodular melanoma on buttocks skin that has only seen UV from artificial sources,” says Mark Naylor, M.D., a Dermatologist and Tumor Researcher at the Oklahoma Medical Research Foundation. “And they almost always have a history of tanning, and especially the use of tanning salons.” Dr. Naylor describes many of his patients as “train wrecks,” who are coming in at a younger age with multiple, simultaneous skin cancers and advanced photoaging that Dr. Naylor attributes directly to year-round tanning. However, there are many who are not convinced that the link between UV rays and skin cancer is that firm or that the advice that physicians give to their patients to avoid UV radiation, either from sun exposure or tanning beds, is necessarily going to help their patients avoid skin cancer. In fact, there are those who believe that the public has been scared into avoiding the sun to such a degree that there is now an epidemic of vitamin D deficiency in this country with a corresponding increase in other diseases, including other forms of cancer. The Connection Between Tanning and Skin Cancer The Scandinavian study looked at a group of women who filled out reports in the early 90s and followed up on those women about 8 years after they had completed the initial report. Of the 106,379 women, 187 cases of malignant melanoma were reported. The study authors reported that the data showed that there was a 55% greater incidence of melanoma among women who had used tanning salons when compared to women who had not done any indoor tanning. However, fewer than 2% of the women in the initial survey reported using tanning salons. In addition, the women who used tanning salons were also more likely to engage in other behaviors that may be risk factors for skin cancer, including smoking and alcohol use. The study authors point out that the low number of reported cancers makes the difference statistically insignificant. Despite the media attention to the study, the numbers involved are not sufficient to draw meaningful conclusions about the relationship between tanning salons and skin cancer. Does this mean that tanning salons and UV exposure in general are not risk factors for skin cancer? No. There is sufficient evidence to show that UV exposure, especially early in life, is an extremely important factor, and the Department of Health and Human Services has added UV radiation to its list of known carcinogens. However, other factors, such as genetics, physical makeup, environmental exposures and even the size of the individual, may be more important. Keep in mind that most of the women in the study who developed melanoma had never visited a tanning salon, so to lay so much of the blame on UV exposure may deflect interest from other more significant risk factors and causes. There are those, however, that feel that UV exposure from any source at any level is to be avoided. “The evidence of the connection between UV and skin cancer is overwhelming, as is the evidence that chronic exposure increases your risk,” says James Spencer, M.D., Vice Chairman of Dermatology and Director of Dermatological Surgery at Mount Sinai School of Medicine in New York. “For people, especially young people, to deliberately expose themselves to the high levels of UV radiation that tanning beds produce simply for the short-term benefit of a tan is dangerous and foolish.” Dr. Naylor agrees with that assessment. “There is no safe level of exposure to a known carcinogen, and that holds for UV radiation as well,” says Dr. Naylor. “In my view, UV radiation is responsible for virtually all cases of melanoma, and many of the other skin cancers.” The Rising Level of Skin Cancer According to the American Cancer Society (ACS), an estimated 1 million new skin cancer cases were diagnosed in 2003 in the United States. Of these, about 54,000 cases were melanomas. While the incidence of non-melanoma skin cancer has been dipping in recent decades, the incidence of melanoma has more than doubled to 13 per 100,000 people in 1999 from six in 100,000 in 1973. The ACS estimated that nationwide about 9,800 deaths occurred in 2003 from all types of skin cancer. Of that, 7,000 will be from melanoma. Vilma Cokkinades, Program Director of risk factor surveillance for the ACS, has little doubt that UV radiation is responsible for the majority of skin cancers and that people should continue to follow the advice to avoid excessive exposure to UV radiation, either from the sun or from tanning beds. “The American Cancer Society strongly recommends that people avoid tanning salons. The evidence that points to a causal link between UVA exposure and cancer is growing, and it has been associated with melanoma and basal cell cancer,” says Ms. Cokkinades. “Recent research using animals showed that UV radiation can cause skin damage, including cancer. Human studies show that UVA exposure can cause molecular changes in the skin in terms of DNA operation and the cells’ ability to repair DNA damage. There is more than sufficient evidence to establish a clear connection between UV radiation exposure and skin cancer.” While some have called for the federal government to ban tanning salons and tanning beds, the FDA has resisted such a ban for a number of reasons. “The FDA is convinced that there are risks associated with use of sunlamps and warns people about these risks, including the possibility of skin cancer. The FDA also realizes that melanoma is a serious disease and has joined other public health agencies in warning the public to avoid overexposure to ultraviolet