INTO THE LIGHT Joseph G. Morelli, M.D.


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  • Basal cell carcinoma (BCC) is the most common cancer in the US.
    Most occur on the face, and the vast majority (over 95%) are cured with standard therapy, usually surgical excision.
    Mortality and metastases are rare, but basal cell cancers can invade and destroy adjacent vital structures.
    Death can result from erosion into a vital structure (e.g., skull, carotid artery) or due to secondary infection - but this usually occurs when the cancer is neglected and far advanced.
  • Squamous cell carcinomas (SCC) of the skin most commonly occur on the face.
    Over 95% of these cancers are cured with standard therapy.
    Death is uncommon. Lesion size, depth and location are risk factors for metastasis and death.
    Metastatic squamous cell carcinoma has a dismal prognosis.
    Certain sites, including the lips and ears, are associated with worse prognosis. Major organ transplant recipients have a very high risk of SCC, which is an important cause of death in this population.Note that squamous cell carcinomas that occur on genital and anal skin:
    -are associated with human papilloma virus
    -are relatively aggressive
    -are generally not related to sun exposure
  • self explanatory
  • 10071 cancer deaths in US according to American Cancer Society (2006)
    Compares skin cancer deaths to things often talked about by pediatricians or primary care docs – shows the urgency of prevention.
  • For the under age 35 cohort in Colorado, the male non-Hispanic white
    melanoma incidence rate was 5.1 per 100,000 during 1991-95 (about 37
    cases per year) and increased 12% to 5.7 during 1999-2003 (about 45
    cases per year). 
    The female non-Hispanic white melanoma rate increased
    30%, from 9.1 during 1991-95 (about 63 cases per year) to 11.8 during
    1999-2003 (about 88 cases per year).
    For melanoma deaths in the under age 35 cohort, I pooled males and
    females because of the smaller numbers and used 2001-2005 for the more
    recent time period. 
    The rate during 1991-95 was 0.4 per 100,000 (about
    8 deaths per year) and decreased to 0.2 per 100,000 during 2001-2005
    (about 4 deaths per year).
  • Exposure to the sun’s uv light is the most common modifiable cause of all three types of skin cancer.
    All three types of skin cancers are increasing with frequency over time.
    All three types increase in frequency with age.
    This graph only shows melanoma because BC Carcinoma and SC carcinoma are not reported to cancer registries – only Melanoma is so that is where we have the best, most available data, but all indications are that the graphs for BCC and SCC would look very similar
    They can all occur in any skin type – but most frequently in those whose skin color is light – white or tan.
    Note: Co data are annual statewide incidence rates among all races and both sexes. From” Cancer in Colorado: 1990-2000” December 2002”, p. 120
    US data are from Ries et al. (2005). “SEER Cancer Statistics Review, 1975-2002” (Table XVI-2 – SEER Incidence Rates, Age-Adjusted and Age-Specific Rates, by Race and Sex. Used rates for all races and both sexes) National Cancer Institute, Bethesda MD,
    http://seer, based on November 2004 SEER data submission, posted to the SEER website 2005.
  • With regard to phenotype, it is skin tone, NOT race determines risk.
  • Estimated that 80% of lifetime sun exposure occurs in childhood
    Behaviors established in early childhood tend to remain later in life
    New parents are eager to do what is best for their child
    High frequency of visits in early childhood provides many opportunities for providers to give and reinforce advice about sun protection
    Health Care Providers have large impact on parent’s behavior towards children
  • This slide and the one after it show the key messages given to parents from written program materials and from their provider in the clinic:
    Babies should be kept out of the sun as much as possible.
    When they are taken outside they should be covered with clothing or a light blanket.
    Sunglasses need to be UV-rated not toy sunglasses
    Babies should always wear a wide brimmed sun hat or a “flap hat” – like baseball cap with a cape
    Always check out a child’s daycare center to ensure they employ sun safe practices.
    Is there adequate playground shade?
    Do they have written policies about sun protection?
    Do children wear hats and sunglasses when outside?
    Do teachers apply sunscreen and reapply later if children are outside for an extended period?
  • INTO THE LIGHT Joseph G. Morelli, M.D.

