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Americans are being diagnosed with melanoma, the deadliest form of skin cancer, at steadily rising rates.
According to the National Cancer Institute, the rate of new melanoma cases among American adults has tripled since the 1970s, from 7.9 per 100,000 people, in 1975, to 23 per 100,000, in 2016 (NCI 2019).
Just as alarming, the melanoma death rate for white American men, the highest risk group, has escalated sharply, from 2.6 deaths per 100,000, in 1975, to 4.3, in 2016.
Since 2003, the rates of new melanoma cases among both men and women have climbed, by 1.7 and 1.4 percent per year, respectively, according to the Centers for Disease Control and Prevention (CDC 2016).
The reasons for these trends are unclear, as are strategies for preventing this deadly cancer. Although we don’t know the exact cause of melanoma, scientists have established that risk factors include family history, indoor tanning, fair skin, freckles, moles, ultraviolet radiation and severe sunburns (CDC 2014). It’s possible to control just 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 70 percent of American adults say they protect themselves from the sun. CDC surveys found the number increased between 2005 and 2010 and has remained level since then (NCI 2017).
The market in so-called sun care products appears to be thriving. IBISWorld, a market research company, reports that sunscreen product sales grew 2.6 percent a year between 2011 and 2016 and generated $394 million annually (IBISWorld 2016).
The Food and Drug Administration allows most sunscreens to advertise “broad spectrum” skin protection and to claim that, with proper use, their products can help reduce the risk of skin cancer. However, the evidence that sunscreen use can reduce skin cancer is inconclusive, in part due to the decades that may separate exposure from cancer.
In early 2019, the FDA released its final draft sunscreens monograph, which states that since 2011, the evidence linking UVA exposure to skin cancers has increased. In an effort to protect consumers, the agency is reverting in part to its 2007 proposal to strengthen the required UVA protection of sun protection factor, or SPF, products. EWG has highlighted the need for strong UVA protection and incorporated it into our top products list for close to a decade.
Every major public health authority – the FDA, the National Cancer Institute and the 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).
More than 3 million Americans develop skin cancer each year (ACS 2017). Most cases involve one of two disfiguring but rarely fatal forms of skin cancer – basal and squamous cell carcinomas. Studies suggest that basal and squamous cell cancers are strongly related to UV exposure over a period of 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).
Each year an estimated 91,000 people will be diagnosed with melanoma, and 9,000 Americans will die from it (NCI 2018). White Americans have much higher melanoma rates than people of other races. Men have higher rates than women. Sun exposure appears to play a role, but melanoma is a complex disease with many unanswered questions. One puzzling fact: Melanomas do not usually appear on 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 a person has had, particularly during childhood (Dennis 2010).
The use of artificial tanning beds dramatically increases melanoma risk (Coleho 2010). 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. For this reason, in 2014, the FDA reclassified tanning beds to require new warnings stating that they can damage skin and shouldn’t be used by anyone under age 18.
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 in people with regular sun exposure may play a role in reduced melanoma risk (Godar 2011, Newton-Bishop 2011, Field 2011).
Although the science is not definitive, the consensus among researchers is that the most important step anyone can take to reduce his or her risk of melanoma is to avoid sunburn but not all sun exposure (Planta 2011).
EWG strongly disagrees with the FDA’s decision to allow sunscreen makers to claim their products prevent cancer. We are concerned that this labeling 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 we have seen that sunburns are linked to cancer. The CDC has reported that the percentage of American adults who say they have gotten sunburned has increased since 2005 (CDC 2012).
Scientists don’t know for certain whether sunscreen can help prevent melanoma. A 2011 study of sun-savvy Australians found that they cut their risk of melanoma in half by age 50 when they applied SPF 15 sunscreen daily, wore hats and avoided the sun in other ways (Green 2011). Additional studies indicate that sunscreens protect against melanoma (Autier 1995, Green 2010, Westerdahl 2000, Wolf 1994). Other studies have not reached such 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 incidences of melanoma among frequent sunscreen users (Autier 1998, Beitner 1990, Westerdahl 2000, Wolf 1998).
Stanford University dermatologists who reviewed CDC national survey data concluded that people who relied solely on sunscreens for sun protection got 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 by children was linked to more sunburns (Rodvall 2010). Several other studies of real-world sunscreen use found that people who use sunscreen for skin protection during periods of intense UV exposure had 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 UV radiation striking the earth’s surface.
More numerous UVA rays, by contrast, can be equally damaging without blistering the skin. Because UVA radiation penetrates more deeply than UVB radiation, it can cause a different type of DNA damage than UVB radiation (Cadet 2009).
For decades, both sunscreen manufacturers and users assumed that preventing or delaying sunburn would also avert other 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 subtler 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.
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