radiation. The FDA is working on proposals to strengthen these warnings,” says Howard Cyr, Ph.D., a research biophysicist with the FDA’s Office of Science and Technology. “However, the risk of death from UV exposure (of which sunlamps may be a minor source of UV) is substantially less than the risks of other legal activities, such as smoking cigarettes or drinking alcohol. In addition, the risk of melanoma from the use of sunlamps is less than that from exposure to solar ultraviolet radiation, a source of potential harm that can neither be regulated nor restricted.” The Consequences of Sun Avoidance However, Michael Holick, M.D., Ph.D., a Professor of Medicine, Dermatology, Physiology and Biophysics at the Boston University School of Medicine takes a slightly different view of UV radiation exposure. “The people who go to tanning salons certainly face a higher risk of basal cell and squamous carcinomas, but it is debatable what impact tanning has on melanoma. There are certain risks involved, but there are certain risks in everything we do, and if it makes these individuals feel better, I don’t know why we would stop them,” says Dr. Holick. “Moreover, as a result of all the warnings that are out there, people are now shunning the sun almost all the time, resulting in a significant vitamin D deficiency, which has very serious consequences, especially in children.” According to Dr. Holick, author of The UV Advantage, which will be available in May, 90% to 95% of people get their supply of vitamin D from exposure to the sun and not from diet or supplements. Unfortunately, many people are avoiding any exposure to the sun and this is creating a problem. “We have done studies that show that of girls ages 9 to 11, 48% were vitamin D deficient at the end of winter and that 17% were deficient at the end of summer,” says Dr. Holick. “That is all because of the paranoia that is out there about sun exposure. There are people who are putting sunscreen on their children everyday. That should alarm physicians.” In Dr. Holick’s view, lack of vitamin D causes serious consequences while an adequate supply can result in significant health benefits. Dr. Holick’s research shows that many chronic diseases are exacerbated by vitamin D deficiencies, including colon, prostrate, breast and ovarian cancers. He feels that the increased risk from these diseases outweighs the risk of skin cancer through UV exposure. Marji McCullough, ScD., Senior Epidemiologist for the ACS disagrees. “I think it is premature to compare the risks of these different cancers,” says Dr. McCullough. “The increased risk of skin cancer from UV exposure is real and the role of vitamin D in preventing cancers may be real as well. However, you can get vitamin D from diet and from sun exposure. Small amounts of sun exposure increase levels of vitamin D in the blood, but I do not advocate tanning as a way to increase your level of vitamin D. There are better ways to do it.” Vitamin D deficiencies may also result in a greater risk of having higher blood pressures. A study conducted by Dr. Holick showed that hypertensive patients had their blood pressure restored to normal levels after using tanning beds with UVB. “We did the same thing with patients but with tanning beds without UVB and there was no change in their blood pressure,” says Dr. Holick. “We know that at higher latitudes, people are more likely to have higher blood pressure and more heart disease. And studies show that you are more likely to have congestive heart failure if you have a vitamin D deficiency.” Studies do show that most of the cells in the body recognize vitamin D. One of the organs that vitamin D is found in is the pancreas, and children who are vitamin D deficient have a 4-fold higher risk of developing diabetes. “You have to ask yourself how important vitamin D is if it is recognized by most cells,” says Dr. Holick. “I think that as we learn more, we will discover that there are many other serious chronic diseases and conditions, such as bone health (bone density), that are influenced by vitamin D levels.” Dr. Spencer disagrees with that view. “Patients with known bone disease, or the weak and debilitated, may indeed have lower vitamin D levels,” says Dr. Spencer, “however, I am not aware of any evidence that people with high levels of vitamin D have reduced their risk of other diseases.” Many experts counter that vitamin D levels can be easily maintained through diet and supplements. “A healthy diet that includes sources of vitamin D, such as milk and fatty fishes, a daily vitamin or a calcium supplement containing vitamin D should be sufficient to maintain healthy levels of vitamin D,” says Dr. McCollough. “In addition, depending on the time of year and where you live, just 15 minutes of sun exposure on your arms and head each week is enough to synthesize the vitamin D that your body needs.” Dr. Holick says that the population as a whole cannot be relied on to assiduously take a supplement. “The problem with vitamin D supplements is that you need at least 1,000 units of vitamin D a day, milk may have 100 units in a glass and daily vitamins have about 400. How do you convince the population at large to take a daily supplement?” “In terms of tanning, I don’t advocate tanning and I never have, but I also believe that if a person wishes to tan, they should be permitted to do so. And that if they are going to do it, they should be permitted to do it responsibly,” says Dr. Holick. “As far as indoor tanning, if people want to tan, that is their prerogative. As long as