    1. 1. INTO THE LIGHTINTO THE LIGHT Joseph G. Morelli, M.D.Joseph G. Morelli, M.D. Professor of Dermatology and Pediatrics,Professor of Dermatology and Pediatrics, UCDUCD Section Head, Pediatric Dermatology, TCHSection Head, Pediatric Dermatology, TCH
    2. 2. INTO THE LIGHTINTO THE LIGHT • The effects of the sun on the skin and the need for sun protection
    3. 3. DISCLOSURE INFORMATIONDISCLOSURE INFORMATION • I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity.
    5. 5. TYPES OF SKIN CANCERTYPES OF SKIN CANCER • Melanoma • Non melanoma (basal cell and squamous cell carcinoma)
    6. 6. Types of Skin Cancer:Types of Skin Cancer: Basal Cell CarcinomaBasal Cell Carcinoma
    7. 7. Types of Skin Cancer:Types of Skin Cancer: Squamous Cell CarcinomaSquamous Cell Carcinoma
    8. 8. Skin Cancer Age of Onset (allSkin Cancer Age of Onset (all types)types) • May be seen as early as late teens • Incidence rises rapidly after age 40 • Continues to increase with age
    9. 9. Skin Cancer DeathsSkin Cancer Deaths • 10,071 skin cancer deaths in the US (2006) • Over 3X the number of motorcycle deaths • Over 3X the number of drowning • 10X the number of people killed on a bicycle
    10. 10. MELANOMAMELANOMA • Because most of the deaths due to skin cancer are from melanoma, I will concentrate on it for the rest of the talk, although the sun protection advice which will be given later is applicable to minimizing all types of skin cancer
    11. 11. Years of Potential life lost due to cancerYears of Potential life lost due to cancer • Melanoma is the most common cancer for women 25-29 • 2nd to breast cancer for women 30-34 • Melanoma deaths represent an average of 17.1 years of potential life lost (YPLL) • Ranks second in YPLL only to adult leukemia • Outranks breast cancer (12.2 YPLL) and colon cancer (9.5 YPLL)
    12. 12. Skin Cancer in ColoradoSkin Cancer in Colorado • Colorado’s high altitude and sunny climate increase risk • UV intensity increases approx. 4% with every 1000 feet of altitude • From 1993-2003 the melanoma incidence rate for non-Hispanic whites rose 12% for men, and 30% for women
    13. 13. 10 12 14 16 18 20 22 24 19 90 1991 1992 1993 19 94 1995 1996 199 7 199 8 1999 2000Year Incidence CO US Melanoma in Colorado •Consistently outpaces US Incidence •Incidence increasing over time
    14. 14. MELANOMAMELANOMA • Cause of melanoma is a combination of genes and sun exposure
    15. 15. MELANOMA AND GENES IMELANOMA AND GENES I • There is a single gene which if mutated causes melanoma • There are families in which this mutated gene is inherited • In these families, almost everyone will get melanoma • Fortunately, this is very rare
    16. 16. MELANOMA AND GENES IIMELANOMA AND GENES II • In other melanoma susceptible individuals, there are varied genetic abnormalities, that are not completely understood
    17. 17. MELANOMA AND SUNMELANOMA AND SUN EXPOSUREEXPOSURE • In those people susceptible to melanoma, sun exposure increases their risk for the development of that problem
    18. 18. SUN EXPOSURESUN EXPOSURE • Ultraviolet radiation is the portion of the spectrum of light involved in skin cancer development
    19. 19. ULTRAVIOLET RADIATIONULTRAVIOLET RADIATION • UVC <290 nm (blocked by ozone) • UVB 290-320 nm (sunburn, DNA damage) • UVA 320-400 nm (photo aging)
    20. 20. MelanomaMelanoma • If melanoma is rare in childhood, why is a Pediatrician talking to you?
