INTRODUCTION

0370647

2683

CA Cancer J Clin

CA: a cancer journal for clinicians

0007-92351542-4863

27232110

5124531

10.3322/caac.21352

NIHMS783572

Article

State of the Science on Prevention and Screening to Reduce Melanoma Incidence and Mortality: The Time is Now

Tripp

Mary K.

PhD, MPHDepartment of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TexasWatson

Meg

MPHDivision of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GeorgiaBalk

Sophie J.

MDChildren’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NYSwetter

Susan M.

MDDepartment of Dermatology, Pigmented Lesion and Melanoma Program, Stanford University Medical Center and Cancer Institute Stanford, California; Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CaliforniaGershenwald

Jeffrey E.

MDDepartment of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas

Correspondence: Jeffrey E. Gershenwald, MD, Dr. John M. Skibber Professor, Department of Surgical Oncology, Professor, Department of Cancer Biology, Medical Director, Melanoma and Skin Center, Co-Leader, MD Anderson Melanoma Moon Shot, Unit 444; The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, jgershen@mdanderson.org, Office – 713-792-6936

2852016

2752016

12112016

27112017

666460480

Although overall cancer incidence rates are decreasing, melanoma incidence rates continue to increase about 3% annually. Melanoma is a significant public health problem that exacts a substantial financial burden. Years of potential life lost from melanoma deaths contribute to the social, economic and human toll of this disease. However, most cases are potentially preventable. Research has clearly established that exposure to ultraviolet (UV) radiation increases melanoma risk. Unprecedented anti-tumor activity and evolving survival benefit from novel targeted therapies and immunotherapies are now available for patients with unresectable and/or metastatic melanoma. Still, prevention (minimizing sun exposure that may result in tanned or sunburned skin and avoiding indoor tanning) and early detection (identifying lesions before they become invasive, or at an earlier stage) have significant potential to reduce melanoma incidence and melanoma-associated deaths. This paper reviews the state of the science on prevention and early detection of melanoma, and current areas of scientific uncertainty and ongoing debate. The US Surgeon General’s Call to Action to Prevent Skin Cancer and US Preventive Services Task Force reviews on skin cancer have propelled a national discussion on melanoma prevention and screening that makes this an extraordinary and exciting time for diverse disciplines in multiple sectors – health care, government, education, business, advocacy and community – to coordinate efforts and leverage existing knowledge to make major strides in reducing the public health burden of melanoma in the US.

MelanomaSkin cancerMelanoma/prevention & control*Melanoma/epidemiologySunbathingSuntanUltraviolet rays/adverse effects*Indoor tanningLegislation as TopicEarly Detection of CancerUnited States Food and Drug AdministrationUnited States Preventive Services Task ForcePublic health

INTRODUCTION

The incidence of melanoma has been increasing for more than forty years in the US, since population-based cancer statistics have been collected.¹ Although the incidence rate for all cancer sites combined is decreasing, the melanoma incidence rate has continued to increase.² Melanoma is the only cancer which is not projected to meet federal objectives for reductions in death rates.³ Melanoma is a significant public health problem that exacts a substantial financial and social burden; however, most cases are potentially preventable.¹ Research has clearly established that exposure to ultraviolet (UV) radiation increases melanoma risk.^{4, 5}

Melanoma prevention recommendations include minimizing overexposure^a to the sun and avoiding indoor tanning, yet studies show that US adults, adolescents and children are not adequately protected from the sun, and indoor tanning remains prevalent in older adolescents and young adults.^6–9 These alarming data, along with the availability of best practices and evidence-based interventions to reduce UV exposure, inspired the US Surgeon General to publish a “Call to Action to Prevent Skin Cancer” in 2014.¹ Key goals of this effort are to increase opportunities for sun protection in outdoor settings, provide individuals with information to make informed, healthy choices about UV exposure, promote policies that advance the national goal of preventing skin cancer, reduce harms from indoor tanning, and strengthen research, surveillance, monitoring, and evaluation related to skin cancer prevention. Along with this Call to Action, recent state legislation to support sun protection in schools and restrict minors’ access to indoor tanning, and actions by the US Food and Drug Administration (FDA) to reclassify tanning devices¹⁰ and propose a new federal rule restricting minors’ access to tanning beds,¹¹ have heralded a national focus on melanoma prevention that is unparalleled in US history. Together these changes present a significant opportunity for the US to change norms and policies to increase sun protection and reduce tanning behaviors.

Unprecedented anti-tumor activity and evolving survival benefit from novel targeted therapies and immunotherapies that are now available have ushered in a new era for patients with unresectable and/or metastatic melanoma.^12–18 Still, prevention (through minimizing overexposure to the sun and avoiding indoor tanning) and early detection (identifying lesions at earlier stages of development) have significant potential to reduce melanoma incidence and melanoma-associated deaths. Earlier detection of thinner melanomas is linked to higher survival rates, although no randomized, controlled trials have been conducted to assess the impact of clinician screening on melanoma mortality. The lack of clear evidence regarding effectiveness of population-based screening to reduce melanoma mortality resulted in a US Preventive Services Task Force (USPSTF) recommendation in 2009, and an updated draft recommendation statement proposed in 2015, that current evidence for skin screening of the general population is, “insufficient to reliably conclude that early detection of skin cancer through visual examination by a clinician reduces morbidity or mortality.”^{19, 20} The USPSTF’s 2015 draft recommendation statement highlights research needs and gaps, and this critical guidance can be utilized to further develop the scientific evidence base for screening.

The national discussion on melanoma prevention and screening makes this an extraordinary and exciting time for clinicians and researchers to impact melanoma incidence and mortality. The time is now for diverse disciplines in multiple sectors – health care, government, education, business, advocacy and community – to coordinate efforts and leverage existing knowledge to make major strides in reducing the public health burden of melanoma in the US. Examples of how clinicians and researchers are collaborating to embrace approaches with broad reach and maximal impact include The University of Texas MD Anderson Cancer Center’s Melanoma Moon Shot, which as a component of this broad effort emphasizes a program of innovative behavioral research and dissemination of evidence-based prevention strategies and public policy initiatives alongside a research focus on personalized melanoma treatment strategies (http://www.cancermoonshots.org/cancer-types/melanoma),^21–23 and Oregon Health and Science University’s War on Melanoma, which prioritizes research, public education and early detection (https://www.ohsu.edu/xd/health/services/dermatology/war-on-melanoma/).

Epidemiology of melanoma and nonmelanoma skin cancer

Nearly 5 million patients receive treatment for melanoma or nonmelanoma skin cancer (NMSC) in the US each year.²⁴ These cases are primarily keratinocyte carcinomas (i.e., basal cell [BCC] and squamous cell carcinomas [SCC]), which are the most common cancers in the US but are not tracked in central cancer registry systems. Although melanoma is less common, it causes nearly 75% of skin cancer deaths.²⁵ Melanoma is the fifth and sixth most common cancer in males and females, respectively,²⁵ and is one of the most common cancers among adolescents and young adults.²⁶ In 2012, the most recent year for which national data are available, 67,753 people in the US were diagnosed with invasive melanomas of the skin,²⁵ and the American Cancer Society estimates that 76,380 cases of invasive melanoma and 68,480 cases of melanoma in situ will be diagnosed in 2016.²⁷ From 1975 to 2012, incidence increased steadily at an annual average rate of 3.2% in males and 2.4% in females (Figure 1).²⁸ Unlike most other cancers for which the incidence rate is either stable or decreasing,² the incidence rate for melanoma is expected to continue to rise. Indeed, a recent estimate projected that 112,000 new invasive melanomas (i.e., exclusive of melanoma in situ) will be diagnosed in the US in 2030 in the absence of new public health interventions.²⁹

Melanoma incidence is more common overall among some groups: non-Hispanic whites, males, and older individuals (Tables 1 and 2). However, among individuals younger than age 50, melanoma is more common among females than males.²⁵ Some have attributed higher rates and recent increases among young females to intentional tanning behaviors, especially indoor tanning.³⁰ After age 50, melanoma incidence rates stabilize for females while increasing steeply among males.²⁵ These patterns by age and gender likely reflect different sun protection and exposure patterns over a lifetime among women compared to men.⁹

The scientific community has debated the reasons for trends in melanoma incidence over time.³¹ Mortality has remained relatively stable, and early-stage melanomas make up much of the increase in incidence, leading some to suggest that increased incidence may be due solely to screening and overdiagnosis of potentially indolent lesions.^{32, 33} Screening for skin cancer has become increasingly common.³⁴ However, recent analyses have described incidence increases among melanomas of all thicknesses,^{35, 36} and melanoma mortality among males has been gradually increasing about 1% a year (Figure 2). Increasing melanoma incidence also has been observed across all socioeconomic status (SES) groups in the California subset of the Surveillance, Epidemiology, and End Results (SEER) Program.³⁷ Among the lowest SES group, who may have limited access to screening, the highest increases were observed for 2.01 to 4.00 mm and ≥ 4.01 mm tumors. Overall, findings suggest that melanoma incidence increases are not solely a result of increased screening.

In 2012, 9,251 persons died from melanoma in the US: 6,013 males and 3,238 females (rate of 4.0 and 1.7 per 100,000, respectively),³⁸ with an estimated 10,130 deaths expected to occur in 2016.²⁷ Deaths due to melanoma are most common among those with the highest incidence: non-Hispanic whites, males and individuals over age 50.³⁸ Melanoma survival is strongly associated with stage at diagnosis;³⁹ individuals diagnosed at a later stage have poorer survival.^{35, 40} Five-year survival has been higher in females than males, even when stratified by stage at diagnosis.⁴⁰ Although black and Hispanic patients are generally diagnosed with melanoma at later stages and have poorer survival compared to non-Hispanic whites, differences were not statistically significant when controlled for stage at diagnosis.⁴⁰ Overall, melanoma survival has been improving over the past two decades, with 92% of people diagnosed during 2001–2003 surviving 5 years after diagnosis compared to 88% of those diagnosed during 1989–1991.³⁵ Based on a SEER Cancer Statistics Review, the overall 5-year relative survival rate for those diagnosed 2005–2011 was 92%.⁴¹ Ninety-eight percent of patients diagnosed with local disease survived for five years, compared to 63% diagnosed with regional nodal disease and only 17% diagnosed with distant metastasis. These wide variations highlight not only the tremendous heterogeneity of prognosis across all stages of disease, but also the significant opportunity to reduce the public health burden of melanoma with successful prevention and early detection efforts in the US. Remarkably, only since 2011 have new treatment options become available – including both checkpoint inhibitor-based immunotherapy and targeted therapy for patients with BRAF mutations – that together are beginning to provide great promise for patients with advanced melanoma.^12–18

Financial and Social Costs

The average annual cost of melanoma treatment increased by 288%, compared to 25% for all other cancers combined, between 2002–2006 and 2007–2011.²⁴ Overall, skin cancer treatment costs $8.1 billion in the US each year, with $3.3 billion attributable to melanoma.²⁴ Indirect costs such as lost productivity attributable to melanoma are estimated to be $39.2 million for morbidity and $3.3 billion for mortality each year.⁴² Beyond treatment, each potentially preventable melanoma death causes about 15 additional years of potential life lost, which contribute to the social, economic, and human toll of this disease. Prevention interventions aimed at reducing melanoma incidence have the potential to substantially decrease melanoma-related costs by an estimated $250 million per year (Figure 3).²⁹

MELANOMA PREVENTION AND EARLY DETECTION

The following sections elaborate on the state of the science pertaining to prevention strategies (sun protection and avoidance of indoor tanning) and evidence-based interventions and best practices for early detection and screening. USPSTF recommendations concerning skin cancer counseling and screening are discussed along with current areas of ongoing debate.