they are made aware of the risks, which are mainly basal and squamous cell carcinoma. Most melanomas occur in unexposed areas, and that is not a result of nude tanning, because it has been true in the past. We do know that the number of sunburns you have had, the number of moles that you have on your body, your hair color and your genetics are all factors.” On the other hand, Dr. Naylor sees the increase in the use of tanning salons as a sign that the skin cancer situation is going to get dramatically worse very quickly. “I expect to see the incidence of skin cancer in men jump from around 20 per 100,000 in the year 2000, the latest year for which we have numbers, to levels in excess of 50, perhaps even approaching 100, per 100,000 people. In our lifetime, we will see melanoma become the single most prevalent form of serious cancer in the United States, exceeding even the most common tumors, such as lung cancer and breast cancer,” says Dr. Naylor. “Sadly, it is preventable and if we could eliminate intentional cosmetic tanning as a desirable activity, we would not even be having this discussion.” Keeping Patients Safe from All Risks While it is difficult to ignore the evidence that UV radiation is a significant risk factor for skin cancer as well as a host of other conditions, some question the wisdom of taking the extremely hard line approach of having people shun the sun completely. Some are concerned that the population in general and tanners in particular are given a message that is so strident that they tend to ignore the warnings because of their extreme nature. “In my view, doctors and especially dermatologists have overreacted to the dangers of UV radiation and have taken an extreme position about not being exposed to any sunlight without protection. I do not think that that is the wisest approach,” says Dr. Holick. “There needs to be a sensible message that goes out about UV exposure. A little bit of sun exposure is ok, even enough to get a tan. From my perspective, I would argue that by taking a more realistic approach, advising their patients that a little bit of sun can be beneficial but to protect themselves afterward, people will become more aware of the dangers.” However, most of those in the medical profession are convinced that UV exposure, no matter what the level of exposure, is dangerous and that tanning beds are simply too risky to even consider. “I think reducing your exposure to UV radiation is the best way to reduce your risk of skin cancer,” says Dr. McCullough. “As far as tanning beds go, I think that it is not at all healthy to subject yourself to massive doses of UV radiation.” That sentiment is echoed by Ms. Cokkinades. “People should simply accept the natural color of their skin and not tan for beauty reasons,” says Ms. Cokkinades “The risk of skin cancer, as well as the other skin problems that tanning can cause, is clearly not worth the rather short-term tan. And going regularly to a tanning salon to maintain a tan, especially for the young, is extremely risky.” Dr. Naylor takes the warning to an even higher level. “Vitamin D deficiencies is a straw man used to justify cosmetic tanning. You can no more defend tanning as a healthy pastime then you can defend cigarette smoking, but the tobacco industry has its defenders and so does the tanning industry.”
Tanning Beds: A lot of Risk for a Little Reward?
V ery few dermatologists were surprised when the Journal of the National Cancer Institute published a study recently that reported that the use of tanning salons resulted in a 55% increase in melanoma in a group of Scandinavian women. Most people, including most doctors, accept the link between ultraviolet (UV) radiation and skin cancer, and many saw this study as verification of what they considered obvious. “In my practice, I am seeing an increase in the number of young patients who present with multiple irregular nevi and at least one nodular melanoma on buttocks skin that has only seen UV from artificial sources,” says Mark Naylor, M.D., a Dermatologist and Tumor Researcher at the Oklahoma Medical Research Foundation. “And they almost always have a history of tanning, and especially the use of tanning salons.” Dr. Naylor describes many of his patients as “train wrecks,” who are coming in at a younger age with multiple, simultaneous skin cancers and advanced photoaging that Dr. Naylor attributes directly to year-round tanning. However, there are many who are not convinced that the link between UV rays and skin cancer is that firm or that the advice that physicians give to their patients to avoid UV radiation, either from sun exposure or tanning beds, is necessarily going to help their patients avoid skin cancer. In fact, there are those who believe that the public has been scared into avoiding the sun to such a degree that there is now an epidemic of vitamin D deficiency in this country with a corresponding increase in other diseases, including other forms of cancer. The Connection Between Tanning and Skin Cancer The Scandinavian study looked at a group of women who filled out reports in the early 90s and followed up on those women about 8 years after they had completed the initial report. Of the 106,379 women, 187 cases of malignant melanoma were reported. The study authors reported that the data showed that there was a 55% greater incidence of melanoma among women who had used tanning salons when compared to women who had not done any indoor tanning. However, fewer than 2% of the women in the initial survey reported using tanning salons. In addition, the