Sun, Skin and Health

Introduction

Terry Slevin

We all spend time in the sun and we all want a healthy life. If these two things are true for you, then this book is important to you. And chances are, as you’ve bothered opening its pages, you or someone close to you has had skin cancer.

That is not an uncommon thing in Australia or New Zealand. In fact, it’s so common that skin cancer is known by some in the cancer world as ‘the Australian cancer’.

We live in a sunny place – and we revel in that. A week cannot go by without us hearing about the sun – we get too much or we get too little, skin cancer, eye problems, vitamin D problems. Despite all that, most of us are happy to read a weather forecast that predicts a sunny day.

This book is about understanding how to get the very best out of our sunny climate, while minimising the risk that is inherent in it.

A little history

Put simply, Australia and New Zealand are countries now made up of people who mostly do not have a skin type that suits our climate. Indigenous people of our islands are naturally darker skinned. Recently scientists have postulated that this is Darwinism on display. Family lines of pale skinned people did not survive as long in the intensive sun we experience, compared to people with darker or ‘pigmented’ skin.

People who evolved in our lands over thousands of years developed dark skin to protect themselves from that sun. The further north they went, the closer they got to the equator, the more they were exposed to the sun, the darker their skin colour became.

Then a few hundred years ago a great immigration occurred, in the form of European settlement. It led to more people living here with skin types better suited to northern Europe. For the first one and a half centuries of European settlement those people retained much of their social norms of covering up with clothing and hats, as they would have in the lands from which they came.

More recently, social norms have changed. Displaying more skin in public is not only acceptable, it has become standard. It also symbolises the free and easy outdoor lifestyle we love and cherish.

But for that ‘freedom’ we pay a price. And that price is skin cancer. And a high price it is.

The cost of skin cancer

Recent projections suggest we are likely to see close to a million (yes, 1 000 000) skin cancers treated per year in Australia before the end of this decade. They will range from some fairly low-impact basal cell carcinomas (BCCs) that might be quite easily treated with a topical cream which causes no more than inconvenience and discomfort for a few weeks, through to aggressive advanced melanoma, which might cause death within a few short months of diagnosis.

Non-melanoma skin cancers (NMSCs) make up most of the skin cancers: about 11 000 melanomas are currently diagnosed in Australia each year. NMSCs are so common they are not counted by our cancer registries, so much of our data on these are estimates. But the numbers are doubtless enormous. And every single one generates anxiety, often a scar and all too often far more serious impacts.

Add to the health and human cost the financial cost. When we include the out-of pocket-expenses of all the people who have skin cancers removed, to the cost to the health care system, lost productivity and other costs, by 2020 the cost per year in Australia could be approaching $1 billion.

No matter how it is measured, Australia and New Zealand are far and away the skin cancer champions of the world. And we are still to come to terms with how to cope with the extremes of sun exposure (ultraviolet radiation, UV or UVR) that reaches us for a large part of our lives.

A family issue

If you are among the hundreds of thousands, probably well over a million Aussies or Kiwis alive today who has had a skin cancer removed, then it is also likely that your skin colour has been passed to your kids and they will pass it to theirs. And that makes them vulnerable to skin cancer in the same way you were. And that makes skin cancer a family issue.

So if you’ve come this far you’ll know that you and your family, we, all of us, need to learn more of the complexities of this disease and, perhaps most importantly, understand some of the complexities of how to prevent it. Frustratingly, it is not as simple as it seems.

Why a book?

With that in mind, this book aims to bring together some of the country’s and in some cases the world’s leading experts in various aspects important to the sun, health and skin cancer – prevention, diagnosis or treatment and what happens after.

Each author has a different perspective.

Some have dedicated their professional lives to treating the disease, some to researching various aspects of importance to its cause, or its prevention. Those experts tackle the mysteries of skin cancer, its various forms and what evidence we have on its causes, on UV radiation and the curious world of the solarium (albeit with its limited future in Australia). They fill us in on sunscreens and shade and their strengths and weaknesses as tools for sun protection. They walk us through how tanning happens and how it came to be a behaviour we indulge in. They cover eye health and the impact of UVR on our eyes. Of course the controversies about vitamin D could not be ignored, so a chapter on what we do and don’t know about vitamin D is key.

There are also chapters that deepen our understanding of how to spot, manage and recover from skin cancer.

Some of our experts bring a very personal perspective, and that’s OK. All know their stuff and all use their experience and passion to explain their field.