    21. 21. WHY IS A PEDIATRICIANWHY IS A PEDIATRICIAN TALKING TO YOUTALKING TO YOU • Risk factors for developing melanoma can be identified in childhood • These are the children who must be extra vigilant about sun protection
    22. 22. Risk FactorsRisk Factors • Freckling • Sunburns • Multiple nevi (moles) • Abnormal nevi (moles) • Susceptible phenotype • Chronic sun exposure • Presence of multiple factors can lead to a 200 fold increase in risk
    23. 23. MOLES IN CHILDHOODMOLES IN CHILDHOOD • An increase number of moles in childhood is a major sign of risk for developing melanoma later in life
    24. 24. MOLES IN CHILDHOODMOLES IN CHILDHOOD • I am part of a group at the University of Colorado who have been studying mole development in childhood
    25. 25. MEDIAN TOTAL NEVI BYMEDIAN TOTAL NEVI BY RACE/ETHNICITY AGE 3-8RACE/ETHNICITY AGE 3-8 YEARSYEARS 0 5 10 15 20 25 30 35 3 4 5 6 7 8 Age in years Medianno.ofnevi White, Non-Hispanic White, Hispanic Black Asian/Pacific Islander
    26. 26. SUMMARYSUMMARY • Non Hispanic white children in Colorado develop 4-6 new nevi per year from age 3 to 8 years • >90% remain < 2mm in size
    27. 27. GENDER DIFFERENCESGENDER DIFFERENCES a. All nevi, whole body 0 5 10 15 20 25 30 35 3 4 5 6 7 8 A ge in ye a rs
    28. 28. SUMMARYSUMMARY • Accumulation of nevi in intermittently exposed areas is the same in males and females • Accumulation of nevi in chronically exposed areas is greater in males than females starting at age 6
    29. 29. DEVELOPMENT OF NEVIDEVELOPMENT OF NEVI • Genetic predisposition (including skin color) • Sun exposure
    30. 30. SUN EXPOSURESUN EXPOSURE • Environment (geography and climate) • Behavior
    31. 31. SUN EXPOSURESUN EXPOSURE • Estimated that 80% of lifetime UV sunlight exposure occurs in childhood
    32. 32. BEHAVIORBEHAVIOR • As boys get older parents may be less vigilant with sun protection • Boys may just be outside more
    33. 33. RED HEADSRED HEADS • Children with red hair increase risk for the development of melanoma • Children with red hair have increased freckling • But, children with red hair have less nevi
    34. 34. RED HEADSRED HEADS • Children with light brown and hair and increased freckling have more nevi
    35. 35. RED HEADSRED HEADS • Red hair is determined by polymorphisms of the melanocortin 1 receptor • Homozygotes or compound heterozygotes at certain alleles have red hair • 4 highly penentrant alleles (R alleles) • V92M, R151C, R160W,D294H
    36. 36. RED HEADSRED HEADS • Red heads have increased risk of melanoma, but have less nevi • Is the mechanism for melanoma development different in red heads?
    37. 37. NEVUS DENSITYNEVUS DENSITY • Effect of sunburn • Sunburn history at age 5 and 6 years • Nevus counts age 7 years
    38. 38. SUNBURNSUNBURN • More than 2/3 reported at least one sunburn • Face and shoulders most commonly burned • Followed by back and arms
    39. 39. EFFECT OF SUNBURNSEFFECT OF SUNBURNS • Higher prevalence of nevi over the total body was associated with the total number of sunburns • This may be the effect of circulating inflammatory mediators or just a sign that increased sunburns mean less overall protection
    40. 40. EFFECT OF SUNBURNSEFFECT OF SUNBURNS • Three or more sunburns on the back were associated with higher nevus number on the back • No number of sunburns on the face, arms or legs was not associated with any increase in nevi
    41. 41. EFFECT OF SUNBURNSEFFECT OF SUNBURNS SUMMARYSUMMARY • Any history of sunburn leads to greater overall nevus number • Sunburns on the back an area of intermittent exposure lead to greater nevus density on the back • Sunburns on chronically exposed areas do not increase local nevus density
    42. 42. THE WHITEST OF THE WHITETHE WHITEST OF THE WHITE • Well established that lighter skinned children have more nevi than darker skinned children • What about the whitest of the white? • Does tanning effect nevus development in very light skinned children?