women who used tanning salons were also more likely to engage in other behaviors that may be risk factors for skin cancer, including smoking and alcohol use. The study authors point out that the low number of reported cancers makes the difference statistically insignificant. Despite the media attention to the study, the numbers involved are not sufficient to draw meaningful conclusions about the relationship between tanning salons and skin cancer. Does this mean that tanning salons and UV exposure in general are not risk factors for skin cancer? No. There is sufficient evidence to show that UV exposure, especially early in life, is an extremely important factor, and the Department of Health and Human Services has added UV radiation to its list of known carcinogens. However, other factors, such as genetics, physical makeup, environmental exposures and even the size of the individual, may be more important. Keep in mind that most of the women in the study who developed melanoma had never visited a tanning salon, so to lay so much of the blame on UV exposure may deflect interest from other more significant risk factors and causes. There are those, however, that feel that UV exposure from any source at any level is to be avoided. “The evidence of the connection between UV and skin cancer is overwhelming, as is the evidence that chronic exposure increases your risk,” says James Spencer, M.D., Vice Chairman of Dermatology and Director of Dermatological Surgery at Mount Sinai School of Medicine in New York. “For people, especially young people, to deliberately expose themselves to the high levels of UV radiation that tanning beds produce simply for the short-term benefit of a tan is dangerous and foolish.” Dr. Naylor agrees with that assessment. “There is no safe level of exposure to a known carcinogen, and that holds for UV radiation as well,” says Dr. Naylor. “In my view, UV radiation is responsible for virtually all cases of melanoma, and many of the other skin cancers.” The Rising Level of Skin Cancer According to the American Cancer Society (ACS), an estimated 1 million new skin cancer cases were diagnosed in 2003 in the United States. Of these, about 54,000 cases were melanomas. While the incidence of non-melanoma skin cancer has been dipping in recent decades, the incidence of melanoma has more than doubled to 13 per 100,000 people in 1999 from six in 100,000 in 1973. The ACS estimated that nationwide about 9,800 deaths occurred in 2003 from all types of skin cancer. Of that, 7,000 will be from melanoma. Vilma Cokkinades, Program Director of risk factor surveillance for the ACS, has little doubt that UV radiation is responsible for the majority of skin cancers and that people should continue to follow the advice to avoid excessive exposure to UV radiation, either from the sun or from tanning beds. “The American Cancer Society strongly recommends that people avoid tanning salons. The evidence that points to a causal link between UVA exposure and cancer is growing, and it has been associated with melanoma and basal cell cancer,” says Ms. Cokkinades. “Recent research using animals showed that UV radiation can cause skin damage, including cancer. Human studies show that UVA exposure can cause molecular changes in the skin in terms of DNA operation and the cells’ ability to repair DNA damage. There is more than sufficient evidence to establish a clear connection between UV radiation exposure and skin cancer.” While some have called for the federal government to ban tanning salons and tanning beds, the FDA has resisted such a ban for a number of reasons. “The FDA is convinced that there are risks associated with use of sunlamps and warns people about these risks, including the possibility of skin cancer. The FDA also realizes that melanoma is a serious disease and has joined other public health agencies in warning the public to avoid overexposure to ultraviolet radiation. The FDA is working on proposals to strengthen these warnings,” says Howard Cyr, Ph.D., a research biophysicist with the FDA’s Office of Science and Technology. “However, the risk of death from UV exposure (of which sunlamps may be a minor source of UV) is substantially less than the risks of other legal activities, such as smoking cigarettes or drinking alcohol. In addition, the risk of melanoma from the use of sunlamps is less than that from exposure to solar ultraviolet radiation, a source of potential harm that can neither be regulated nor restricted.” The Consequences of Sun Avoidance However, Michael Holick, M.D., Ph.D., a Professor of Medicine, Dermatology, Physiology and Biophysics at the Boston University School of Medicine takes a slightly different view of UV radiation exposure. “The people who go to tanning salons certainly face a higher risk of basal cell and squamous carcinomas, but it is debatable what impact tanning has on melanoma. There are certain risks involved, but there are certain risks in everything we do, and if it makes these individuals feel better, I don’t know why we would stop them,” says Dr. Holick. “Moreover, as a result of all the warnings that are out there, people are now shunning the sun almost all the time, resulting in a significant vitamin D deficiency, which has very serious consequences, especially in children.” According to Dr. Holick, author of The UV Advantage, which will be available in May, 90% to 95% of people get their supply of vitamin D from exposure to the sun and not from diet or supplements. Unfortunately, many people are avoiding any exposure to the sun and