Americans are being diagnosed with melanoma, the deadliest form of skin cancer, at steadily spiraling rates.
According to the National Cancer Institute, over the past 35 years the rate of new melanoma cases among American adults has tripled, from 7.89 per 100,000 population in 1975 to 23.57 in 2010. (NCI 2013).
Just as alarming, the melanoma death rate for white American men, the highest risk group, has also escalated sharply, from 2.64 deaths per 100,000 in 1975 to 4.10 in 2010.
Since the year 2000, the rates of new melanoma cases among both men and women have been climbing by 1.9 percent per year, according to the federal Centers for Disease Control and Prevention (CDC 2013). Escalating melanoma incidence has not spared the young. Teenagers experienced a 2 percent per year increase between 1973 and 2009 (Wong 2013).
The reasons for these trends are elusive, as are strategies for preventing this deadly cancer. While the exact cause of melanoma is not known, scientists have established that risk factors for melanoma include family history, indoor tanning, the number of moles on a person’s skin, fair skin, freckles, ultraviolet radiation and severe sunburns (CDC 2013, NCI 2013). People can control three of these risk factors: indoor tanning, exposure to UV radiation and severe sunburns.
By all accounts, Americans are aware that excessive exposure to sunlight can cause cancer. The CDC has reported that at least 61 percent of American adults say they protect themselves from the sun. The public health agency’s surveys also found that the number of Americans who say they make an effort to protect themselves from sun increased between 2005 and 2010.
The market in so-called suncare products appears to be thriving. IBISWorld, a market research company, reports that sunscreen product sales grew 4.2 percent a year between 2007 and 2012 and generated $1 billion annually (IBISWorld 2013).
Last December, the federal Food and Drug Administration began to enforce new rules on sunscreens. These rules were meant to improve sunscreens and consumer protection. They bar certain bogus label claims, a step long sought by EWG and other public health advocates. But they allow most sunscreens to advertise that they offer “broad spectrum” skin protection. Sunscreen makers are permitted to tell consumers that with proper use, their products can help reduce the risk of skin cancer.
Every major public health authority – the FDA, National Cancer Institute and International Agency for Research on Cancer – has concluded that the available data do not support the assertion that sunscreens alone reduce the rate of skin cancer (FDA 2011a, IARC 2001b, NCI 2011).
One reason sunscreens cannot guarantee protection from cancer and other skin health problems appears to be that sunscreen users differ in important ways from sun avoiders. Another reason is that U.S. sunscreens are not as protective as they should be.
More than 2 million Americans develop skin cancer each year (NCI 2013). Most cases involve one of two disfiguring but rarely fatal forms of skin cancer called basal and squamous cell carcinomas. Some 40 to 50 percent of Americans who live to the age of 65 will be diagnosed with one of these tumors at least once during their lifetimes, according to the U.S. Environmental Protection Agency (EPA 2011).
Studies suggest that basal and squamous cell cancers are strongly related to UV exposure over years.
Several researchers have found that regular sunscreen use lowers the risk of squamous cell carcinoma (Gordon 2009, van der Pols 2006) and diminishes the incidence of actinic keratosis – sun-induced skin changes that may advance to squamous cell carcinoma (Naylor 1995, Thompson 1993).
Researchers have not found strong evidence that sunscreen use prevents basal cell carcinoma (Green 1999, Pandeya 2005, van der Pols 2006, Hunter 1990, Rosenstein 1999, Rubin 2005).
Whether sunscreen can help prevent melanoma is unknown. In 2009, the most recent year for which figures are available, 61,646 people, including 35,436 men and 26,201 women, were diagnosed with melanoma, and 9,199 Americans died from it (CDC 2013). White Americans have much higher melanoma rates than people of other races. Men have higher melanoma rates than women.
Sun exposure appears to play a role in melanoma, but it is a complex disease for which many questions have not been answered. One puzzling fact: melanomas are not usually located on the parts of the body that get daily sun exposure. Both UVA and UVB rays can cause melanoma, as evidenced by laboratory studies on people with extreme sun exposures. In the general population, there is a strong correlation between melanoma risk and the number of sunburns someone has had, particularly in childhood (Dennis 2010). The use of artificial tanning beds dramatically increases melanoma risk (Coleho 2010). For this reason, on May 6, 2013 FDA commissioner Margaret A. Hamburg proposed reclassifying tanning beds from “low risk” to “moderate risk” and requiring new warnings on tanning beds and sun lamps that they “can damage your skin and increase your risk of developing skin cancer.”