And all would like to know more. There is no doubt we do not have all the answers when it comes to the sun, health and skin cancer. There remain many unknowns about treating advanced disease. We do not have a system for identifying, with 100% accuracy, the dangerous skin cancer from the harmless skin spot. There are numerous debates about the precise causal pathways. And of course there are many, many controversies. Questions abound on vitamin D (have we gone too far and are now suffering more from too little sun?), nanoparticles in sunscreen, sunscreen effectiveness, methods of detection, solarium bans and more.

Each and every fact and issue raised here can be found – somewhere or other – on the web. We all have it at our fingertips. What this book does is bring the most relevant and up to date information of relevance to skin cancer into one place. It is a fast and easy reference that gives access to the best information science can currently muster, to answer important skin cancer questions.

By the time it is published, some of it will be out of date. That is the nature of a field where constant research is underway. New theories, new cures, new evidence will emerge to challenge what is on these pages. That is a good thing.

Personal note – why bother doing this?

I have worked in skin cancer prevention for 20 years.

In that time I have seen an enormous change in our acceptance of its importance, the level of understanding of skin cancer issues in the community and what we can do about it.

I have also seen confusion, misinformation and misunderstanding, and I’ve been frustrated with the lack of commitment and investment in prevention as a means of reducing the burden skin cancer has on the people around me.

I have my own story. Of Anglo-Celtic stock, I grew up in the 1960s and 1970s when back-slapping your mates in the school playground on Monday morning was the way to find out who had been to the beach that weekend. Busting blisters onto the inside of school shirts was considered a bonus and a red peeling nose was a sign that summer had arrived.

After having worked at the Cancer Council for about 10 years I had my own brush with skin cancers to deal with. A handful of BCCs on the face and a deeper one on the left shoulder was a remnant of my sun-soaked youth in the coastal city of Newcastle.

I recall first seeing the first Sid Seagull ‘Slip Slop Slap’ adverts on telly when I was in my late teens. So my generation is the last to have spent a childhood not knowing about sun protection and skin cancer.

There are signs that those early efforts, exhorting us to ‘Slip on a shirt, Slop on some sunscreen and Slap on a hat’ might actually be starting to influence the skin cancer statistics. It takes between 20 and 40 years for cancer prevention efforts to really take effect.

And those efforts need to be widespread.

I have to stop myself approaching sunbathing teens on the beach, or tapping the shoulder of the bloke who is putting sunscreen on just before jumping in the pool (it is likely to wash off). When in the pool, swimming laps, I want to point out to the woman wearing the rashie that the UV at 5.30 p.m. is not going to do her damage. While in a supermarket checkout queue, I want to tell the bloke in front that maybe the GP should look at that spot on his neck.

I can’t help feeling that a better understanding of the basics, like:

•   how skin cancer works

•    how the UV levels fluctuate throughout the day and throughout the year

•    how sunscreen functions

•    the role shade can play in our homes, public buildings, workplaces and schools

•    how to keep an eye out for early signs for skin cancer

•    what to expect if they do come along.

... will serve us all better.

I hope this book sits in family bookcases, finds its way into Christmas stockings and is sitting on the pillow when people arrive home from day surgery after another round of skin cancer treatment. I hope families talk about its content. I hope they debate its precision, or whether something has been reported in the news that might make something in these pages obsolete.

Most of all, I hope people flick through its pages and learn something about skin cancer and then do something about it.

Who is it for?

This book is important to those who have had skin cancer and want to reduce their chance of getting more. It is not too late to start covering up!

But perhaps more importantly, this book aims to give information to families. Families who want to pass on the knowledge and tips for skin cancer prevention, based on sound science, to their kids and to their extended families, so that we can tackle and face one of the most preventable of cancers. Ultimately we want the antipodeans to step off the dais of skin cancer champions. We want to join the ranks of countries where skin cancer is more an oddity that does not dominate the cancer statistics.

Particularly the men

I take this opportunity to lean on the blokes. It drives me nuts that the rates of skin cancer in Australia have been going up for 30 years, but the rates in men are increasing alarmingly fast. Much more than for women. It is now the case that men are about twice as likely to be diagnosed with skin cancer as are women and that, when diagnosed, men are about twice as likely to die of the disease. There seems no biologically plausible reason for this. Rates of melanoma were similar in men and women in the early 1980s when accurate records began in Australia.

Our culture seems to create an expectation that women will care for their skin and their appearance far more than seems the norm for men. It must be time to turn this around. Ladies, please, if the blokes in your lives are not getting on board, weigh into them!