Melanoma Prevention: Reducing UV Exposure

The vast majority of skin cancers are caused by UV exposure from the sun and/or indoor tanning devices.^{4, 43} Melanoma prevention strategies include sun protection (i.e., using sunscreen regularly; wearing protective clothing, wide-brimmed hats and sunglasses; seeking shade and limiting time outdoors during midday hours when UV radiation from the sun is most intense) and avoidance of indoor tanning.^{27, 44} Although it is clear that UV exposure plays a key role in the development of most skin cancers, the importance of age at overexposure is unclear, with some research showing that sunburns in childhood are particularly harmful and other studies showing that sunburn during any life period raises risk.^{45, 46} Scientific evidence links indoor tanning to an increased risk of developing melanoma, BCC and SCC.^47–50 Moreover, genetic sequencing data support the role of UV exposure in increasing risk for melanoma; recent studies, including the melanoma effort of The Cancer Genome Atlas Program, demonstrated that melanoma has the highest mutation rate among all solid tumors studied and that the majority of somatic mutations in melanomas are associated with a “UV signature.”^51–53

Occupational exposure to UV may play a role in the development of melanoma. Some ecological studies have shown that outdoor workers were at increased risk of SCC and BCC, but not melanoma.^{54, 55} However, studies on the relationship between occupational UV exposure and melanoma are often limited by lack of information on other related factors.^{56, 57} A large meta-analysis stratifying studies by latitude found that workers in UV-intense areas were at increased risk of melanoma.⁵⁸ An Australian analysis of melanoma by body site found that occupational exposure was associated with melanomas of the head and neck, whereas recreational exposures were associated with melanomas of the trunk.⁵⁹

Sun ProtectionPrevalence of Sunburn and Sun Protection Behavior

In 2010, 38% of US adults reported being sunburned in the past year.⁹ Although most (70%) US adults reported usually or always protecting their skin from the sun when outdoors for more than an hour on a sunny day,⁹ individual methods of protection were less common. For example, only 31% of adults (21% of men and 41% of women) reported use of sunscreen with a sun protection factor (SPF) of 15 or higher on exposed skin. Non-Hispanic whites had the highest prevalence of sunscreen use (37%), followed by Hispanics (22%) and non-Hispanic blacks (10%). Sunscreen use was less common in younger adults ages 18 to 24 (23%) compared to individuals 25 or older (32%). More males (46%) than females (34%) wore protective clothing, while more females (44%) than males (31%) sought shade; adults 25 and older were more likely to use protective clothing and shade.⁹ Research shows that some melanoma survivors sunbathe, experience sunburns or do not use adequate protection despite their diagnosis.⁶⁰

A 2004 population-based survey of adolescents ages 11 to 18 showed that 69% reported at least one sunburn during the previous summer; 5% routinely wore wide-brimmed hats, 23% wore protective clothing and 22% sought shade.⁶¹ According to the 2013 Youth Risk Behavior Survey (YRBS), a nationally representative sample of high school students in grades 9 through 12, only 10% of high school students (13% of females and 7% of males) reported using sunscreen with SPF 15 or higher always or most of the time when outside for more than one hour on a sunny day.⁸ Sunscreen use was highest in Asian students (16%; 24% of females and 8% of males) followed by non-Hispanic white students (12%; 15% of females and 8% of males). US population-based estimates of parent sun protection practices for children are lacking. In a population-based study of fifth-grade children from Framingham, Massachusetts, 55% of children reported experiencing one or more sunburns during the previous summer, and only 25% reported routinely using sunscreen.⁶²

Evidence on Effectiveness of Community-wide Programs

The Community Preventive Services Task Force conducted systematic reviews on the effectiveness of community-based interventions to prevent skin cancer. Recommendations based on these reviews are published in The Guide to Community Preventive Services (aka The Community Guide). Currently, The Community Guide states that there is sufficient evidence to recommend education and policy approaches to increase preventive behaviors in the following settings: child care centers, primary and middle schools, outdoor recreational and tourism areas, and occupational settings.⁶³

The Community Guide also states that multicomponent community-wide interventions are effective at increasing preventive behaviors. These interventions are defined as having at least two distinct components (such as strategies directed toward individuals, mass media campaigns or environmental and policy changes) implemented in multiple settings or the entire community in a defined geographic area.⁶³ Although mass media campaigns, specifically, were found to be effective when used as one component in a multicomponent community-wide intervention, the small number of studies regarding mass media campaigns in the absence of other initiatives, as well as methodological issues, led to a finding of insufficient evidence for mass media campaigns alone.

Much of The Community Guide’s review of multicomponent community-wide interventions was based on research conducted in Australia,⁶³ which has one of the highest skin cancer incidence rates in the world.⁶⁴ In 1988, a sun protection program called SunSmart began in the state of Victoria, and has since been implemented in all Australian states and territories.⁶⁵ After decades of prevention efforts in Australia, skin cancer incidence rates are beginning to stabilize or decline among adolescents and young adults.^{66, 67} A recent study estimated that regular sunscreen use in Australia has likely reduced skin cancer incidence by 10–15%, potentially preventing 14,190 people from developing SCCs and 1,730 people from developing melanomas.⁶⁸ An economic evaluation of Australia’s SunSmart program demonstrated that the program saved an estimated $AU2.30 in health care costs for each $AU1 invested in the program.⁶⁹

Policies and Environmental Interventions to Support Sun Protection in Schools, Occupational, and Recreational Settings

In 2002, the CDC published guidelines for school programs to prevent skin cancer.⁷⁰ This document underscores the importance of policies in schools to support skin cancer prevention through strategies such as allowing or encouraging students to wear hats and protective clothing, and to carry and apply sunscreen in schools. Addressing the physical environment is also a priority of the school guidelines, especially by increasing shade in outdoor areas. As a follow-up to the publication of the guidelines, the CDC produced a document, “Shade Planning for America’s Schools,” to provide specific guidance on how to evaluate and increase the availability of shade on school grounds.⁷¹

According to the 2012 School Health Policies and Practices Study (SHPPS), which examined state and school district policies, 31% of states reported developing, revising or assisting in developing model policies related to sun safety for schools or districts, and 32% reported distributing such policies to districts or schools.⁷² Less than 2% of school districts required that schools allow students to apply sunscreen while at school, and most districts had no policy either requiring or recommending that schools allow students to apply sunscreen. School district guidance regarding other sun protection strategies, such as avoiding outdoor activities during peak hours of UV exposure intensity or encouraging students to wear sun protective clothing and hats, was not required or recommended in over 50% of school districts.⁷²

The 2014 SHPPS, which examined individual school policies, reported that 15% of schools surveyed reported scheduling outdoor activities to avoid times when the sun was at peak UV intensity, 48% of schools reported that teachers allowed time for students to apply sunscreen at school and 28% stated that teachers reminded students to apply sunscreen before going outside.⁷³ Additionally, 30% of schools reported encouraging students to wear protective clothing, while 8% prohibited students from wearing hats or visors when in the sun during the school day. SHPPS did not directly report on schools allowing or prohibiting use of sunscreen while on school grounds. California, Oregon and Texas have passed state laws allowing children to carry and apply sunscreen while on school property.^74–76

Municipal and recreational policies and environmental interventions are also critical to support sun protection. The city of Phoenix, Arizona, adopted a Master Shade Plan, led by the city’s Parks and Recreation department, to increase shade and tree cover in the city.⁷⁷ The city of Toronto, Canada, also has implemented a municipal shade policy since 2010, intended to increase shade in that city.⁷⁸ Several municipalities and organizations have increased availability of sunscreen for the public. The city of Miami Beach has partnered with Mount Sinai Medical Center and a sunscreen manufacturer to offer sunscreen at 50 dispensers in public pools, parks and beaches.⁷⁹ The city of Boston has distributed 30 sunscreen dispensers in city parks, in partnership with the Melanoma Foundation of New England and Make Big Change.⁸⁰ Additionally, some sports venues have made free sunscreen available.^81–84 Likewise, colleges and universities can support skin cancer prevention by making sunscreen available in outdoor recreation and sports venues and implementing policies to promote sun protection and the avoidance of indoor tanning.⁸⁵ Although these particular efforts have not been evaluated, The Community Guide recommends environmental approaches to sun protection in outdoor and tourism settings.⁶³

Sun protection interventions in outdoor occupational settings are also recommended by The Community Guide.⁶³ Educational, environmental and policy approaches increased uptake of sun protection among outdoor workers. Policy approaches, such as requiring or providing sun protective clothing or rotating workers out of UV-intense tasks, may be particularly important for outdoor workers because they may have little individual control over their environment and UV exposure levels while at work.

Indoor Tanning

Indoor tanning is the practice of using tanning beds (also called “sunbeds”), booths or lamps to tan the skin for cosmetic purposes. Most tanning devices emit primarily UVA radiation and small amounts of UVB, though amounts vary widely.^{86, 87} Although UVB radiation is much more potent than UVA radiation in causing sunburn, high doses of UVA can lead to erythema, burning and tanning; both UVA and UVB radiation have been shown to cause skin cancer.^{88, 89} Almost 2,000 indoor tanning-related injuries were treated in emergency departments in 2012; most of these injuries were skin burns.⁹⁰ Studies show that, depending on the type of tanning device used, the amount of UVA exposure may be 4 to 13 times the amount typically received from summer noontime sun in the District of Columbia.^{86, 87} Frequent indoor tanners may receive 1.2 to 4.7 times the yearly dose of UVA they receive from sunlight, in addition to doses received by sun exposure.⁸⁷

Carcinogenicity of indoor tanning

The first expert review of tanning bed use and skin cancer was published in 2006 by the World Health Organization’s (WHO) International Agency for Research on Cancer (IARC).⁹¹ In that review, IARC released results of its meta-analysis of 19 studies of associations between tanning bed use and skin cancer risk. The IARC meta-analysis showed a 15% increase in melanoma risk (summary relative risk [RR], 1.15; 95% confidence interval [CI], 1.00, 1.31) for those who had ever used a sunbed compared to those who never had. Based on those data, in 2009 IARC added UV-emitting tanning devices to its list of group 1 carcinogens – meaning that tanning lamps are “carcinogenic to humans.”⁵ Recent evidence shows that the tanning response is mediated in large part by signals emanating directly from damage to DNA and that tanning does not occur without DNA damage.⁹²

Early life exposure and melanoma risk

The IARC meta-analysis showed that melanoma risk was greater with first exposure to an indoor tanning device before age 35 (summary RR, 1.75; 95% CI, 1.35, 2.26).⁹¹ Although some challenged these findings because the association was weak, a dose-response relationship could not be confirmed, and studies did not examine exposures to specific tanning devices, more recent research has strengthened the evidence of an association between tanning bed exposure and melanoma risk. A Minnesota case-control study of indoor tanning and melanoma risk revealed that risk increased with the number of years, hours, and sessions of indoor tanning, and risk increased independent of outdoor exposure.⁹³ An Australian population-based case-control study of early onset melanoma showed that ever using a sunbed (i.e., indoor tanning device), compared to never using one, was associated with a greater risk of developing melanoma (odds ratio [OR], 1.41; 95% CI, 1.01, 1.96).⁹⁴ This association was stronger for earlier age at first use (p_trend = 0.02). There was a doubling of risk for > 10 lifetime sunbed sessions (OR, 2.01; 95% CI, 1.22, 3.31). This association was stronger for melanoma diagnosed between ages 18 and 29 (OR for > 10 lifetime sessions, 6.57; 95% CI, 1.41–30.49) than for melanoma diagnosed between ages 30 and 39 (OR, 1.60; 95% CI, 0.92–2.77; p_interaction = .01). Among those who ever used a sunbed and were diagnosed with melanoma between ages 18 and 29, 76% of melanomas were estimated to be attributable to sunbed use.⁹⁴ A recent case-control study from Minnesota found that 97% of women in the study who were diagnosed with melanoma younger than age 30, and 94% of women who were diagnosed from age 30 to 39, had engaged in indoor tanning; the median age of initiation of indoor tanning was 16 years, and the median number of sessions was over 100, in both age groups.⁹⁵ In a study in Norway and Sweden, authors concluded that the risk of melanoma appeared to increase with accumulating solarium exposure during early adulthood.⁹⁶ More recent meta-analyses have continued to document increased risk of melanoma for indoor tanners, especially those who start at younger ages or tan more frequently.^{48, 49, 97} It is estimated that for each additional session of tanning bed use per year, there is a 1.8% increase in melanoma risk.^{48, 49}

Prevalence of Use

Indoor tanning’s popularity surged in the US in the 1980s.⁹⁸ Approximately 18,000 to 19,000 indoor tanning salons and 15,000 to 20,000 other commercial facilities (e.g., health clubs, gyms and spas) offer tanning services in the US.¹¹ A report of data from 116 US cities showed that the average number of tanning salons exceeded the average number of Starbucks or McDonald’s in those cities.⁹⁹ Tanning services are sometimes offered as amenities in gyms and residential settings such as apartment buildings.¹⁰⁰ In an observational study of 125 US colleges and universities, researchers found that indoor tanning was available on campus in 12% of colleges and in off-campus housing in 42% of colleges. More than 14% of colleges allowed campus cash cards to be used to pay for indoor tanning at off-campus facilities.¹⁰¹

An estimated 1 million people visit a US tanning facility each day,¹⁰² and 11.3 million people engage in indoor tanning each year.^{6, 7} According to the 2013 National Health Interview Survey, a representative sample of the US civilian noninstitutionalized population age 18 or older, 4.2% of all adults (6.5% of females and 1.7% of males) reported using an indoor tanning device in the past 12 months.⁷ Use was most common among young adults ages 18 to 29 (11%; 19% of females and 4% of males). Although all percentages represent significant reductions in prevalence compared to 2010,⁷ these data suggest that about 7.8 million US adult females and 1.9 million males engaged in indoor tanning in 2013. Research shows that about 25% of female indoor tanners ages 18 to 25 practiced indoor tanning in locations other than tanning salons, mostly in gyms, private homes or apartments, and year-round tanning was more common in this group.¹⁰⁰ Adult males who self-reported as gay, homosexual or bisexual (sexual minority males) were more likely to report engaging in indoor tanning than males who self-reported as heterosexual. Sexual minority females were less likely to report indoor tanning than heterosexual females.¹⁰³ Remarkably, some melanoma survivors continue to engage in indoor tanning despite known risks.⁶⁰

According to the 2013 YRBS, 5% of US high school student males and 20% of females reported using an indoor tanning device one or more times during the 12 months before the survey (not including spray tanning).⁶ Indoor tanning was most common among non-Hispanic white females in higher grades: 35% of 11^th graders and 40% of 12^th graders.⁸ Among students who reported using devices within the past year, more than one-half (51%) were “frequent tanners,” doing so ≥ 10 times within the past year. Among non-Hispanic white female high school students, 31% reported using a tanning device in 2013, representing a decrease from 37% in 2009.⁶ Despite reductions in indoor tanning prevalence, about 1.5 million female and 400,000 male students are still estimated to use indoor tanning devices; most (1.6 million) of these students are younger than 18.