The risk of melanoma goes up when you use a tanning bed at any age, but the International Agency for Research on Cancer calculates that if you start using tanning beds before age 30, your risk of developing melanoma jumps by 75 percent.
A 2011 study of sun-savvy Australians found that they reduced their risk of melanoma by daily, year-round use of a high quality SPF 15 sunscreen, wearing hats and avoiding the sun in other ways (Green 2011). Other studies have not come to clear conclusions. Some suggest that sunscreen users are at increased risk of melanoma (Gorham 2007). A number of studies conducted in the 1990s reported higher, not lower, incidence of melanoma among frequent sunscreen users (Autier 1998, Beitner 1990, Westerdahl 2000, Wolf 1998). Other studies suggest that sunscreens protect against melanoma (Autier 1995, Green 2010, Westerdahl 2000, Wolf 1994).
Several factors suggest that regular sun exposure may not be as harmful as intermittent and high intensity sunlight. Paradoxically, outdoor workers report lower rates of melanoma than indoor workers (Radespiel-Troger 2009). Melanoma rates are higher among people who live in northern American cities with less year-round UV intensity than among residents of sunnier cities (Planta 2011). Researchers speculate that higher vitamin D levels for people with regular sun exposure may play a role in reduced melanoma risk (Godar 2011, Newton-Bishop 2011, Field 2011).
Though the science is incomplete, the consensus among researchers who study skin cancer is that the most important step people can take to reduce their melanoma risk is to avoid sunburn but not all sun exposure (Planta 2011).
EWG disagrees with FDA’s decision to allow sunscreen makers to claim that their products prevent cancer. We are concerned that this policy will lead people to rely on sunscreen use alone to mitigate their cancer risk – and that this may backfire.
People who rely on sunscreens tend to burn, and burns are linked to cancer. The CDC has reported that the percentage of American adults who say they have gotten sunburned has increased since 2005.
Stanford University dermatologists who reviewed CDC national survey data concluded that people who relied solely on sunscreens for sun protection had more sunburns than people who reported infrequent sunscreen use but wore hats and clothing to shield themselves from the sun (Linos 2011). In Sweden, increased use of sunscreen was linked to a higher number of sunburns in children (Rodvall 2010). Several other studies of real world sunscreen use find that people who use sunscreen for skin protection during periods of intense UV-exposure end up with more sunburns (Koster 2010, Autier 2007).
Sunscreen products are not as good as they should be. Today’s sunscreens do not fully protect skin from all types of UV damage. Sunscreens were invented to stop sunburn and they are commonly indexed by their SPF rating, which describes the product’s ability to prevent burning. High-energy UVB rays burn skin and directly damage skin DNA, but they make up just 3 to 5 percent of the UV radiation striking Earth’s surface.
More numerous UVA rays, by contrast, can be equally damaging without leaving the painful reminder of blistered skin. Because UVA radiation penetrates deeper into the body than UVB, it can cause a different type of DNA damage than UVB (Cadet 2009).
For decades, sunscreen manufacturers and sunscreen users assumed that preventing or delaying sunburn would also avert other dangerous damage, such as skin cancer. Today, many experts realize that both UVA and UVB exposure may contribute to melanoma risk (Donawho 1996, Garland 2003, Godar 2009, Setlow 1993).
When people use sunscreen properly to prevent sunburn, they often extend their time in the sun. They may prevent burns, but they end up with more cumulative exposure to UVA rays, which inflict more subtle damage (Autier 2009, Lautenschlager 2007).
The ideal sunscreen would afford a similar level of UVB and UVA protection (Diffey 2009, Osterwalder 2010). It might also help prevent skin cancer – if it were packaged with clear information about its limitations and instructions for proper use.
The reality is that U.S. sunscreens are far from ideal and not as good as sunscreens sold in Europe. The FDA’s new regulations allow nearly every sunscreen already on the market to claim “broad spectrum” protection and a role in skin cancer prevention. Until FDA tightens its rules, people will continue to misuse inferior products.
The widespread marketing of sunscreens with SPF values of 50 to 100 means that consumers are increasingly (and unknowingly) selecting products with less proportional UVA protection. Newer, modern UVA-filtering ingredients developed for European sunscreens could remedy this problem, but FDA has not acted on petitions from sunscreen makers to allow these ingredients in U.S. sunscreens.
This year, as in the past, EWG found widespread use of retinyl palmitate in sunscreen. This form of vitamin A has been linked to skin cancer in FDA-sponsored laboratory studies.
In light of the shortcomings of today’s sunscreens, EWG suggests that you adjust your attitude about sun exposure.