this is creating a problem. “We have done studies that show that of girls ages 9 to 11, 48% were vitamin D deficient at the end of winter and that 17% were deficient at the end of summer,” says Dr. Holick. “That is all because of the paranoia that is out there about sun exposure. There are people who are putting sunscreen on their children everyday. That should alarm physicians.” In Dr. Holick’s view, lack of vitamin D causes serious consequences while an adequate supply can result in significant health benefits. Dr. Holick’s research shows that many chronic diseases are exacerbated by vitamin D deficiencies, including colon, prostrate, breast and ovarian cancers. He feels that the increased risk from these diseases outweighs the risk of skin cancer through UV exposure. Marji McCullough, ScD., Senior Epidemiologist for the ACS disagrees. “I think it is premature to compare the risks of these different cancers,” says Dr. McCullough. “The increased risk of skin cancer from UV exposure is real and the role of vitamin D in preventing cancers may be real as well. However, you can get vitamin D from diet and from sun exposure. Small amounts of sun exposure increase levels of vitamin D in the blood, but I do not advocate tanning as a way to increase your level of vitamin D. There are better ways to do it.” Vitamin D deficiencies may also result in a greater risk of having higher blood pressures. A study conducted by Dr. Holick showed that hypertensive patients had their blood pressure restored to normal levels after using tanning beds with UVB. “We did the same thing with patients but with tanning beds without UVB and there was no change in their blood pressure,” says Dr. Holick. “We know that at higher latitudes, people are more likely to have higher blood pressure and more heart disease. And studies show that you are more likely to have congestive heart failure if you have a vitamin D deficiency.” Studies do show that most of the cells in the body recognize vitamin D. One of the organs that vitamin D is found in is the pancreas, and children who are vitamin D deficient have a 4-fold higher risk of developing diabetes. “You have to ask yourself how important vitamin D is if it is recognized by most cells,” says Dr. Holick. “I think that as we learn more, we will discover that there are many other serious chronic diseases and conditions, such as bone health (bone density), that are influenced by vitamin D levels.” Dr. Spencer disagrees with that view. “Patients with known bone disease, or the weak and debilitated, may indeed have lower vitamin D levels,” says Dr. Spencer, “however, I am not aware of any evidence that people with high levels of vitamin D have reduced their risk of other diseases.” Many experts counter that vitamin D levels can be easily maintained through diet and supplements. “A healthy diet that includes sources of vitamin D, such as milk and fatty fishes, a daily vitamin or a calcium supplement containing vitamin D should be sufficient to maintain healthy levels of vitamin D,” says Dr. McCollough. “In addition, depending on the time of year and where you live, just 15 minutes of sun exposure on your arms and head each week is enough to synthesize the vitamin D that your body needs.” Dr. Holick says that the population as a whole cannot be relied on to assiduously take a supplement. “The problem with vitamin D supplements is that you need at least 1,000 units of vitamin D a day, milk may have 100 units in a glass and daily vitamins have about 400. How do you convince the population at large to take a daily supplement?” “In terms of tanning, I don’t advocate tanning and I never have, but I also believe that if a person wishes to tan, they should be permitted to do so. And that if they are going to do it, they should be permitted to do it responsibly,” says Dr. Holick. “As far as indoor tanning, if people want to tan, that is their prerogative. As long as they are made aware of the risks, which are mainly basal and squamous cell carcinoma. Most melanomas occur in unexposed areas, and that is not a result of nude tanning, because it has been true in the past. We do know that the number of sunburns you have had, the number of moles that you have on your body, your hair color and your genetics are all factors.” On the other hand, Dr. Naylor sees the increase in the use of tanning salons as a sign that the skin cancer situation is going to get dramatically worse very quickly. “I expect to see the incidence of skin cancer in men jump from around 20 per 100,000 in the year 2000, the latest year for which we have numbers, to levels in excess of 50, perhaps even approaching 100, per 100,000 people. In our lifetime, we will see melanoma become the single most prevalent form of serious cancer in the United States, exceeding even the most common tumors, such as lung cancer and breast cancer,” says Dr. Naylor. “Sadly, it is preventable and if we could eliminate intentional cosmetic tanning as a desirable activity, we would not even be having this discussion.” Keeping Patients Safe from All Risks While it is difficult to ignore the evidence that UV radiation is a significant risk factor for skin cancer as well as a host of other conditions, some question the wisdom of taking the extremely hard line approach of having people shun the sun completely. Some are concerned that the population in general and tanners in particular are given a message that is so strident that they tend to ignore the warnings because of their extreme nature. “In my view, doctors and especially dermatologists have