Association with other Risk Behaviors

Frequent tanning bed use was associated with smoking cigarettes, binge-drinking, having high concern about weight and other risk behaviors in female teens.¹⁰⁴ According to the 2009 YRBS, male high school students who tanned indoors were more likely to have ever taken steroids without a doctor’s prescription, used unhealthy weight control practices, engaged in binge drinking and attempted suicide.¹⁰⁵ In a survey of Colorado high school students, use of steroids, alcohol, marijuana and illicit drugs was positively associated with indoor tanning.¹⁰⁶ In young women, indoor tanning was associated with substance and alcohol use.^{107, 108}

Motivations for Tanning

Some people continue to intentionally tan even if they are aware that UV exposure raises skin cancer risk,¹⁰⁹ often believing that having a tan is attractive and appears healthy.⁶¹ Some have promoted sunless tanning (such as “spray tanning”) as an alternative to indoor tanning.¹¹⁰ However, a significant majority of tan seekers continue to sunbathe or indoor tan despite also using sunless tanning products.^{111, 112} Sunless tanning has preceded initiation of indoor tanning in teens.¹¹³ Exposure to chemicals through inhalation is another concern with sunless tanning.¹¹⁴

About 5 to 10% of indoor tanners have met criteria for tanning dependence,^115–117 similar to prevalence rates for substance dependence. Assessments of tanning dependence have been adapted from Diagnostic and Statistical Manual of Mental Disorders criteria^{118, 119} or the CAGE, a brief screening instrument for problematic alcohol use.¹²⁰ Other studies in humans and mice add evidence to the possibility of tanning addiction.^121–124 Exposure to UV light triggers damage to DNA in the nucleus of keratinocytes, resulting in activation of the p53 tumor suppressor gene. This then transcriptionally up-regulates the expression of the gene encoding proopiomelanocortin (POMC) that is processed to melanocyte-stimulating hormone, inducing tanning. At the same time, another POMC-derived peptide, β-endorphin, is synthesized in skin, elevating plasma levels.⁹² Endogenous β-endorphin has analgesic effects and promotes relaxation and feelings of well-being in humans, similar to opiates.

Recommendations of Organizations

In addition to individual statements from numerous professional and other organizations (WHO, American Academy of Pediatrics [AAP], American Academy of Dermatology, American Medical Association, Canadian Pediatric Society, National Council on Skin Cancer Prevention and Society for Behavioral Medicine), leading cancer-focused and other concerned organizations signed a “Joint Position Statement on Indoor Tanning” in July 2015, citing high usage of tanning beds by teens and young women and the carcinogenicity of this exposure. The statement strongly supported state and federal legislation to prohibit the use of indoor tanning by minors under 18, educational efforts to effectively communicate risks of indoor tanning to teens and their parents, and counter-advertising to de-normalize the perceived beauty of tanned skin.¹²⁵ To date, 22 organizations have endorsed this joint position statement on indoor tanning.

Regulation of Tanning DevicesFederal Regulation

The FDA is responsible for regulating UV tanning devices. Until 2014, the FDA categorized tanning devices as Class 1 medical devices, in the same category as tongue depressors and Band-Aids®. On March 25, 2010, the General and Plastic Surgery Devices Panel of the FDA Center for Devices and Radiologic Health Medical Devices Advisory Committee convened a public meeting to discuss tanning devices whereby experts discussed evidence that tanning bed exposure increases skin cancer risk; counter-arguments were provided by representatives of the indoor tanning industry.¹²⁶ On May 27, 2014, the FDA issued a final order announcing the reclassification of UV sunlamp products from ‘low-risk’ Class I devices to ‘moderate-risk’ Class II devices that require stricter controls for design and safety and carry a visible boxed warning: “Attention: This sunlamp product should not be used on persons under the age of 18 years.”¹⁰

On December 18, 2015, the FDA announced a proposed rule to restrict the use of sunlamp products to people ages 18 and older.¹¹ If finalized, this rule will become law in the US, superseding state laws. The rule also will require users over age 18 to sign a risk acknowledgement certification before use, and then every 6 months, stating that they have been informed about health risks.

The Tanning Accountability and Notification (“TAN Act”) (HR 945) of 2007 requires the FDA to conduct consumer testing to determine if warning labels on commercial tanning beds are positioned correctly and provide sufficient information pertaining to skin cancer risk.¹²⁷ The Affordable Care Act (ACA) mandated in 2010 that indoor tanning services be levied with a 10% excise tax (the “tanning tax” or “tan tax”) to provide revenue for the ACA.^{128, 129} Tanning salons must receive a payment for indoor UV tanning services, report the tax each quarter and remit the tax to the Internal Revenue Service. The tan tax was expected to raise 2.7 billion dollars over 10 years, but initially the number of taxpayers filing tanning services excise tax returns was lower than expected.¹³⁰ Research suggests that most salons are collecting the tax from clients, and that younger clients do not appear to mind paying the tax.¹³¹

State and Local Regulations

In 2009, Howard County, MD, became the first US jurisdiction to ban tanning for children under age 18. In October 2011, Governor Brown of California signed the first state law banning under-18 salon tanning, effective January 2012. As of April 2016, 13 other states (Delaware, Hawaii, Illinois, Louisiana, Massachusetts, Minnesota, Nevada, New Hampshire, North Carolina, Oregon, Texas, Vermont and Washington), the District of Columbia and other jurisdictions have passed under-18 bans. Now 42 states have at least some kind of legislation regarding minors’ use of indoor tanning.^{132, 133}

Are State Indoor Tanning Laws Effective?

Studies examining parental permission laws found that tanning facilities had poor compliance with these laws,^134–136 and these laws were not effective in reducing indoor tanning among teens.^{137, 138} More recently, researchers have evaluated tanning bed laws including age restrictions using data from the YRBS.¹³⁹ Tanning laws were classified into “systems access” (e.g., requirements for indoor tanning device operators to obtain signed statements from patrons and post a warning sign); and “youth access” (parental permission [laws prohibiting minors under a certain age from using indoor tanning devices without parental consent or parental accompaniment] and age restrictions [laws prohibiting minors under a certain age from using indoor tanning devices]). The presence of any law was associated with a significant reduction in indoor tanning by 30% among female students. Systems access, parental permission and age restriction laws were associated with a larger reduction, 42%, in indoor tanning by female students. Of all forms of legislation, age restrictions appeared to be most effective at reducing rates of indoor tanning.¹³⁹ Given the small number of states with these laws, states were not categorized by type of age restriction law and thus the study was unable to assess effects of different age restrictions on tanning rates. Associations between indoor tanning laws and reported indoor tanning among male students were not statistically significant, possibly due to their lower prevalence of indoor tanning and older age of tanning initiation.¹³⁹

Enforcement provisions for tanning legislation vary across states, and there is a need for future research to examine the enforcement of stated provisions and the impact on indoor tanning behavior and skin cancer incidence.¹⁴⁰ To realize the public health benefits intended by legislation to restrict minors’ access to tanning beds, facilities must comply. Research on California’s age restriction law showed that 77% of facilities were compliant.¹⁴¹ Data were collected by telephone by an individual posing as a 17 year-old, which is a common methodology in studies that evaluate large numbers of tanning facilities where it may be resource-prohibitive to conduct in-person visits to collect compliance data. Research suggests that telephone assessment of compliance with tanning laws is comparable to face-to-face assessment,¹⁴² but additional study of intermethod reliability would advance this research. While a majority of California facilities appeared compliant with the under-18 ban, statewide education or other interventions may be indicated to enhance compliance, especially considering that most facilities in this study denied that UV tanning posed any dangers and made specific unlawful claims about health benefits. Direct sales to the public can present problems for enforcement; WHO recommends prohibiting direct sales and unsupervised use of tanning equipment as a complement to age restrictions.¹⁴³

Tanning Restrictions in other Nations

Austria, Belgium, Finland, France, Germany, Iceland, Italy, Norway, Portugal, Spain, the United Kingdom and several Canadian provinces ban tanning salon access for minors under age 18 years. Brazil and all states and territories in Australia have banned indoor tanning beds for everyone, regardless of age.^144–146

Targeting the Tanning Industry’s False and Deceptive Practices

The US Federal Trade Commission (FTC) issued a complaint against the Indoor Tanning Association (ITA) alleging that its 2008 advertising campaign included false statements portraying indoor tanning as safe and beneficial and sanctioned by the government (thus misrepresenting the nature of FDA approval). In January 2010, a settlement was reached barring the ITA and related entities from making the misrepresentations or providing deceptive advertisements.¹⁴⁷ In 2016, the FTC reached a settlement with Mercola indoor tanning systems; the company will pay refunds to consumers and will be permanently banned from marketing or selling indoor tanning systems.¹⁴⁸

In 2012, a minority investigative report commissioned by representatives of the US House of Representatives Committee on Energy and Commerce revealed findings of false and misleading health information given to adolescents by the vast majority of tanning salons contacted by investigators.¹⁴⁹ Salons minimized the dangerous effects of indoor tanning; 51% of salons specifically denied that indoor tanning would increase skin cancer risk.

Two state attorneys general have filed suits against several tanning chains or franchises in their states; suits were related to false health claims, unlawful concealment of indoor tanning risks and the offer of unlimited tanning by salons. These suits have generally been resolved through the payment of fines or agreements resulting in salons changing their messaging, including ceasing to make claims regarding the health or safety of indoor tanning.^150–153

Melanoma Prevention Recommendations for Clinicians

Clinicians have an important role to play in addressing prevention of skin cancer, yet studies show that only about one-third of primary care physicians counsel patients on sun protection and one-half counsel on the avoidance of indoor tanning.¹⁵⁴ In a population-based survey of adolescents and their parents, 44% reported receiving sun protection counseling from a physician.¹⁵⁵ Counseling rates may be higher in pediatricians^{156, 157} or for patients who are at higher risk of skin cancer.¹⁵⁴

A review of clinical preventive services conducted by the USPSTF in 2012 recommended that health care providers counsel fair-complexioned children, adolescents and young adults ages 10 to 24 to minimize UV exposure to reduce skin cancer risk, assigning this service a “B”grade.^{158, 159} The implications of the rating are significant, as an “A” or “B” grade means that the USPSTF recommends that providers offer or provide the service. The USPSTF ratings mean that there is high certainty that the net benefit is substantial (“A” grade) or moderate, or there is moderate certainty that the net benefit is moderate to substantial (“B” grade). Effective counseling used cancer prevention or appearance-focused messages to promote the use of broad-spectrum sunscreen with a minimum SPF of 15, protective clothing including hats, shade, avoidance of the outdoors during midday hours and avoidance of indoor tanning. The USPSTF identified effective low-intensity counseling strategies that could be conducted during the primary care session, including self-guided booklets, a video, peer counseling, clinician counseling with computer-assisted feedback and UV photography which shows the patient the extent of UV-induced facial skin damage.^160–164 Through the Affordable Care Act, recommended preventive services with an A or B rating from the USPSTF are reimbursable to providers under most insurance plans, and must be provided with no cost sharing to patients. However, specific details regarding coverage vary by insurers, and providers and patients may be unaware of requirements.¹⁶⁵ There is no specific billing code for skin cancer prevention counseling (though there is an existing code for “other specified counseling”).

The AAP recognizes that skin cancer prevention is a life-long effort. Beginning in infancy, pediatricians are advised to incorporate skin cancer prevention advice into at least one well child visit per year, and during “teachable moments” as when a child or teen presents with a sunburn. AAP also advises pediatricians to encourage children and teens to engage in outdoor physical activities, but to do so in a sun-safe manner.¹⁶⁶ As pediatricians often have relationships with families over years and decades, they are well positioned to discuss with pre-teens, teens and their families the importance of avoiding indoor tanning.¹⁶⁷ Discussions about indoor tanning could be included in the confidential part of the teen interview that requests information such as the teen’s tobacco and electronic cigarette use, alcohol and substance use, and sexual activity.

Early Detection: Skin Examination and Screening

Early detection of melanomas is important, as those diagnosed at later stages are associated with a greater risk of death from melanoma and are overall less treatable. However, the evidence on the best way to reduce melanoma mortality through early detection is currently a subject of ongoing debate. The following sections present information about three approaches that could potentially detect melanomas earlier: skin self-examination, clinician skin examination, and population-based screening.