Maybe we can reduce this disease to a minor and easily managed condition taking far fewer of our resources, and of course far fewer lives. We have come some of the way, but there is still a bit of work to do before we get to that point.

Chapter 1

What is skin cancer and how does it form?

David Whiteman and Catherine Olsen

Key messages

•    Australia and New Zealand experience by far the highest rates of skin cancer in the world.

•    Excessive sun exposure is the most likely cause of the large majority of skin cancers, so the majority of skin cancer is preventable.

•    Keratinocyte cancers (abbreviated here as KCs, and also commonly referred to as non-melanoma skin cancers or NMSCs), are by far the most common form of skin cancer.

•    Melanomas are less common than KCs, but are responsible for the most deaths from skin cancer.

•    People with lighter skin colours are at higher risk of skin cancer compared to people with darker skin colours.

•    Family history influences skin colour and plays a major role in determining who is at higher risk of skin cancer.

•    People with a past history of BCC and SCC have about a three-fold higher risk of developing melanoma than the population average.

Apples and oranges: the different types of skin cancer

What is the skin, exactly?

The skin is the largest organ in the body, and performs many different functions. The skin is our outermost protective barrier – its job is to keep out germs, toxins, radiation and a host of other nasties in the environment. The skin also regulates our temperature – keeping us warm in winter and cool in summer. To perform its many functions, the skin is made up of different types of cells in different layers (see Fig. 1.1). The outermost layer is called the epidermis, and it mostly contains flat cells called keratinocytes. It is these cells, the keratinocytes, that dry out to form the flaky outermost layer of keratin. Keratin is also used to form hair and nails. Another common cell found in the epidermis is the pigment cell or melanocyte, so called because it produces melanin. Melanin is the compound that tans our skin and gives freckles and hair their distinctive colours. Other cells found in the epidermis include sensory cells and immune cells.

The next layer down is the dermis, which contains fat, nerves, blood vessels and the bundles of fibres which give the skin its strength and flexibility. Below the dermis are the deeper fat layers. Between the epidermis and dermis is a very thin membrane, which forms a very important landmark for describing skin cancer. Cancers that are contained wholly within the epidermis and which have not crossed the boundary into the dermis, are considered pre-invasive cancers. That is, they are cancers that have not yet invaded into the deeper layers of the skin. Such cancers are considered to be very early stage cancers. Their technical name in Latin is in situ, which means literally ‘in position’ or ‘in its natural place’. In contrast, invasive skin cancers are those which have spread from the epidermis and crossed the boundary into the dermis.

Fig. 1.1: The epidermis as viewed under a microscope. ©QIMR Berghofer Medical Research Institute.

Cell division

As we go about our lives, we are constantly shedding skin cells. Each and every day, we scrape and scratch and damage our skin. To replace the cells that are being lost and to prevent our skin from being worn away completely, the skin cells undergo an orderly process of cell division (which scientists call ‘mitosis’). In this process, a ‘mother’ cell in the lowest layer of the epidermis divides into two ‘daughter’ cells. Each daughter cell is an exact copy of the mother cell and contains all of the genetic material that is needed to function as a skin cell. The process of cell division is under extremely tight control to make sure that each new cell is a perfect copy of the original. This control also makes sure that cells divide only when they are supposed to. Sometimes, however, the genetic material inside a cell is damaged, for example by exposure to ultraviolet radiation in sunlight or by infection with a virus. These types of events can mutate (or disrupt) the genes inside the cell. Because each daughter cell is an exact copy of the mother cell, a mutation that occurs in a gene in the mother cell will be passed on to the daughter cells (Fig. 1.2). Many mutations have no bad effects, and some mutations can even have good effects. However, if a mutation occurs in one of a very small number of genes that are critically important for mitosis, then it can have very bad effects. For example, some mutations can make a cell keep dividing when it is not supposed to, leading to uncontrolled, continuous cell division. This type of uncontrolled behaviour is the classic feature of cancer. This is why cancers are sometimes called ‘growths’ – quite literally, the relentlessly dividing mass of cells leads to a big lump of growing tissue.

Fig. 1.2: The process of cell division. Here, one of the daughter cells has developed a mutation as a result of high-energy wavelengths of sunlight. This mutation is then passed on to the next generation of daughter cells.