overreacted to the dangers of UV radiation and have taken an extreme position about not being exposed to any sunlight without protection. I do not think that that is the wisest approach,” says Dr. Holick. “There needs to be a sensible message that goes out about UV exposure. A little bit of sun exposure is ok, even enough to get a tan. From my perspective, I would argue that by taking a more realistic approach, advising their patients that a little bit of sun can be beneficial but to protect themselves afterward, people will become more aware of the dangers.” However, most of those in the medical profession are convinced that UV exposure, no matter what the level of exposure, is dangerous and that tanning beds are simply too risky to even consider. “I think reducing your exposure to UV radiation is the best way to reduce your risk of skin cancer,” says Dr. McCullough. “As far as tanning beds go, I think that it is not at all healthy to subject yourself to massive doses of UV radiation.” That sentiment is echoed by Ms. Cokkinades. “People should simply accept the natural color of their skin and not tan for beauty reasons,” says Ms. Cokkinades “The risk of skin cancer, as well as the other skin problems that tanning can cause, is clearly not worth the rather short-term tan. And going regularly to a tanning salon to maintain a tan, especially for the young, is extremely risky.” Dr. Naylor takes the warning to an even higher level. “Vitamin D deficiencies is a straw man used to justify cosmetic tanning. You can no more defend tanning as a healthy pastime then you can defend cigarette smoking, but the tobacco industry has its defenders and so does the tanning industry.”
V ery few dermatologists were surprised when the Journal of the National Cancer Institute published a study recently that reported that the use of tanning salons resulted in a 55% increase in melanoma in a group of Scandinavian women. Most people, including most doctors, accept the link between ultraviolet (UV) radiation and skin cancer, and many saw this study as verification of what they considered obvious. “In my practice, I am seeing an increase in the number of young patients who present with multiple irregular nevi and at least one nodular melanoma on buttocks skin that has only seen UV from artificial sources,” says Mark Naylor, M.D., a Dermatologist and Tumor Researcher at the Oklahoma Medical Research Foundation. “And they almost always have a history of tanning, and especially the use of tanning salons.” Dr. Naylor describes many of his patients as “train wrecks,” who are coming in at a younger age with multiple, simultaneous skin cancers and advanced photoaging that Dr. Naylor attributes directly to year-round tanning. However, there are many who are not convinced that the link between UV rays and skin cancer is that firm or that the advice that physicians give to their patients to avoid UV radiation, either from sun exposure or tanning beds, is necessarily going to help their patients avoid skin cancer. In fact, there are those who believe that the public has been scared into avoiding the sun to such a degree that there is now an epidemic of vitamin D deficiency in this country with a corresponding increase in other diseases, including other forms of cancer. The Connection Between Tanning and Skin Cancer The Scandinavian study looked at a group of women who filled out reports in the early 90s and followed up on those women about 8 years after they had completed the initial report. Of the 106,379 women, 187 cases of malignant melanoma were reported. The study authors reported that the data showed that there was a 55% greater incidence of melanoma among women who had used tanning salons when compared to women who had not done any indoor tanning. However, fewer than 2% of the women in the initial survey reported using tanning salons. In addition, the women who used tanning salons were also more likely to engage in other behaviors that may be risk factors for skin cancer, including smoking and alcohol use. The study authors point out that the low number of reported cancers makes the difference statistically insignificant. Despite the media attention to the study, the numbers involved are not sufficient to draw meaningful conclusions about the relationship between tanning salons and skin cancer. Does this mean that tanning salons and UV exposure in general are not risk factors for skin cancer? No. There is sufficient evidence to show that UV exposure, especially early in life, is an extremely important factor, and the Department of Health and Human Services has added UV radiation to its list of known carcinogens. However, other factors, such as genetics, physical makeup, environmental exposures and even the size of the individual, may be more important. Keep in mind that most of the women in the study who developed melanoma had never visited a tanning salon, so to lay so much of the blame on UV exposure may deflect interest from other more significant risk factors and causes. There are those, however, that feel that UV exposure from any source at any level is to be avoided. “The evidence of the connection between UV and skin cancer is overwhelming, as is the evidence that chronic exposure increases your risk,” says James Spencer, M.D., Vice Chairman of Dermatology and Director of Dermatological Surgery at Mount Sinai School of Medicine in New York. “For people, especially young people, to deliberately expose themselves to the high levels of UV radiation that tanning beds produce simply for the short-term benefit