Skin Self-Examination (SSE)

In a population-based, case-control study of 1,199 Connecticut residents, Berwick et al.¹⁶⁸ reported a 63% reduction in fatal or advanced melanoma associated with SSE. While only 13% of patients performed SSE, the mean thickness of melanomas on the back was significantly lower in those who performed SSE (1.09 mm) compared to those who did not (1.65 mm) (p = 0.014). Subsequent analysis of the data at a median of 5.4 years demonstrated a lower risk of death from melanoma in patients with increased skin awareness; SSE was not associated with reduced melanoma mortality.^{169, 170} A 2003 study found that regular SSE performance was significantly associated with a reduced likelihood of being diagnosed with a melanoma > 1 mm (OR, 0.65; 95% CI, 0.45–0.93), although details regarding the thoroughness and frequency of SSE were not reported.¹⁷¹ Swetter et al. assessed SSE in 566 newly-diagnosed melanoma patients, and routine SSE of some/all of the body compared with none was associated with nearly twice the likelihood of a ≤ 1 mm melanoma at diagnosis (OR, 1.98; 95% CI, 1.24–3.18), with the greatest benefits observed in individuals older than 60 years and in men who used a melanoma picture to aid in SSE.¹⁷² Thoroughness of SSE, as measured by the number of body sites examined and use of a picture aid illustrating a melanoma, has been shown to be the best predictor of reduced melanoma thickness.^{172, 173} However, variable study definitions of SSE, including the number or percent of body sites examined, frequency and method of examination,^{174, 175} and the small number of studies examining supplemental techniques such as the use of photographs,¹⁷⁶ impede the understanding of the potential effect of SSE on melanoma thickness at diagnosis.

The USPSTF evaluated SSE in their 2009 statement, which designated the evidence as insufficient to recommend SSE for the general population.¹⁹ Despite the potential benefit of SSE for early melanoma detection, SSE prevalence in the general population is low, with less than 20% of individuals in the US estimated to practice regular, thorough SSE.^{174, 177} Rates of SSE in middle-aged and older men also appear to be low. In a population-based telephone survey in Queensland, Australia, 20% of men 50 years or older reported conducting whole-body SSE one or more times in the past year.¹⁷⁸ Various educational and interventional programs, including dual patient and partner skin examination training, workbooks, videos and postcard reminders, and mole-mapping diagrams,^179–182 have successfully increased SSE performance in higher risk populations.

Clinician Skin Examination

Melanomas detected by clinicians through directed skin examinations or during the course of routine physical examinations (i.e., “opportunistic screening”) are thinner than those found by patients or their significant others.^{172, 183–187} In an analysis of 3 international studies of more than 2,400 patients, tumor thickness was reduced by a mean of 0.55 mm when comparing melanomas initially detected by physicians versus by patients or family members.¹⁸⁸ A population-based, case-control study was conducted by Aitken et al.¹⁸⁴ of more than 3,700 Queensland residents with histologically-confirmed first primary invasive melanoma diagnosed between January 2000 and December 2003, and a similar number of eligible controls. Whole-body physician skin examination (PSE) in cases in the three years before diagnosis was inversely associated with melanoma thickness (χ2 test for trend, 44.37; p < .001), ranging from a 14% lower risk of being diagnosed with a melanoma > 0.75 mm (OR, 0.86; 95% CI, 0.75–0.98) to a 40% lower risk for melanomas ≥ 3 mm (OR, 0.60; 95% CI, 0.43–0.83). Skin screening was associated with a 38% increased likelihood of being diagnosed with melanoma ≤0.75 mm and a 32% higher likelihood of melanoma ≤ 1 mm (OR, 1.32; 95% CI, 1.18–1.47), resulting in a projected (though not proven) 26% fewer melanoma deaths in screened cases versus unscreened cases within 5 years.

Similar benefit of PSE within the year prior to diagnosis was noted in an observational cohort study of 566 newly-diagnosed adults with cutaneous melanoma referred to 2 geographically-distinct US academic institutions.¹⁷² Tumors (≤1mm) were significantly associated with physician discovery (p ≤ .0001), which was reported by only 19% of patients. However, patients who had a whole-body skin examination by a physician in the year prior to diagnosis were more than twice as likely to have a ≤ 1 mm tumor (OR, 2.51; 95% CI, 1.62–3.87), largely due to the effect of physician skin examination in men > 60 years, who had over 4 times the odds of a ≤ 1 mm melanoma (OR, 4.09; 95% CI, 1.88–8.89) and thus, appeared to benefit most from PSE.

Worldwide Data on Melanoma Population-Based Screening, Incidence, and Mortality

Population-based melanoma screening studies include a community-based clinical trial in Queensland, Australia,¹⁸⁹ a screening program conducted at Lawrence Livermore National Laboratory (LLNL),¹⁹⁰ and a pilot study of general population screening in the German state of Schleswig-Holstein beginning in 2003,^{191, 192} which was followed by a nationwide screening program initiated in Germany in 2008.^{193, 194}

Queensland, Australia

Forty-four eligible Queensland communities (estimated population of 560,000 adults who were 30 years or older) were randomized into intervention or control groups to compare the effects of a three-year community-based melanoma screening intervention and usual medical care.¹⁸⁹ The Queensland trial was designed to detect a 20% reduction in mortality from melanoma during the 15 years following the start of the screening intervention. Due to financial constraints, the trial was not completed, although some observations were made from 18 communities enrolled and randomized in the study.¹⁹⁵ Within intervention communities, the overall rate of skin cancer detected per patient screened increased, and men and attendees 50 years or older were more frequently referred and diagnosed with melanoma,¹⁹⁶ again supporting the value of targeted screening to older individuals, and men in particular.¹⁹⁷ Melanomas detected by the screening intervention tended to be less advanced than melanomas detected in the general population of Queensland: 39% were in situ lesions, 55% were < 1 mm, and 6% were ≥ 1 mm,¹⁹⁶ in contrast to the general population of Queensland from 1999 through 2002, in which 36% were in situ lesions, 48% were < 1 mm, and 16% were ≥ 1 mm.¹⁹⁸ Furthermore, the specificity (86%) for detection of melanoma through whole-body skin examination was deemed comparable to that of other screening tests, including mammography for breast cancer.¹⁹⁶

Lawrence Livermore National Laboratory (LLNL)

A long term employee program conducted at the LLNL included melanoma education, SSE, and the opportunity for skin screening by a physician.¹⁹⁰ The incidence of melanomas > 0.75 mm was reduced by 69% in the screening program period (1984 to 1996) compared to the preceding early awareness period (1976 to 1984, during which time employees learned about their melanoma risk). This program also showed a crude reduction in melanoma mortality in the LLNL workforce compared with California during this timeframe, based on observed mortality in five San Francisco-Oakland-Bay Area counties as reported to the SEER program from 1984 to 1996: 0 deaths at LLNL compared to an expected number of 3.39 deaths (p = .034).¹⁹⁰

Schleswig-Holstein, Germany

The most compelling population-based data regarding potential screening effectiveness were collected from the “Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany” (SCREEN) pilot project conducted in the northern state of Schleswig-Holstein, Germany.^{191, 192} General practitioners and dermatologists completed an 8-hour skin cancer training program. Sixty-four percent (1,673) of Schleswig-Holstein’s general practitioners participated in the screening, along with 98% (116) of dermatologists. Whole-body skin examination by a general practitioner was followed by referral to a dermatologist for further evaluation of suspicious skin findings and biopsy if necessary. It was possible for patients to initially visit a dermatologist based on skin cancer risk factors alone, but most patients opted to visit a general practitioner first.

Following a two-year pre-screening period of intensive public education regarding melanoma clinical warning signs and the screening initiative, almost 20% of the adult population aged 20 years or older (360,288 participants with a mean age of 49.7 [SD = 16.2] years¹⁹²) was screened over a one-year period from 2003 to 2004. The majority of initial screening examinations (77%) were performed by general practitioners; dermatologists performed 23% of the initial examinations.^{191, 192} Although 73,710 individuals (26%) were referred to dermatologists following initial general practitioner screening, nearly 37% of those referred did not undergo consult by a dermatologist and were lost to follow-up.¹⁹² In 2009 (5 years after the screening program), age- and sex-adjusted melanoma mortality rates declined by 48% (a 47% decline in men and 49% decline in women), compared to historical mortality rates in Schleswig-Holstein and prior and 2009 mortality rates in surrounding states and Denmark, where no screening intervention took place.¹⁹¹

To what degree extensive pre-SCREEN public awareness campaigns themselves contributed to the mortality reduction remains unclear, as it is difficult to separate the potential mortality benefit of this education on early detection from the visual skin inspections by clinicians during the one-year screening period. Additionally, the demonstration of improved survival is insufficient evidence of the benefit of screening, as this may simply reflect lead-time, length bias, or overdiagnosis. Some have hypothesized that differences in coding of death data could have been responsible for temporal declines in melanoma mortality.^{194, 199}

An increased incidence of melanoma and NMSC occurred during the screening intervention and early follow-up period; an initial increase was expected given the detection of existing skin cancer in the population.¹⁹² The proportion of individuals diagnosed with early stage tumors increased from 52% in the pre-SCREEN period (2001 to 2003) to 64% in the one-year screening period (2003 to 2004).¹⁹² In July 2008, the German Federal Joint Committee included skin cancer screening as part of nationwide services provided by the Health Insurance Funds.^{192, 193, 200} Whole-body screenings have been offered free of charge once every 2 years for an estimated 45 million German residents who are 35 years of age or older, with the 8-hour physician training course and dual screening process used in the pilot study in Schleswig-Holstein.^{192, 193, 200}

The first analyses of this nationwide effort showed that melanoma mortality in Schleswig-Holstein increased to its pre-SCREEN rate for both sexes and all ages, thus demonstrating only a transient decline in mortality in Schleswig-Holstein five years after the SCREEN pilot project.^{193, 194} No decrease in mortality has been observed five years after screening began in Germany overall; a slight increase was actually noted, likely due to population changes per census data in men and individuals 64 years of age or older.^{193, 194} Potential reasons for the lack of a measurable reduction in mortality rates in Germany or Schleswig-Holstein after the nationwide screening effort include: less intensive or thorough screening (e.g., poorer quality, less consistently performed skin exams and suboptimal referral patterns from primary care providers [PCP] to dermatologists); higher age of eligibility for the nationwide screening program (≥ 35 years of age) compared to the pilot SCREEN program (≥ 20 years of age); inability to accurately track participation rates by physicians or patients; nonreferral of individuals by general practitioners to dermatologists based on melanoma risk factors alone (as was permissible in the Schleswig-Holstein pilot); and lack of intensive nationwide mass-media publicity as was used in SCREEN.^{193, 194} It is possible that reduced mortality will be observed with longer follow-up, although no such trend has yet been observed in preliminary analyses. The economic impact of this ambitious nationwide skin cancer screening endeavor, and how the German health care system has managed the various screening-related outcomes, have not been reported.

USPSTF Recommendations for Screening by Primary Care Providers (PCP)

Given the lack of a prospective, randomized controlled trial assessing the impact of screening on melanoma mortality, the USPSTF in 2009 recommended neither for nor against routine skin cancer screening of the general population by PCPs, assigning a rating of “I” for “insufficient” evidence to support this practice.¹⁹ The USPSTF further noted that the potential harms of screening had not been adequately addressed, including both physical and psychological effects related to misdiagnosis and unnecessary biopsies.

In preparing the 2015 draft recommendation, the USPSTF evaluated an AHRQ evidence-based systematic review of literature published from January 1, 1995 through June 1, 2015, which yielded 13 relevant studies. Studies focused primarily on the SCREEN program, which was assessed to be of “fair-quality.”¹⁹¹ However, the recent analyses of melanoma incidence and mortality in Schleswig-Holstein and Germany following the nationwide screening initiated in 2008^{193, 194} were not included in the systematic review, given the date of publication. The updated 2015 Task Force review differed from that which led to the 2009 recommendation in that NMSC was excluded as an outcome of interest due to its low mortality rates and lack of “substantial morbidity.” The USPSTF Draft Recommendation Statement was released on November 30, 2015, followed by a four-week period for public comment (closed December 28, 2015) before the final statement will be issued.²⁰ The USPSTF concluded that, “current evidence is insufficient to assess the balance of benefits and harms of visual skin cancer screening in adults,” and has once again tentatively assigned this practice an “I” grade, pending a final recommendation.

The USPSTF noted limitations of the SCREEN pilot, including the high proportion of “lower-risk” women screened compared to higher-risk men, the 37% of general practitioner-referred patients who did not follow up with dermatologists for their suspicious skin lesions, and the inability to assess the impact of the pre-SCREEN public education program apart from the visual skin cancer screening. Furthermore, the population-based changes in mortality in the SCREEN program could not be interpreted as causal because individual-level data on outcomes for screened individuals were not available. The USPSTF Evidence Synthesis concluded that the absolute mortality reduction of 0.8 deaths per 100,000 individuals screened suggested a modest benefit overall.²⁰¹ Additional analyses have raised concerns about the design of the SCREEN study, including potential underreporting of melanoma deaths by physicians and self-referral of high-risk participants, and thus the data that demonstrated the initial reductions are a subject of ongoing debate.^{194, 199} The lack of available data regarding thickness-specific incidence or potential benefit of screening in certain subgroups (e.g., older men) makes firm conclusions regarding the German nationwide screening effort premature. Nonetheless, Germany’s national screening program provides a valuable opportunity to collect effectiveness data on population-based screening.

Importantly, the USPSTF noted that their latest screening recommendation does not apply to patients with a history of premalignant skin lesions or skin cancer, who present with a suspicious skin lesion, or are already followed for increased risk of skin cancer based on abnormal mole phenotype or family history of melanoma. Potential harms of screening related to overdiagnosis and overtreatment were noted, though precise assessment of these harms was not possible from data included in the Evidence Synthesis.²⁰¹ Further research regarding screening high risk groups, and case-control studies of screened versus unscreened individuals – without potential confounding from an educational campaign or other intervention – was deemed necessary to fully evaluate the benefit of skin screening.