Cancers of the skin

Any of the cells that are found in the skin can, at least in theory, form cancers. By far the most common cancers are those that arise from the keratinocytes. Keratinocyte cancers occur as two main types called basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). These two types of skin cancer earn their names because of how they appear when viewed under a microscope.

BCCs are the most common of all cancers in humans. They typically occur from the middle decades of life, and become more frequent with age. While most common on the face, scalp and neck, they also occur on the trunk and limbs. These cancers are often first noticed as a lump or sore on the skin that does not heal. Another name for BCCs is ‘rodent ulcer’. This name describes their appearance (i.e. an ulcer on the skin usually with rolled edges), as well as their tendency to burrow into the skin. Fortunately, most BCCs grow quite slowly and can be treated very effectively.

SCCs are the second most common cancers in humans. They tend to occur on parts of the body that get lots of sun, such as the face, ears, neck, scalp and arms. They are very rare on body parts that are not exposed to the sun. Like BCCs, they often come to attention as a skin sore, but they tend to grow more quickly than BCCs. In rare cases, they can invade the bloodstream and spread through the body. For this reason, it is important to treat them early.

Melanomas are cancers that arise from the pigment cells of the skin. These cancers usually come to attention as a ‘funny mole’ on the skin. They are noticed most often because they have changed in colour or shape or feel. While melanomas are often dark in colour, some can be light-coloured and so can be difficult to see on the skin. Melanomas can arise anywhere on the body but the greatest numbers occur on the back; many also arise on the legs, arms and head. Melanomas can grow and spread to other parts of the body very quickly, so it is important to diagnose them early.

Other types of skin cancer include Merkel cell carcinoma, Kaposi’s sarcoma, various lymphomas and other rare types. Merkel cell carcinoma is a rare but highly aggressive skin cancer, which forms from Merkel cells. Merkel cells are also found in the epidemis of the skin. It was recently discovered that most of these cancers appear to be caused by a virus (the so-called ‘Merkel cell polyomavirus’). Merkel cell tumours can be flesh-coloured, pink or blue, and usually present as firm painless nodules.

Kaposi’s sarcoma (KS) is a tumour that used to be very rare but became much more common during the 1980s with the HIV/AIDS epidemic. Unlike the other cancers of the skin, Kaposi’s sarcoma does not arise from keratinocytes or melanocytes in the epidermis, but from the cells that line lymph or blood vessels.

The abnormal cells of KS form purple, red or brown blotches or tumours on the skin. Interestingly, these cancers are also caused by a virus, in this case, the human herpes virus 8 (HHV8). This virus is reasonably common and actually does not harm people, unless their immune system has been damaged (e.g. following infection with HIV).

Why all the fuss? The burden of skin cancer

Skin cancers impose a massive toll on the Australian population. Indeed, it is hard to overstate the burden from these diseases. The bald statistics make for sober reading. Each year, more than 400 000 Australians develop at least one BCC or SCC – that’s more than 1000 people every single day of the year. Skin cancers are so common that they account for more than 80% of all cancers diagnosed in Australia. They impose the highest costs on the Australian health system of any cancer type. More than 750 000 treatments for skin cancer are billed through Medicare each year, costing the Australian government more than half a billion dollars. (These costs do not include the very large out-of-pocket expenses to patients that add to the total bill, such as gap payments to doctors and the costs of dressings, painkillers, time off work etc.) By 2015, the figures are predicted to rise to nearly 1 million skin cancer treatments at a cost to Medicare of $703 million. Often mistakenly thought of as trivial cancers, BCCs and SCCs cause enormous ill health and, unfortunately, kill many more people than we might realise. Each year in Australia, BCCs and SCCs lead to 85 000 hospital admissions (more than twice the number of admissions for each of bowel, breast or prostate cancers) and cause 500 deaths. BCCs are rarely fatal; most deaths from keratinocyte cancers are due to SCCs.

Melanomas add to this terrible burden. In 2012, more than 200 Australians every week were diagnosed with these dangerous skin cancers, resulting in an annual total of more than 11 000 people with new melanomas. Not counting BCC and SCC, melanoma is the third most commonly occurring cancer in Australian men (after prostate and bowel cancers) and women (after breast and bowel cancers). The rate at which Australians develop melanoma is the highest in the world.

Each year, out of every 100 000 people living in this country, 57 will be newly diagnosed with melanoma. This is much higher than the rate of melanoma observed in other western countries such as the USA, UK, Canada and Sweden. Only our nearest neighbour, New Zealand, has a rate of melanoma approaching that of Australia, affecting