of a tan is dangerous and foolish.” Dr. Naylor agrees with that assessment. “There is no safe level of exposure to a known carcinogen, and that holds for UV radiation as well,” says Dr. Naylor. “In my view, UV radiation is responsible for virtually all cases of melanoma, and many of the other skin cancers.” The Rising Level of Skin Cancer According to the American Cancer Society (ACS), an estimated 1 million new skin cancer cases were diagnosed in 2003 in the United States. Of these, about 54,000 cases were melanomas. While the incidence of non-melanoma skin cancer has been dipping in recent decades, the incidence of melanoma has more than doubled to 13 per 100,000 people in 1999 from six in 100,000 in 1973. The ACS estimated that nationwide about 9,800 deaths occurred in 2003 from all types of skin cancer. Of that, 7,000 will be from melanoma. Vilma Cokkinades, Program Director of risk factor surveillance for the ACS, has little doubt that UV radiation is responsible for the majority of skin cancers and that people should continue to follow the advice to avoid excessive exposure to UV radiation, either from the sun or from tanning beds. “The American Cancer Society strongly recommends that people avoid tanning salons. The evidence that points to a causal link between UVA exposure and cancer is growing, and it has been associated with melanoma and basal cell cancer,” says Ms. Cokkinades. “Recent research using animals showed that UV radiation can cause skin damage, including cancer. Human studies show that UVA exposure can cause molecular changes in the skin in terms of DNA operation and the cells’ ability to repair DNA damage. There is more than sufficient evidence to establish a clear connection between UV radiation exposure and skin cancer.” While some have called for the federal government to ban tanning salons and tanning beds, the FDA has resisted such a ban for a number of reasons. “The FDA is convinced that there are risks associated with use of sunlamps and warns people about these risks, including the possibility of skin cancer. The FDA also realizes that melanoma is a serious disease and has joined other public health agencies in warning the public to avoid overexposure to ultraviolet radiation. The FDA is working on proposals to strengthen these warnings,” says Howard Cyr, Ph.D., a research biophysicist with the FDA’s Office of Science and Technology. “However, the risk of death from UV exposure (of which sunlamps may be a minor source of UV) is substantially less than the risks of other legal activities, such as smoking cigarettes or drinking alcohol. In addition, the risk of melanoma from the use of sunlamps is less than that from exposure to solar ultraviolet radiation, a source of potential harm that can neither be regulated nor restricted.” The Consequences of Sun Avoidance However, Michael Holick, M.D., Ph.D., a Professor of Medicine, Dermatology, Physiology and Biophysics at the Boston University School of Medicine takes a slightly different view of UV radiation exposure. “The people who go to tanning salons certainly face a higher risk of basal cell and squamous carcinomas, but it is debatable what impact tanning has on melanoma. There are certain risks involved, but there are certain risks in everything we do, and if it makes these individuals feel better, I don’t know why we would stop them,” says Dr. Holick. “Moreover, as a result of all the warnings that are out there, people are now shunning the sun almost all the time, resulting in a significant vitamin D deficiency, which has very serious consequences, especially in children.” According to Dr. Holick, author of The UV Advantage, which will be available in May, 90% to 95% of people get their supply of vitamin D from exposure to the sun and not from diet or supplements. Unfortunately, many people are avoiding any exposure to the sun and this is creating a problem. “We have done studies that show that of girls ages 9 to 11, 48% were vitamin D deficient at the end of winter and that 17% were deficient at the end of summer,” says Dr. Holick. “That is all because of the paranoia that is out there about sun exposure. There are people who are putting sunscreen on their children everyday. That should alarm physicians.” In Dr. Holick’s view, lack of vitamin D causes serious consequences while an adequate supply can result in significant health benefits. Dr. Holick’s research shows that many chronic diseases are exacerbated by vitamin D deficiencies, including colon, prostrate, breast and ovarian cancers. He feels that the increased risk from these diseases outweighs the risk of skin cancer through UV exposure. Marji McCullough, ScD., Senior Epidemiologist for the ACS disagrees. “I think it is premature to compare the risks of these different cancers,” says Dr. McCullough. “The increased risk of skin cancer from UV exposure is real and the role of vitamin D in preventing cancers may be real as well. However, you can get vitamin D from diet and from sun exposure. Small amounts of sun exposure increase levels of vitamin D in the blood, but I do not advocate tanning as a way to increase your level of vitamin D. There are better ways to do it.” Vitamin D deficiencies may also result in a greater risk of having higher blood pressures. A study conducted by Dr. Holick showed that hypertensive patients had their blood pressure restored to normal levels after using tanning beds with UVB. “We did the same thing with patients but with tanning beds without UVB and there was no change in their blood pressure,” says