Potential Impact of Screening on NMSC Morbidity and Cost

Detection of (highly curable) NMSC was not a directive of the latest USPSTF review and in fact, was considered a potential harm of screening for “lesions that may have little potential for malignant spread and mortality.”¹⁹ Concern for overtreatment of both indolent pigmented lesions mimicking melanoma (i.e., “false-positives” detected through screening) as well as nonfatal NMSCs was raised in the 2009 USPSTF recommendation statement. However, SCC results in the second highest rate of skin cancer-associated mortality after melanoma; up to 5.2% of patients with cutaneous SCC will develop nodal metastasis and up to 2.1% will die from distant disease.²⁰² The economic burden of treating NMSC cannot be ignored, in addition to patient-related factors including optimizing surgical and cosmetic outcome and reducing lost work-time. The annual cost of treating NMSC in the U.S. has been estimated at $4.8 billion.²⁴ Earlier detection of NMSC is likely to result in fewer surgeries with more rapid patient recovery, improved cosmetic outcome for these UV-related tumors on the head and neck, and lower cost of treatment.

Feasibility of Skin Cancer Screening Implementation in the US

Recent evidence from the screening studies in Germany and the latest USPSTF recommendation raise questions regarding where screening is headed for PCPs in the US. A nationwide screening program as was conducted in Germany is not likely to be feasible, and findings of population-based skin screening studies in other countries may not generalize to the US depending on the comparability of skin cancer risk factor distributions across populations. PCPs may not be adequately trained to identify early skin cancer.^{203, 204} A survey of more than 1,600 randomly-selected physicians found that time constraints, competing comorbidities, and patient embarrassment were the top three barriers to performing whole-body skin examinations.²⁰⁵ Factors that facilitated examination by physicians included having more patients at high risk for skin cancer, patient demand for a complete examination or mole check, and appropriate training.

It is unclear what implementation techniques will overcome these barriers in clinical practice, though various training strategies are being tested. A 1.5 hour, web-based curriculum entitled INFORMED (INternet-based program FOR Melanoma Early Detection, available at www.skinsight.com/info/for_professionals/skin-cancer-detection-informed/skin-cancer-education) was designed to provide clinical guidance for early detection of melanoma (as well as other common skin cancers) by PCPs.²⁰⁶ A study evaluating the effect of INFORMED on 54 PCPs in two integrated health care delivery systems suggested that it decreased dermatology referrals, particularly for benign skin lesion assessment.²⁰⁷ The INFORMED training improved appropriate PCP diagnosis and management from 36% pre-training to 47% post-training, and dermatology utilization decreased without any change in biopsies performed or skin cancers diagnosed.

A population-based study in France evaluated the effect of a PCP awareness and training campaign on stage-specific melanoma incidence.²⁰⁸ All (1,241) general practitioners in the region of Champagne-Ardenne received repeated postal mailings to raise melanoma awareness, and 398 (32%) attended a 2.5-hour, dermatologist-led, skin cancer training session. From pre- (2005–2007) to post-intervention (2009–2011), Champagne-Ardenne showed a 34% reduction in the incidence of melanomas ≥ 3 mm in tumor thickness, from 1.07 to 0.71/100,000 habitants per year (standardized for age) (p = .01). This reduction was most pronounced in men compared with women (44% vs 11 %, respectively). Likewise, the proportion of in situ and < 1 mm melanomas increased from 20 to 28% (p = .001) and from 51% to 57% (p = .05), respectively. There were no significant changes in incidence in the control area that comprised regions without the PCP educational campaign.

Since Americans make an average of 1.7 visits to PCPs each year,²⁰⁹ PCPs can serve as an important source of skin cancer diagnosis and triage. Although the USPSTF did not recommend skin cancer screening, they advised clinicians that biopsy of suspicious skin lesions noted during physical examinations is warranted.¹⁵⁹ Implementation of skin screening requires a paradigm shift in the way primary care is delivered, necessitating evaluation of feasibility including adequate time to conduct the exam, and possible harms, such as cost and utilization of scarce resources, along with further study of the potential benefits of early melanoma detection.

SUMMARY AND CONCLUSIONS

US adults, adolescents and children are not adequately protected from excessive UV exposure, despite expert guidance and the existence of evidence-based, melanoma prevention interventions recommended by The Community Guide and USPSTF. The Surgeon General’s Call to Action highlights youth as a critical population to reach with intervention to promote sun protection and discourage indoor tanning, and invites multiple sectors across the US to coordinate efforts and leverage existing knowledge to reduce the nation’s skin cancer burden.

There is a lack of national, population-based data or estimates of parent sun protection practices for children in the US, and estimates of behaviors other than indoor tanning and sunscreen use across age groups. Furthermore, physician counseling for sun protection and assessments of provider knowledge of skin cancer prevention are understudied areas. These gaps in research minimize our ability to spot trends, target interventions and evaluate progress.

As increasing numbers of states prohibit indoor tanning among minors, researchers will need to evaluate compliance with and enforcement of such laws. The proposed FDA rule to ban minors’ access to tanning is significant, but finalization of this age restriction rule may not occur for months or years after the public comment period. Despite the expansive effects of legislation and FDA regulations, it is necessary to continue to develop and disseminate evidence-based interventions to reduce positive tanning attitudes and tanning behaviors, starting in childhood, given the current availability of indoor tanning devices at home through direct purchase as well as the alternative to sunbathe for individuals seeking a tan.

While multiple studies support the value of early detection of melanoma through clinician skin examination,¹⁸⁸ evidence that this translates into reduced population-based melanoma mortality has been insufficient, in both 2009 and 2015, for the USPSTF to recommend skin screening as part of primary care practice.^{19, 20} An observational study of a population-based screening program in one state in Germany showed promising results, with large reductions in mortality rates not observed in surrounding states without screening programs.¹⁹¹ Based on these early results, the screening program was expanded to the rest of the country, but mortality rates have remained stable nationally and mortality reductions in the state initially piloting the screening program were not sustained.¹⁹³ There is a critical need to augment evidence regarding the potential benefits of skin screening; PCP and other providers’ education regarding skin cancer awareness, SSE and screening; and appropriate triage to dermatologists, as PCPs account for the majority of physician-detected melanoma. The proliferation of new technologies may hold promise for future prevention and early detection of melanoma. For example, smart phone applications (or “apps”) are available to give users real-time information regarding their UV exposure based on their location, methods of protection, and skin type, and may be effective at improving sun protection.²¹⁰ The growing popularity of wearable health monitoring devices has incorporated sun protection, and some devices include wearable UV sensors.²¹¹ Mole mapping apps can assist high-risk patients with many nevi keep track of any changes, and tele-dermatology may expand access for some who have questionable lesions but do not live close to a dermatologist.^{212, 213} Though these new approaches are exciting, evaluation of their effectiveness in the real world will be important; one study from 2008 found that users of personal UV sensors were likely to use less sun protection when wearing the sensor.²¹⁴

Increased attention to the problems of melanoma resulting in high-level government support such as the Surgeon General’s Call to Action and continuing FDA actions to address the harms of indoor tanning have the potential to reduce their future health burden if implemented and supported. New tools for early detection may result in earlier diagnoses. Moreover, improved understanding of the molecular and immunological underpinnings of melanoma have ushered in a new era of transformative treatment options for patients with advanced melanoma over the past five years that have already begun to improve survival outcomes. In conclusion, we are at a uniquely exciting time in the area of melanoma prevention and treatment – the time to act is now to continue to reduce the burden of melanoma in the US and beyond.

Authors would like to thank Alan C. Geller, MPH, RN, Senior Lecturer of Social and Behavioral Sciences, Harvard T.H. Chan School Of Public Health and Director, Melanoma Epidemiology, Massachusetts General Hospital, Boston MA for his insights into the conceptualization of this review article.

Funding source: Support provided, in part, by the generous philanthropic contributions to The University of Texas MD Anderson Cancer Center Melanoma Moon Shots Program, the Cancer Center Support Grant (CA16672, PI: R. DePinho, MD Anderson Cancer Center), from the National Cancer Institute, National Institutes of Health, and the Michael and Patricia Booker Melanoma Research Endowment. Dr. Gershenwald has participated on an advisory board for Merck since June 2014, and this advisory role is not related to the content of this review article. Dr. Tripp reported stock ownership in Merck, Abbott Laboratories and AbbVie, and these financial relationships are not related to the content of this review article. The remaining authors have no financial disclosures to report.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Author Contributions: Mary K. Tripp: Conceptualization, investigation, writing – original draft, and writing – review and editing. Meg Watson: Conceptualization, methodology, formal analysis, writing – original draft, and writing – review and editing. Sophie J. Balk: Conceptualization, writing – original draft, and writing – review and editing. Susan M. Swetter: Conceptualization, investigation, writing – original draft, and writing – review and editing. Jeffrey E. Gershenwald: Conceptualization, methodology, investigation, resources, writing – original draft, writing – review and editing, visualization, supervision, project administration, and funding acquisition.

For the purposes of this document, overexposure is defined as sun exposure that may result in tanned or sunburned skin, or that may increase a person’s risk of skin cancer.¹

U.S. Department of Health and Human ServicesThe Surgeon General’s Call to Action to Prevent Skin CancerWashington, DC

U.S. Department of Health and Human Services, Office of the Surgeon General

www.surgeongeneral.gov/library/calls/prevent-skin-cancer/call-to-action-prevent-skin-cancer.pdf

2014

Siegel

Miller

Jemal

Cancer statistics, 2016

CA Cancer J Clin201666730

26742998

Weir

Thompson

Soman

Moller

Leadbetter

White

Meeting the Healthy People 2020 objectives to reduce cancer mortality

Prev Chronic Dis201512E104

26133647

Armstrong

Kricker

How much melanoma is caused by sun exposure?

Melanoma Res19933395401

8161879

El Ghissassi

Baan

Straif

A review of human carcinogens–part D: radiation

Lancet Oncol200910751752

19655431

Guy

JrBerkowitz

Everett Jones

Holman

Garnett

Watson

Trends in indoor tanning among US high school students, 2009–2013

JAMA Dermatol201515144850

25535810

Guy

JrBerkowitz

Holman

Hartman

Recent changes in the prevalence of and factors associated with frequency of indoor tanning among US adults

JAMA Dermatol201515112569

26131768

Centers for Disease Control and Prevention1991–2013 High School Youth Risk Behavior Survey Datahttps://nccd.cdc.gov/youthonline/. Accessed December 16, 2015

Centers for Disease Control and Prevention National Center for Health StatisticsUV Exposure and Sun Protective Practices. National Health Interview Survey NCI and CDC co-sponsored Cancer Control Supplement, 1992–2010, 2005–2010http://www.progressreport.cancer.gov/prevention/sun_protection. Accessed December 16, 2015

Federal RegisterGeneral and Plastic Surgery Devices: Reclassification of Ultraviolet Lamps for Tanning, Henceforth To Be Known as Sunlamp Products and Ultraviolet Lamps Intended for Use in Sunlamp Productshttps://www.federalregister.gov/articles/2014/06/02/2014-12546/general-and-plastic-surgery-devicesreclassification-of-ultraviolet-lamps-for-tanning-henceforth-to. Accessed November 4, 2015

U.S. Food and Drug AdministrationGeneral and Plastic Surgery Devices: Restricted Sale, Distribution, and Use of Sunlamp ProductsDate posted: Dec 22, 2015. 21 CFR Part 878 Federal Register Number:2015-32024

Larkin

Ascierto

Dreno

Combined vemurafenib and cobimetinib in BRAF-mutated melanoma

N Engl J Med2014371186776

25265494

Larkin

Chiarion-Sileni

Gonzalez

Combined nivolumab and ipilimumab or monotherapy in untreated melanoma

N Engl J Med20153732334

26027431

Long

Stroyakovskiy

Gogas

Combined BRAF and MEK inhibition versus BRAF inhibition alone in melanoma

N Engl J Med2014371187788

25265492

Hodi

O’Day

McDermott

Improved survival with ipilimumab in patients with metastatic melanoma

N Engl J Med201036371123

20525992

Flaherty

Infante

Daud

Combined BRAF and MEK inhibition in melanoma with BRAF V600 mutations

N Engl J Med20123671694703

23020132

Robert

Karaszewska

Schachter

Improved overall survival in melanoma with combined dabrafenib and trametinib

N Engl J Med2015372309

25399551

Robert

Thomas

Bondarenko

Ipilimumab plus dacarbazine for previously untreated metastatic melanoma

N Engl J Med2011364251726

21639810

U.S. Preventive Services Task Force

Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement

Ann Intern Med200915018893

19189908

U.S. Preventive Services Task ForceDraft recommendation statement: skin cancer: screening2015http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement168/skin-cancer-screening2. Accessed January 20, 2016

Watson

Thomas

Massetti

CDC Grand Rounds: Prevention and Control of Skin Cancer

MMWR Morb Mortal Wkly Rep20156413124

26633233

Centers for Disease Control and PreventionPublic Health Grand Rounds: Prevention and Control of Skin Cancer4212015http://www.cdc.gov/cdcgrandrounds/archives/2015/april2015.htm. Accessed January 26, 2016

Gershenwald

Guy

Stemming the rising incidence of melanoma: Calling prevention to action

J Natl Cancer Inst2016108.djv381

10.1093/jnci/djv381

Guy

JrMachlin

Ekwueme

Yabroff

Prevalence and costs of skin cancer treatment in the U.S., 2002–2006 and 2007–2011

Am J Prev Med2015481837

25442229

U.S. Cancer Statistics Working GroupUnited States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report2015www.cdc.gov/uscs. Accessed December 15, 2015

Weir

Marrett

Cokkinides

Melanoma in adolescents and young adults (ages 15–39 years): United States, 1999–2006

J Am Acad Dermatol201165S3849

22018066

American Cancer SocietyCancer Facts & Figures 2016Atlanta, GA

American Cancer Society

2016

Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence – SEER 9 Regs Research Data, Nov 2014 Sub (1973–2012) <Katrina/Rita Population Adjustment> – Linked To County Attributes – Total U.S., 1969–2013 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2015 based on the November 2014 submission.