    43. 43. THE WHITEST OF THE WHITETHE WHITEST OF THE WHITE • We evaluated the effect of tanning on the lightest skinned subjects in our cohort by chromameter readings • Red heads were excluded • Tan level determined by chromameter
    44. 44. THE WHITEST OF THE WHITETHE WHITEST OF THE WHITE • Tan level determined by late summer differences between chromameter readings taken from the inner upper arm and outer lower arm
    45. 45. THE WHITEST OF THE WHITETHE WHITEST OF THE WHITE • Year Tan level N Nevi P value • 2004 <5 20 18.4 0.049 • >5 111 25.2 • 2005 <5 20 23.3 0.020 • >5 111 33.2 • 2006 <5 20 25.9 0.016 • >5 111 38.6
    46. 46. THE WHITEST OF THE WHITETHE WHITEST OF THE WHITE • Similar analysis in darker skinned subjects showed no effect of tanning on nevus development
    47. 47. THE WHITEST OF THE WHITETHE WHITEST OF THE WHITE • In very light skin children tanning leads to an increase in nevus number • We do not know if the untanned group did not tan because of the inability to tan or because of better sun protection
    48. 48. SUMMARYSUMMARY • Light skinned children have more nevi than dark skinned children • Boys have more nevi in chronically exposed areas than girls • Red heads have less than nevi other children with other hair color • Sunburns increase the number of moles
    49. 49. SUN PROTECTIONSUN PROTECTION • Sunscreen does not equal sun protection
    50. 50. SUN PROTECTIONSUN PROTECTION • Avoidance is the best protection • 10:00 am to 4:00 pm are peak hours
    51. 51. UVB and Temperature Data forUVB and Temperature Data for JulyJuly A Sunny DayA Sunny Day 0.00 20.00 40.00 60.00 80.00 100.00 120.00 0:00:00 0:45:00 1:30:00 2:15:00 3:00:00 3:45:00 4:30:00 5:15:00 6:00:00 6:45:00 7:30:00 8:15:00 9:00:00 9:45:00 10:30:00 11:15:00 12:00:00 12:45:00 13:30:00 14:15:00 15:00:00 15:45:00 16:30:00 17:15:00 18:00:00 18:45:00 19:30:00 20:15:00 21:00:00 21:45:00 22:30:00 23:15:00 Time of Day Temperature 0 F UVB 25(watts/m2 )
    52. 52. SUN PROTECTIONSUN PROTECTION • If one must be outside during the peak UV hours of the day, it is best to stay in the shade as much as possible
    53. 53. SUN PROTECTIONSUN PROTECTION • Tightly woven cotton long sleeve shirts and pants are excellent sun protection • Swim shirts worn at the pool are excellent sun protection • Broad rimmed hair should also be worn
    54. 54. SUN PROTECTIONSUN PROTECTION • Cover all exposed skin with sunscreen • Apply ½ hour before going out and again when you arrive at you destination • Think of it as needing 2 coats of paint to cover a wall
    55. 55. WHAT SUNCREEN SHOULD IWHAT SUNCREEN SHOULD I USE?USE? • The higher the SPF the better • Sunburn is a gross indicator of sun damage • Even if sunburn is prevented by SPF 15 sunscreen, there is evidence of microscopic sun damage • Sunscreen should also have UVA protection
    56. 56. NAMES TO LOOK FORNAMES TO LOOK FOR • Octylcrylene • Avobenzone
    57. 57. SUMMARY ISUMMARY I • Skin cancer is the number one cancer in the United States • Melanoma is a deadly form of skin cancer • Children with risk factors for the development of melanoma can be identified at an early age
    58. 58. SUMMARY IISUMMARY II • Sun protection includes avoiding the mid day sun, staying in the shade, clothing and hats, and sunscreen
    59. 59. REFERENCESREFERENCES • Elwood JM, Jopson J. Melanomaand sun exposure: an overview of published studies. Int J Cancer 1997;73:198-203 • Gallagher RP et al. Suntan, sunburn, and pigmentation factors and the frequency of acquired melanocytic nevi in children. Arch Dermatol 1990;126:770-6
    60. 60. REFERENCESREFERENCES • Gallagher RP, et al. anatomic distribution of acquired melanocytic nevi in white children. A comparison with melanoma: The Vancouver Mole Study. Arch Dermatol 1990;126:466-71 • Dodd AT, et al. Melanocytic nevi and sun exposure in a cohort of Colorado children: anatomic distribution and site-specific sunburn. Cancer Epidemiol Biomarkers Prev 2007;16:1-8