Dr. Holick. “We know that at higher latitudes, people are more likely to have higher blood pressure and more heart disease. And studies show that you are more likely to have congestive heart failure if you have a vitamin D deficiency.” Studies do show that most of the cells in the body recognize vitamin D. One of the organs that vitamin D is found in is the pancreas, and children who are vitamin D deficient have a 4-fold higher risk of developing diabetes. “You have to ask yourself how important vitamin D is if it is recognized by most cells,” says Dr. Holick. “I think that as we learn more, we will discover that there are many other serious chronic diseases and conditions, such as bone health (bone density), that are influenced by vitamin D levels.” Dr. Spencer disagrees with that view. “Patients with known bone disease, or the weak and debilitated, may indeed have lower vitamin D levels,” says Dr. Spencer, “however, I am not aware of any evidence that people with high levels of vitamin D have reduced their risk of other diseases.” Many experts counter that vitamin D levels can be easily maintained through diet and supplements. “A healthy diet that includes sources of vitamin D, such as milk and fatty fishes, a daily vitamin or a calcium supplement containing vitamin D should be sufficient to maintain healthy levels of vitamin D,” says Dr. McCollough. “In addition, depending on the time of year and where you live, just 15 minutes of sun exposure on your arms and head each week is enough to synthesize the vitamin D that your body needs.” Dr. Holick says that the population as a whole cannot be relied on to assiduously take a supplement. “The problem with vitamin D supplements is that you need at least 1,000 units of vitamin D a day, milk may have 100 units in a glass and daily vitamins have about 400. How do you convince the population at large to take a daily supplement?” “In terms of tanning, I don’t advocate tanning and I never have, but I also believe that if a person wishes to tan, they should be permitted to do so. And that if they are going to do it, they should be permitted to do it responsibly,” says Dr. Holick. “As far as indoor tanning, if people want to tan, that is their prerogative. As long as they are made aware of the risks, which are mainly basal and squamous cell carcinoma. Most melanomas occur in unexposed areas, and that is not a result of nude tanning, because it has been true in the past. We do know that the number of sunburns you have had, the number of moles that you have on your body, your hair color and your genetics are all factors.” On the other hand, Dr. Naylor sees the increase in the use of tanning salons as a sign that the skin cancer situation is going to get dramatically worse very quickly. “I expect to see the incidence of skin cancer in men jump from around 20 per 100,000 in the year 2000, the latest year for which we have numbers, to levels in excess of 50, perhaps even approaching 100, per 100,000 people. In our lifetime, we will see melanoma become the single most prevalent form of serious cancer in the United States, exceeding even the most common tumors, such as lung cancer and breast cancer,” says Dr. Naylor. “Sadly, it is preventable and if we could eliminate intentional cosmetic tanning as a desirable activity, we would not even be having this discussion.” Keeping Patients Safe from All Risks While it is difficult to ignore the evidence that UV radiation is a significant risk factor for skin cancer as well as a host of other conditions, some question the wisdom of taking the extremely hard line approach of having people shun the sun completely. Some are concerned that the population in general and tanners in particular are given a message that is so strident that they tend to ignore the warnings because of their extreme nature. “In my view, doctors and especially dermatologists have overreacted to the dangers of UV radiation and have taken an extreme position about not being exposed to any sunlight without protection. I do not think that that is the wisest approach,” says Dr. Holick. “There needs to be a sensible message that goes out about UV exposure. A little bit of sun exposure is ok, even enough to get a tan. From my perspective, I would argue that by taking a more realistic approach, advising their patients that a little bit of sun can be beneficial but to protect themselves afterward, people will become more aware of the dangers.” However, most of those in the medical profession are convinced that UV exposure, no matter what the level of exposure, is dangerous and that tanning beds are simply too risky to even consider. “I think reducing your exposure to UV radiation is the best way to reduce your risk of skin cancer,” says Dr. McCullough. “As far as tanning beds go, I think that it is not at all healthy to subject yourself to massive doses of UV radiation.” That sentiment is echoed by Ms. Cokkinades. “People should simply accept the natural color of their skin and not tan for beauty reasons,” says Ms. Cokkinades “The risk of skin cancer, as well as the other skin problems that tanning can cause, is clearly not worth the rather short-term tan. And going regularly to a tanning salon to maintain a tan, especially for the young, is extremely risky.” Dr. Naylor takes the warning to an even higher level. “Vitamin D deficiencies is a straw man used to justify cosmetic tanning. You can no more defend tanning as a healthy pastime then you can defend cigarette smoking, but the tobacco industry has its defenders and so does the tanning industry.”