Guy

JrThomas

Thompson

Watson

Massetti

Richardson

Vital signs: melanoma incidence and mortality trends and projections – United States, 1982–2030

MMWR Morb Mortal Wkly Rep2015645916

26042651

Bradford

Anderson

Purdue

Goldstein

Tucker

Rising melanoma incidence rates of the trunk among younger women in the United States

Cancer Epidemiol Biomarkers Prev20101924016

20826837

Welch

Black

Overdiagnosis in cancer

J Natl Cancer Inst201010260513

20413742

Swerlick

Chen

The melanoma epidemic: more apparent than real?

Mayo Clin Proc19977255964

9179141

Glusac

The melanoma ‘epidemic’: lessons from prostate cancer

J Cutan Pathol2012391720

22211331

Lakhani

Saraiya

Thompson

King

Guy

Total body skin examination for skin cancer screening among U.S. adults from 2000 to 2010

Prev Med2014617580

24418263

Shaikh

Dusza

Weinstock

Oliveria

Geller

Halpern

Melanoma thickness and survival trends in the United States, 1989 to 2009

J Natl Cancer Inst2016108djv294

10.1093/jnci/djv294

26563354

Jemal

Saraiya

Patel

Recent trends in cutaneous melanoma incidence and death rates in the United States, 1992–2006

J Am Acad Dermatol201165S1725.e1-3

22018063

Linos

Swetter

Cockburn

Colditz

Clarke

Increasing burden of melanoma in the United States

J Invest Dermatol2009129166674

19131946

U.S. Department of Health and Human ServicesUnited States cancer statistics: 1999–2012 mortality2015http://wonder.cdc.gov/CancerMort-v2012.html Accessed December 20, 2015

Balch

Gershenwald

Soong

Final version of 2009 AJCC melanoma staging and classification

J Clin Oncol2009276199206

19917835

Pollack

Berkowitz

Melanoma survival in the United States, 1992 to 2005

J Am Acad Dermatol201165S7886

22018071

Howlader

Noone

Krapcho

SEER Cancer Statistics Review1975–2012

National Cancer Institute

Bethesda, MD

http://seer.cancer.gov/csr/1975_2012/, based on November 2014 SEER data submission, posted to the SEER website April 2015

Guy

Ekwueme

Years of potential life lost and indirect costs of melanoma and non-melanoma skin cancer: a systematic review of the literature

Pharmacoeconomics20112986374

21846158

Lucas

McMichael

Armstrong

Smith

Estimating the global disease burden due to ultraviolet radiation exposure

Int J Epidemiol200837654667

18276627

Green

Williams

Logan

Strutton

Reduced melanoma after regular sunscreen use: randomized trial follow-up

J Clin Oncol201129257263

21135266

Dennis

Vanbeek

Beane Freeman

Smith

Dawson

Coughlin

Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis

Ann Epidemiol200818614627

18652979

Han

Laden

Qureshi

Long-term ultraviolet flux, other potential risk factors, and skin cancer risk: a cohort study

Cancer Epidemiol Biomarkers Prev20142310809

24876226

Wehner

Shive

Chren

Han

Qureshi

Linos

Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis

BMJ2012345e5909

10.1136/bmj.e5909

23033409

Boniol

Autier

Boyle

Gandini

Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis

BMJ2012345

10.1136/bmj.e4757

e4757

22833605

Boniol

Autier

Boyle

Gandini

Correction: cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis

BMJ2012345e8503

10.1136/bmj.e8503.

Ferrucci

Cartmel

Molinaro

Leffell

Bale

Mayne

Indoor tanning and risk of early-onset basal cell carcinoma

J Am Acad Dermatol201267552562

22153793

Hodis

Watson

Kryukov

A landscape of driver mutations in melanoma

Cell201215025163

22817889

Lawrence

Stojanov

Polak

Mutational heterogeneity in cancer and the search for new cancer-associated genes

Nature20134992148

23770567

The Cancer Genome Atlas Network

Genomic Classification of Cutaneous Melanoma

Cell2015161168196

26091043

Gallagher

Elwood

Yang

Is chronic sunlight exposure important in accounting for increases in melanoma incidence?

Int J Cancer1989448135

2583861

Pukkala

Martinsen

Lynge

Occupation and cancer – follow-up of 15 million people in five Nordic countries

Acta Oncol200948646790

19925375

Diepgen

Mahler

The epidemiology of skin cancer

Br J Dermatol2002146Suppl 6116

Leiter

Garbe

Epidemiology of melanoma and non-melanoma skin cancer—the role of sunlight

Reichrath

Sunlight, Vitamin D and Skin Cancer624

New York, NY

Springer

200889103

Chang

Barrett

Bishop

Sun exposure and melanoma risk at different latitudes: a pooled analysis of 5700 cases and 7216 controls

Int J Epidemiol20093881430

19359257

Whiteman

Stickley

Watt

Hughes

Davis

Green

Anatomic site, sun exposure, and risk of cutaneous melanoma

J Clin Oncol20062431727

16809740

Nahar

Allison Ford

Brodell

Skin cancer prevention practices among malignant melanoma survivors: a systematic review [Epub ahead of print Epub ahead of print December 7, 2015]

J Cancer Res Clin Oncol2015

10.1007/s00432-015-2086-z

Cokkinides

Weinstock

Glanz

Albano

Ward

Thun

Trends in sunburns, sun protection practices, and attitudes toward sun exposure protection and tanning among US adolescents, 1998–2004

Pediatrics200611885364

16950974

Dusza

Halpern

Satagopan

Prospective study of sunburn and sun behavior patterns during adolescence

Pediatrics201212930917

22271688

Guide to Community Preventive ServicesPreventing skin cancer: education and policy approacheswww.thecommunityguide.org/cancer/skin/education-policy/index.html. Last updated: May 22, 2014

Australian Institute of Health and WelfareCancer in Australia: an overviewCancer series no. 78. Cat. no. CAN 75

Canberra

AIHW

2014

SunSmart VictoriaHistory2015http://www.sunsmart.com.au/about/history. Accessed December 20, 2015

Olsen

Williams

Whiteman

Turning the tide? Changes in treatment rates for keratinocyte cancers in Australia 2000 through 2011

J Am Acad Dermatol201471216.e1

24685358

Iannacone

Youlden

Baade

Aitken

Green

Melanoma incidence trends and survival in adolescents and young adults in Queensland, Australia

Int J Cancer20151366039

24806428

Olsen

Wilson

Green

Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use

Aust N Z J Public Health201539471476

26437734

Shih

Carter

Sinclair

Mihalopoulos

Vos

Economic evaluation of skin cancer prevention in Australia

Prev Med20094944953

19747936

Glanz

Saraiya

Wechsler

Centers for Disease Control and Prevention

Guidelines for school programs to prevent skin cancer

MMWR Recomm Rep200251RR-4118

Centers for Disease Control and PreventionShade Planning for America’s Schools2008www.cdc.gov/cancer/skin/pdf/shade_planning.pdf Accessed June 15, 2015

Everett Jones

Barrios

Feldman

Hall-Jordan

Safe and healthy school environment: results from the School Health Policies and Practices Study 2012

editorResults from the School Health Policies and Practices Study 2012U.S. Department of Health and Human Services Centers for Disease Control and Prevention201391109

U.S. Department of Health and Human Services Centers for Disease Control and PreventionResults from the School Health Policies and Practices Study 20142015

http://www.cdc.gov/healthyyouth/data/shpps/pdf/shpps-508-final_101315.pdf

91109

Act of June 1, 2015, 84th Leg., R.S., ch. 1139, §1, 2015 Tex. Gen. Laws 3849 – 3850 (codified at Tex. Education Code §38.021).

California Senate Bill 1632http://www.leginfo.ca.gov/pub/01-02/bill/sen/sb_1601-1650/sb_1632_bill_20020826_chaptered.html. Accessed December 20, 2015.

78th Oregon Legislative AssemblyEnrolled House Bill 3041 (HB 3041-A)https://olis.leg.state.or.us/liz/2015R1/Downloads/MeasureDocument/HB3041. Accessed December 20, 2015.

City of Phoenix Parks and RecreationTree & Shade2015https://www.phoenix.gov/parks/parks/urban-forest/tree-and-shade. Accessed December 20, 2015

Toronto Cancer Prevention CoalitionShade Guidelines2010https://www1.toronto.ca/city_of_toronto/toronto_public_health/healthy_public_policy/tcpc/files/pdf/shade_guidelines.pdf. Accessed December 20, 2015

Flechas

Miami Beach unveils free sunscreen dispensers on sand2015http://www.miamiherald.com/news/local/community/miami-dade/miami-beach/article14060885.html. Accessed December 20, 2015

Ducharme

Boston parks now have free sunscreen dispensers to combat skin cancer2015http://www.bostonmagazine.com/health/blog/2015/06/30/boston-parks-sunscreen-dispensers/. Accessed December 20, 2015

Florida Gators FootballGator football game day initiatives2015http://floridagators.com/news/2015/9/2/31084.aspx. Accessed December 20, 2015

Beauchamp

Stadium Village fan zone offers relief from heat & freebies2015http://www.news4jax.com/sports/stadium-village-fan-zone-offers-relief-from-heat-freebies. Accessed December 20, 2015

Cordova

Hwang

Cactus League preview: Salt River Fields stadium guide2015http://www.azcentral.com/story/entertainment/events/2015/02/25/cactus-league-stadium-guide-salt-river-fields-at-talking-stick/24009267/?from=global&sessionKey=&autologin=. Accessed December 20, 2015

State of Rhode Island Department of HealthAbout skin cancerhttp://www.health.ri.gov/cancer/skin/. Accessed December 20, 2015

The University of Texas MD Anderson Cancer Center. Skin Cancer Prevention Toolkit for Institutions of Higher EducationThe University of Texas MD Anderson Cancer Center2015http://www.texascancer.info/pdfs/skin_cancer_prevention_toolkit.pdf. Accessed January 15, 2016

Hornung

Magee

Lee

Hansen

Hsieh

Tanning facility use: are we exceeding Food and Drug Administration limits?

J Am Acad Dermatol20034965561

14512912

Miller

Hamilton

Wester

Cyr

An analysis of UVA emissions from sunlamps and the potential importance for melanoma

Photochem Photobiol1998686370

9679452

National Toxicology Program

Ultraviolet radiation related exposures: solar radiation, exposure to sunlamps or sunbeds, broad-spectrum UVR, UVA, UVB, UVC

Rep Carcinog20111242933

21863117

World Health OrganizationUltraviolet radiation and healthhttp://www.who.int/uv/uv_and_health/en/index.html. Accessed January 26, 2016

Guy

JrWatson

Haileyesus

Annest

Indoor tanning-related injuries treated in a national sample of U.S. hospital emergency departments

JAMA Intern Med2015175309311

25506731

International Agency for Research on Cancer Working Group on Artificial Ultraviolet (UV) Light and Skin Cancer

The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review

Int J Cancer2006120111622

Fisher

James

Indoor tanning–science, behavior, and policy

N Engl J Med20103639013

20818900

Lazovich

Vogel

Berwick

Weinstock

Anderson

Warshaw

Indoor tanning and risk of melanoma: a case-control study in a highly exposed population

Cancer Epidemiol Biomarkers Prev20101915571568

20507845

Cust

Armstrong

Goumas

Sunbed use during adolescence and early adulthood is associated with increased risk of early-onset melanoma

Int J Cancer201112824252435

20669232

Lazovich

Isaksson Vogel

Weinstock

Nelson

Ahmed

Berwick

Association between indoor tanning and melanoma in younger men and women [Epub ahead of print January 27, 2016]

JAMA Dermatol2016

10.1001/jamadermatol.2015.2938

Veierod

Adami

Lund

Armstrong

Weiderpass

Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi

Cancer Epidemiol Biomarkers Prev20101911120

20056629

Colantonio

Bracken

Beecker

The association of indoor tanning and melanoma in adults: systematic review and meta-analysis

J Am Acad Dermatol201470847857 e01-18

24629998

Edwards

Tanning salons in the U.S

IBISWorld Industry Report 81219c82013

Hoerster

Garrow

Mayer

Density of indoor tanning facilities in 116 large U.S. cities

Am J Prev Med200936243246

19215849

100

Hillhouse

Stapleton

Florence

Pagoto

Prevalence and correlates of indoor tanning in nonsalon locations among a national sample of young women

JAMA Dermatol201515111346

26108092

101

Pagoto

Lemon

Oleski

Availability of tanning beds on U.S. college campuses

JAMA Dermatol20151515963

25353714

102

Levine

Sorace

Spencer

Siegel

The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation

J Am Acad Dermatol20055310381044

16310065

103

Mansh

Katz

Linos

Chren

Arron

Association of skin cancer and indoor tanning in sexual minority men and women

JAMA Dermatol201515113081316

26444580

104

O’Riordan

Field

Geller

Frequent tanning bed use, weight concerns, and other health risk behaviors in adolescent females (United States)

Cancer Causes Control20061767986

16633915

105

Miyamoto

Berkowitz

Jones

Saraiya

Indoor tanning device use among male high school students in the United States

J Adolesc Health20125030810

22325138

106

Sendelweck

Bell

Anderson

Associations between indoor tanning and substance use among Colorado high school students [Epub ahead of print January 20, 2016]

JAMA Dermatol2016

10.1001/jamadermatol.2015.5663

107

Heckman

Cohen-Filipic

Darlow

Kloss

Manne

Munshi

Psychiatric and addictive symptoms of young adult female indoor tanners

Am J Health Promot20142816874

23621780

108

Mosher

Danoff-Burg

Indoor tanning, mental health, and substance use among college students: the significance of gender

J Health Psychol20101581927

20453052

109

Monfrecola

Fabbrocini

Posteraro

Pini

What do young people think about the dangers of sunbathing, skin cancer and sunbeds? A questionnaire survey among Italians

Photodermatol Photoimmunol Photomed200016158

10721859

110

Holman

Fox

Glenn

Strategies to reduce indoor tanning: current research gaps and future opportunities for prevention

Am J Prev Med20134467281

23683986

111

Mahoney

Swetter

Biello

Resnick

Feuerstein

Geller

Attitudes toward indoor tanning among users of sunless tanning products

Arch Dermatol20121481246

22250251

112

Brooks

Dajani

Use of artificial tanning products among young adults

J Am Acad Dermatol20065410606

16713463

113

Quinn

Alamian

Hillhouse

Scott

Turrisi

Baker

Prevalence and correlates of indoor tanning and sunless tanning product use among female teens in the United States

Prev Med Rep201524043

25621199

114

U.S. Food and Drug AdministrationTanning Productshttp://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/Tanning/ucm116434.htm. Accessed December 20, 2015

115

Hillhouse

Baker

Turrisi

Evaluating a measure of tanning abuse and dependence

Arch Dermatol20121488159

22801615

116

Stapleton

Hillhouse

Turrisi

Baker

Manne

Coups

The Behavioral Addiction Indoor Tanning Screener (BAITS): an evaluation of a brief measure of behavioral addictive symptoms

Acta Derm Venereol2015

117

Heckman

Darlow

Kloss

Measurement of tanning dependence

J Eur Acad Dermatol Venereol20142811791185

23980870

118

American Psychiatric AssociationThe Diagnostic and Statistical Manual of Mental Disorders: DSM 5Arlington, VA

American Psychiatric Publishing

2013

119

First

Spitzer

Gibbon

Williams

Structured Clinical Interview for DSM-IV Axis I Disorders (SCID)New York, NY

New York State Psychiatric Institute Biometrics Research Department

1995

120

Mayfield

McLeod

Hall

The CAGE questionnaire: validation of a new alcoholism screening instrument

Am J Psychiatry197413111213

4416585

121

Harrington

Beswick

Graves

Activation of the mesostriatal reward pathway with exposure to ultraviolet radiation (UVR) vs. sham UVR in frequent tanners: a pilot study

Addict Biol2012176806

21481104

122

Feldman

Liguori

Kucenic

Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners

J Am Acad Dermatol2004514551

15243523

123

Kaur

Liguori

Lang

Rapp

Fleischer

JrFeldman

Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners

J Am Acad Dermatol20065470911

16546596

124

Fell

Robinson

Mao

Woolf

Fisher

Skin beta-endorphin mediates addiction to UV light

Cell2014157152734

24949966

125

Association of American Cancer Institutes. AACI CancerBlogUV Safety Month Fuels Efforts to Ban Indoor TanningPosted on7152015http://www.aaci-cancer.org/pdf/JointPositionStatementonIndoorTanning07. Accessed January 26, 2016

126

U.S. Food and Drug Administration. Center for Devices and Radiological Health, Medical Devices Advisory CommitteeGeneral and plastic surgery devices panel: transcript2010http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/GeneralandPlasticSurgeryDevicesPanel/UCM210232.pdf. Accessed December 20, 2015

127

Congress Mandates Better Skin Cancer Warnings on Tanning Bedshttps://maloney.house.gov/media-center/press-releases/congress-mandates-better-skin-cancer-warnings-tanning-beds. Accessed January 17, 2016

128

U.S. Patient Protection and Affordable Care Acthttps://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm. Accessed March 5, 2016

129

U.S. Internal Revenue Service

Indoor Tanning Services; Excise Taxes

Filed by the Office of the Federal Register on June 10, 2013 and published in the issue of the Federal Register for June 11, 2013, 78 FR 34874https://www.irs.gov/irb/2013-28_IRB/ar06.html. Accessed March 5, 2016

130

Treasury Inspector General for Tax AdministrationAffordable Care Act: The number of taxpayers filing tanning excise tax returns is lower than expected9222011Reference Number: 2011-40-115. https://www.treasury.gov/tigta/auditreports/2011reports/201140115fr.pdf

131

Jain

Rademaker

Robinson

Implementation of the federal excise tax on indoor tanning services in Illinois

Arch Dermatol20121481224

22250250

132

National Conference of State LegislaturesIndoor tanning restrictions for minors – a state-by-state comparisonhttp://www.ncsl.org/research/health/indoor-tanning-restrictions.aspx. Accessed December 29, 2015

133

AIM at Melanoma Foundation

Global Advocacy and Engagement

Melanoma Legislationhttps://www.aimatmelanoma.org/global-advocacy-and-engagement/melanoma-legislation/. Accessed January 26, 2016

134

Culley

Mayer

Eckhardt

Compliance with federal and state legislation by indoor tanning facilities in San Diego

J Am Acad Dermatol2001445360

11148477

135

Fleischer

JrLee

Adams

Zanolli

Tanning facility compliance with state and federal regulations in North Carolina: a poor performance

J Am Acad Dermatol199328212217

8432917

136

Forster

Lazovich

Hickle

Sorensen

Demierre

Compliance with restrictions on sale of indoor tanning sessions to youth in Minnesota and Massachusetts

J Am Acad Dermatol200655962967

17097392

137

Cokkinides

Weinstock

Lazovich

Ward

Thun

Indoor tanning use among adolescents in the US, 1998 to 2004

Cancer20091151908

19085965

138

Mayer

Woodruff

Slymen

Adolescents’ use of indoor tanning: a large-scale evaluation of psychosocial, environmental, and policy-level correlates

Am J Public Health2011101930938

21421947

139

Guy

JrBerkowitz

Jones

State indoor tanning laws and adolescent indoor tanning

Am J Public Health2014104e69e74

140

Bulger

Mayer

Gershenwald

Guild

Gottlieb

Geller

Enforcement provisions of indoor tanning bans for minors: an analysis of the first 6 U.S. States

Am J Public Health2015105e10e12

141

Grewal

Haas

Pletcher

Resneck

Compliance by California tanning facilities with the nation’s first statewide ban on use before the age of 18 years

J Am Acad Dermatol201369883889 e4

24120564

142

Hurd

Mayer

Woodruff

Belch

Patel

Comparing two methods of measuring legislation compliance among indoor tanning facilities

Journal of the American Academy of Dermatology200654433439

16488294

143

World Health OrganizationArtificial Tanning Sunbeds Risks and Guidance2003http://www.who.int/uv/publications/en/sunbeds.pdf. Accessed December 20, 2015

144

Cancer Council AustraliaNational Cancer Control Policyhttp://wiki.cancer.org.au/policy/Position_statement_-_Solariums. Accessed January 14, 2016

145

Centers for Disease Control and Prevention

Skin Cancer

http://www.cdc.gov/cancer/skin/basic_info/indoor_tanning.htm. Accessed January 21, 2016

146

Pawlak

Bui

Amir

Burkhardt

Chen

Dellavalle

Legislation restricting access to indoor tanning throughout the world

Arch Dermatol201214810061012

22801924

147

U.S. Federal Trade CommissionIndoor Tanning Association Settles FTC Charges That It Deceived Consumers About Skin Cancer Risks From Tanninghttps://www.ftc.gov/news-events/press-releases/2010/01/indoor-tanning-association-settles-ftc-charges-it-deceived. Accessed January 1, 2016

148

Marketers of Indoor Tanning Systems to Pay Refunds to Consumershttps://www.ftc.gov/news-events/press-releases/2016/04/marketers-indoor-tanning-systems-pay-refunds-consumers. Accessed April 20, 2016

149

U.S. House of Representatives Committee on Energy and Commerce—Minority StaffFalse and Misleading Health Information Provided to Teens by the Indoor Tanning Industry: Investigative Reporthttps://democrats-energycommerce.house.gov/sites/democrats.energycommerce.house.gov/files/False-Health-Info-by-Indoor-Tanning-Industry-2012-2-1.pdf Accessed January 1, 2016

150

Clique 2 HoustonDarque Tan, Texas settle lawsuit over tanning bed claimshttp://www.click2houston.com/news/darque-tan-texas-settle-lawsuit-over-tanning-bed-claims_20151124031337839. Accessed January 1, 2016

151

Office of the New York State Attorney GeneralA.G. Schneiderman Announces Agreements Barring National Tanning Salon Chain Hollywood Tans And Manhattan Franchise From Making Health Claimshttp://www.ag.ny.gov/press-release/ag-schneiderman-announces-agreements-barring-national-tanning-salon-chain-hollywood. Accessed December 31, 2015

152

Office of the New York State Attorney GeneralA.G. Schneiderman Announces Lawsuits Accusing Two NYC & Upstate Tanning Salon Companies Of Unlawfully Concealing Indoor Tanning Riskshttp://www.ag.ny.gov/press-release/ag-schneiderman-announces-lawsuits-accusing-two-nyc-upstate-tanning-salon-companies Accessed January 1, 2016

153

Office of the New York State Attorney GeneralA.G. Schneiderman Announces Agreement With Planet Fitness To Cease Advertising Practices That Encourage Frequent Indoor Tanninghttp://www.ag.ny.gov/press-release/ag-schneiderman-announces-agreement-planet-fitness-cease-advertising-practices. Accessed January 1, 2016

154

Geller

O’Riordan

Oliveria

Valvo

Teich

Halpern

Overcoming obstacles to skin cancer examinations and prevention counseling for high-risk patients: results of a national survey of primary care physicians

J Am Board Fam Pract20041741623

15575033

155

Bandi

Cokkinides

Weinstock

Ward

Physician sun protection counseling: prevalence, correlates, and association with sun protection practices among US adolescents and their parents, 2004

Prev Med2010511727

20478331

156

Dietrich

Olson

Sox

Winchell

Grant-Petersson

Collison

Sun protection counseling for children: primary care practice patterns and effect of an intervention on clinicians

Arch Fam Med200091559

10693733

157

Balk

O’Connor

Saraiya

Counseling parents and children on sun protection: a national survey of pediatricians

Pediatrics2004114105664

15466105

158

U.S. Preventive Services Task ForceFinal Update Summary: Skin Cancer: Counseling2012http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-counseling. Accessed December 20, 2015

159

Moyer

on behalf of the U.S. Preventive Services Task Force

Behavioral counseling to prevent skin cancer: U.S. Preventive Services Task Force recommendation statement

Ann Intern Med20121575965

22751761

160

Hillhouse

Turrisi

Stapleton

Robinson

A randomized controlled trial of an appearance-focused intervention to prevent skin cancer

Cancer2008113325766

18937268

161

Stapleton

Turrisi

Hillhouse

Robinson

Abar

A comparison of the efficacy of an appearance-focused skin cancer intervention within indoor tanner subgroups identified by latent profile analysis

J Behav Med20103318190

20058183

162

Turrisi

Mastroleo

Stapleton

Mallett

A comparison of 2 brief intervention approaches to reduce indoor tanning behavior in young women who indoor tan very frequently

Arch Dermatol200814415214

19015434

163

Norman

Adams

Calfas

A randomized trial of a multicomponent intervention for adolescent sun protection behaviors

Arch Pediatr Adolesc Med200716114652

17283299

164

Mahler

Kulik

Gerrard

Gibbons

Long-term effects of appearance-based interventions on sun protection behaviors

Health Psychol20072635060

17500622

165

Fox

Shaw

Clinical preventive services coverage and the Affordable Care Act

Am J Public Health2015105e7e10

166

Balk

Council on Environmental Health Section on Dermatology

Ultraviolet radiation: a hazard to children and adolescents

Pediatrics2011127e791817

21357345

167

Balk

Fisher

Geller

Teens and indoor tanning: a cancer prevention opportunity for pediatricians

Pediatrics201313177285

23509165

168

Berwick

Begg

Fine

Roush

Barnhill

Screening for cutaneous melanoma by skin self-examination

J Natl Cancer Inst1996881723

8847720

169

Berwick

Armstrong

Ben-Porat

Sun exposure and mortality from melanoma

J Natl Cancer Inst2005971959

15687362

170

Leachman

Cassidy

Chen

Methods of melanoma detection

Cancer Treat Res201616751105

26601859

171

Carli

De Giorgi

Palli

Dermatologist detection and skin self-examination are associated with thinner melanomas: results from a survey of the Italian Multidisciplinary Group on Melanoma

Arch Dermatol200313960712

12756097

172

Swetter

Pollitt

Johnson

Brooks

Geller

Behavioral determinants of successful early melanoma detection: role of self and physician skin examination

Cancer2012118372534

22179848

173

Pollitt

Geller

Brooks

Johnson

Park

Swetter

Efficacy of skin self-examination practices for early melanoma detection

Cancer Epidemiol Biomarkers Prev200918301823

19861521

174

Weinstock

Martin

Risica

Thorough skin examination for the early detection of melanoma

Am J Prev Med19991716975

10987631

175

Oliveria

Christos

Halpern

Fine

Barnhill

Berwick

Evaluation of factors associated with skin self-examination

Cancer Epidemiol Biomarkers Prev199989718

10566551

176

Oliveria

Dusza

Phelan

Ostroff

Berwick

Halpern

Patient adherence to skin self-examination. effect of nurse intervention with photographs

Am J Prev Med2004261525

14751328

177

Weinstock

Risica

Martin

Reliability of assessment and circumstances of performance of thorough skin self-examination for the early detection of melanoma in the Check-It-Out Project

Prev Med2004387615

15193896

178

Aitken

Janda

Lowe

Prevalence of whole-body skin self-examination in a population at high risk for skin cancer (Australia)

Cancer Causes Control20041545363

15286465

179

Robinson

Turrisi

Stapleton

Efficacy of a partner assistance intervention designed to increase skin self-examination performance

Arch Dermatol20071433741

17224540

180

Robinson

Turrisi

Mallett

Stapleton

Pion

Comparing the efficacy of an in-person intervention with a skin self-examination workbook

Arch Dermatol2010146914

20083705

181

Janda

Neale

Youl

Whiteman

Gordon

Baade

Impact of a video-based intervention to improve the prevalence of skin self-examination in men 50 years or older: the randomized skin awareness trial

Arch Dermatol2011147799806

21422325

182

Chiu

Won

Malik

Weinstock

The use of mole-mapping diagrams to increase skin self-examination accuracy

J Am Acad Dermatol20065524550

16844506

183

Epstein

Lange

Gruber

Mofid

Koch

Is physician detection associated with thinner melanomas?

JAMA19992816403

10029126

184

Aitken

Elwood

Baade

Youl

English

Clinical whole-body skin examination reduces the incidence of thick melanomas

Int J Cancer20101264508

19609948

185

Kantor

Routine dermatologist-performed full-body skin examination and early melanoma detection

Arch Dermatol20091458736

19687416

186

Kovalyshyn

Dusza

Siamas

Halpern

Argenziano

Marghoob

The impact of physician screening on melanoma detection

Arch Dermatol2011147126975

21768448

187

Swetter

Johnson

Miller

Layton

Brooks

Geller

Melanoma in middle-aged and older men: a multi-institutional survey study of factors related to tumor thickness

Arch Dermatol2009145397404

19380661

188

Terushkin

Halpern

Melanoma early detection

Hematol Oncol Clin North Am200923481500

19464598

189

Aitken

Elwood

Lowe

Firman

Balanda

Ring

A randomised trial of population screening for melanoma

J Med Screen20029337

11943795

190

Schneider

Moore

2ndMendelsohn

Screening program reduced melanoma mortality at the Lawrence Livermore National Laboratory, 1984 to 1996

J Am Acad Dermatol2008587419

18068264

191

Katalinic

Waldmann

Weinstock

Does skin cancer screening save lives?: an observational study comparing trends in melanoma mortality in regions with and without screening

Cancer20121185395402

22517033

192

Breitbart

Waldmann

Nolte

Systematic skin cancer screening in Northern Germany

J Am Acad Dermatol20126620111

22074699

193

Katalinic

Eisemann

Waldmann

Skin cancer screening in Germany

Dtsch Arztebl Int2015112629634

26429634

194

Boniol

Autier

Gandini

Melanoma mortality following skin cancer screening in Germany

BMJ Open20155e008158

195

Aitken

Youl

Janda

Lowe

Ring

Elwood

Increase in skin cancer screening during a community-based randomized intervention trial

Int J Cancer200611810106

16152577

196

Aitken

Janda

Elwood

Youl

Ring

Lowe

Clinical outcomes from skin screening clinics within a community-based melanoma screening program

J Am Acad Dermatol20065410514

16384764

197

Curiel-Lewandrowski

Chen

Swetter

on behalf of the Melanoma Prevention Working Group-Pigmented Skin Lesion Sub-Committee

Screening and prevention measures for melanoma: is there a survival advantage?

Curr Oncol Rep20121445867

22907282

198

Coory

Baade

Aitken

Smithers

McLeod

Ring

Trends for in situ and invasive melanoma in Queensland, Australia, 1982–2002

Cancer Causes Control200617217

16411049

199

Stang

Jockel

Does skin cancer screening save lives? A detailed analysis of mortality time trends in Schleswig-Holstein and Germany

Cancer20161224327

26480048

200

Geller

Greinert

Sinclair

A nationwide population-based skin cancer screening in Germany: proceedings of the first meeting of the International Task Force on Skin Cancer Screening and Prevention (September 24 and 25, 2009)

Cancer Epidemiol2010343558

20381443

201

Evidence Synthesis Number 137

Screening for Skin Cancer in Adults: An Updated Systematic Evidence Review for the U.S. Preventive Services Task ForceAJRQ Publication no. 14-05210-EF-1122015(Prepared by Kaiser Permanente Research Affiliates Evidence-based Practice Center Group Health Research Institute – Seattle, WA: and Kaiser Permanante Center for Health Research – Portland, OR)

202

Karia

Jambusaria-Pahlajani

Harrington

Murphy

Qureshi

Schmults

Evaluation of American Joint Committee on Cancer, International Union Against Cancer, and Brigham and Women’s Hospital tumor staging for cutaneous squamous cell carcinoma

J Clin Oncol20143232734

24366933

203

Moore

Geller

Zhang

Skin cancer examination teaching in US medical education

Arch Dermatol200614243944

16618862

204

Geller

Venna

Prout

Should the skin cancer examination be taught in medical school?

Arch Dermatol200213812013

12224981

205

Oliveria

Heneghan

Cushman

Ughetta

Halpern

Skin cancer screening by dermatologists, family practitioners, and internists: barriers and facilitating factors

Arch Dermatol20111473944

21242390

206

Shaikh

Geller

Alexander

Developing an interactive web-based learning program on skin cancer: the learning experiences of clinical educators

J Cancer Educ20122770916

22614576

207

Eide

Asgari

Fletcher

Effects on skills and practice from a web-based skin cancer course for primary care providers

J Am Board Fam Med20132664857

24204061

208

Grange

Woronoff

Bera

Efficacy of a general practitioner training campaign for early detection of melanoma in France

Br J Dermatol20141701239

23937244

209

Weinstock

Early detection of melanoma

JAMA20002848869

10938181

210

Buller

Berwick

Lantz

Evaluation of immediate and 12-week effects of a smartphone sun-safety mobile application: a randomized clinical trial

JAMA Dermatol201515150512

25629819

211

Jolly

Wearable devices to prevent sunburn2015http://well.blogs.nytimes.com/2015/06/16/wearable-devices-to-prevent-sunburn/. Accessed December 20, 2015

212

Landow

Mateus

Korgavkar

Nightingale

Weinstock

Teledermatology: key factors associated with reducing face-to-face dermatology visits

J Am Acad Dermatol2014715706

24704089

213

Landow

Weinstock

Teledermatology Within the Veterans Health Administration, 2002–2014

Telemed J E Health20152176973

26083585

214

Carli

Crocetti

Chiarugi

The use of commercially available personal UV-meters does cause less safe tanning habits: a randomized-controlled trial

Photochem Photobiol20088475863

18086243

Figure 1Figure 2Figure 3

Table 1

Melanoma Incidence and Mortality Rates by Age and Sex, United States, 2008–2012

Sex	Age (years)	Rate per 100,000	95% CI	Average annual count
Incidence

Male	0–19	0.3	(0.3–0.4)	143
	20–49	9.9	(9.8–10.0)	6087
	50–64	41.4	(41.0–41.7)	12011
	65+	117.4	(116.7–118.1)	19872

Female	0–19	0.5	(0.5–0.5)	213
	20–49	13.9	(13.8–14.1)	8650
	50–64	27.6	(27.3–27.8)	8379
	65+	44.2	(43.8–44.6)	10223

Mortality

Male	0–19	0.0	(0.0, 0.0)	3
	20–49	1.1	(1.0, 1.1)	658
	50–64	5.7	(5.6, 5.8)	1661
	65+	21.7	(21.4, 22.1)	3613

Female	0–19	0.0	(0.0, 0.0)	4
	20–49	0.7	(0.7, 0.7)	439
	50–64	2.7	(2.6, 2.8)	840
	65+	7.7	(7.6, 7.9)	1852

Source for 2008–2012 incidence rates:

United States Cancer Statistics: 1999 – 2012 Incidence, WONDER Online Database. United States Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2015. Data are from population areas that meet United States Cancer Statistics publication criteria (www.cdc.gov/cancer/npcr/uscs/technical_notes/critera.htm) for 2008–2012 and were reported to the National Program of Cancer Registries (CDC) and the Surveillance, Epidemiology and End Results (SEER) program (NCI). They cover about 99.1% of the U.S. population.

Source for 2008–2012 mortality data: Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Mortality – All COD, Aggregated With State, Total U.S. (1969–2012) <Katrina/Rita Population Adjustment>, National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2015. Underlying mortality data provided by NCHS (www.cdc.gov/nchs).

Table 2

Melanoma Incidence and Mortality Rates by Sex and Race/Ethnicity, United States, 2008–2012

	Both Sexes			Male			Female
	Rate per100,000	95% CI	Averageannualcount	Rate per100,000	95% CI	Averageannualcount	Rate per100,000	95% CI	Averageannualcount
Incidence
All races	19.9	(19.9–20.0)	65,557	25.5	(25.3–25.6)	38,112	15.0	(15.9–16.0)	27,465
White	22.6	(22.5–22.6)	62,009	28.4	(28.3–28.5)	36,256	18.3	(18.2–18.4)	25,753
White, Hispanic	4.3	(4.2–4.4)	1,264	4.8	(4.6–5.0)	577	4.2	(4.0–4.3)	687
White, non-Hispanic	25.1	(25.0–25.2)	60,744	31.2	(31.0–31.3)	35,678	20.7	(20.5–20.8)	25,066
Black	1.0	(1.0–1.1)	342	1.1	(1.0–1.2)	156	1.0	(0.9–1.0)	186
American Indian/Alaska Native	4.6	(4.3–5.0)	135	5.8	(5.1–6.5)	71	3.9	(3.5–4.4)	64
Asian/Pacific Islander	1.3	(1.2–1.4)	191	1.5	(1.4–1.7)	94	1.2	(1.1–1.3)	97
Hispanic*	4.2	(4.1–4.4)	1,354	4.7	(4.5–4.9)	618	4.1	(3.9–4.2)	736
Mortality
All races	2.7	(2.7, 2.7)	9,071	4.1	(4, 4.1)	5,936	1.7	(1.7, 1.7)	3,135
White	3.1	(3.1, 3.2)	8,872	4.6	(4.6, 4.7)	5,838	2	(1.9, 2)	3,033
White, Hispanic	0.8	(0.8, 0.9)	210	1.1	(1, 1.2)	123	0.6	(0.6, 0.7)	87
White, non-Hispanic	3.4	(3.4, 3.4)	8,651	5	(4.9, 5.1)	5,709	2.1	(2.1, 2.2)	2,942
Black	0.4	(0.4, 0.4)	132	0.5	(0.4, 0.5)	63	0.4	(0.3, 0.4)	70
American Indian/Alaska Native	0.7	(0.6, 0.9)	19	1	(0.7, 1.3)	11	0.6	(0.4, 0.8)	8
Asian/Pacific Islander	0.4	(0.3, 0.4)	48	0.4	(0.3, 0.5)	24	0.3	(0.3, 0.4)	24
Hispanic*	0.8	(0.7, 0.8)	214	1	(1, 1.1)	125	0.6	(0.5, 0.6)	88

Hispanic ethnicity includes persons of all races.

Source for 2008–2012 incidence rates: United States Cancer Statistics: 1999 – 2012 Incidence, WONDER Online Database. United States Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2015. Data are from population areas that meet United States Cancer Statistics publication criteria (www.cdc.gov/cancer/npcr/uscs/technical_notes/critera.htm) for 2008–2012 and were reported to the National Program of Cancer Registries (CDC) and the Surveillance, Epidemiology and End Results (SEER) program (NCI). They cover about 99.1% of the U.S. population.