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7. Ultraviolet Radiation and Skin Cancer Maryland Comprehensive Marylandy Comprehensive p Cancer Control Plan 7 u traviolet hhensive Cancer Control PlanMal ryry Control Plan Maryland Comprehp hensive Cancer Control r a MMarylandy 7 . Ultravioleti Comprehediation and nsive prehensive Radiation CCancer ControlCont Cs t l PPlan k in Can Marylandy and Skin Cancer PlanC e Cancer Control Plan Maryland r CCo MarylandMy l d Comprehensive C p h i Cancer C Control C Plan pprehensive Cancer Control Plan Control Plan Marylandy Comprehe p ensive Cancer Control land Comprehensivep Cancer ControlCon Plan MarylandMarylyand CComprehensiveomp rehensive CancerCancer Control Plan hensive Cancer Control Plan MaryMary Control Plan Marylyand Comp reheensive Cancer Control land Comprehensivep Cancer ControlCon Plan Marylandy Comprehensive p Cancer Control Plan pprehensive Cancer Control Plan ControlC t l Plan Pl Maryland My l d Comprehensive C p h Cancer Control land Comprehensive Cancer Control Plan r e C diation a in Can r k s C hapter Contributors and Committee members l (Chair) u traviolet Nanette Liegeois, MD, PhD Johns Hopkins University, School of Medicine, Oncology Center Jill Adler, MS LifeBridge Health Alvin & Lois Lapidus Cancer Institute Alison Ehrlich, MD, MHS Department of Dermatology, George Washington University Medical Center Anne Fischer, MD, PhD Department of Surgery, UT Southwestern Medical School Roberta Herbst, MS Maryland Skin Cancer Prevention Program, Center for a Healthy Maryland Leigh Marquess, RN Caroline County Health Department Catherine Musk, MS, RN Center for Cancer Surveillance and Control, Maryland Department of Health and Mental Hygiene Laura Patrick, RN, MS Caroline County Health Department Amanda Schnitzer Maryland Skin Cancer Prevention Program, Center for a Healthy Maryland William Sharfman, MD Johns Hopkins Medical Institutions - Oncology Center Barbara Summers Child Education Consultant Kurt Wenk, MD Department of Dermatology, George Washington University Medical Center Chapter 7 Maryland CoMprehensive CanCer Control plan 1 2 3 7 4 Ultraviolet radiation 5 and Skin CanCer 6 7 kin cancer is the most commonly 8 diagnosed cancer in the United States, 9 affecting more than 1 million Americans 10 annually and accounting for about 2% 11 of all cancer deaths.1 There are three 12 13 major types of skin cancer: basal cell 14 carcinoma, squamous cell carcinoma, S 15 and malignant melanoma. Basal cell carcinoma usually develops on sun-exposed areas of the body, TERMS TO KNOW especially the head and neck. Squamous cell carcinoma also commonly There are three major types of appears on sun-exposed parts of the body such as the face, ear, neck, lip, and skin cancer. back of the hands, although it can also appear in the genital area. Basal Cell CarCinoma Current estimates are that one in five Americans will develop skin cancer Usually develops on sun-exposed during the course of a lifetime.2 Basal cell carcinoma makes up 75% of all areas of the body, especially the skin cancers, and squamous cell carcinoma accounts for another 20%. Both head and neck. basal and squamous cell carcinoma have high cure rates if treated early but squamous Cell CarCinoma can cause considerable disfigurement and occasionally death if treatment Commonly appears on is delayed. Melanoma, while only accounting for 5% of all skin cancer, is sun-exposed parts of the body such as the face, ear, neck, lip and the most deadly form of skin cancer and is responsible for 75% of all deaths back of the hands. from skin cancer. Melanoma develops in the cells of the skin that give it color melanoma (melanocytes) and is associated with high mortality if not diagnosed and Develops in the cells of the skin treated at an early stage. that give it color (melanocytes). Medical professionals agree that exposure to the sun’s ultraviolet rays appears to be the most important factor in the development of skin cancer. Ultraviolet radiation (UVR) is commonly divided into three bands: UVA, UVB, and UVC. UVC is completely absorbed in the stratosphere before reaching the earth’s surface. The rays of UVB are shorter and are the primary cause of tanning and sunburn. The longer rays of UVA penetrate the skin more Maryland CoMprehensive CanCer Control plan Chapter 7 | 1 4-Year Rolling Average Skin Melanoma Cancer Age-Specific Incidence Rates All Genders and Races, Maryland, 1992-2006 FiGure 7.1 Melanoma Age-Specific Incidence Rates, Maryland, 1992-2006 80.0 70.0 and skin cancer 60.0 ultraviolet radiation 50.0 40.0 30.0 AGE SPECIFIC RATE PER 100,000 POPULATION 20.0 10.0 0.0 9295 9396 9497 9598 9699 9700 9801 9902 0003 0104 0205 0306 YEAR AGES 2029 AGES 3039 AGES 4049 AGES 5059 AGES 6069 AGES 7079 AGES 8085+ Source: Maryland Cancer Registry, 1992-2006. deeply and contribute to wrinkling of the skin as ■ Blue or green or other light-colored eyes. well as tanning. Besides sunburn, skin cancer, and ■ Red or blond hair. wrinkling, other negative effects of UVR include ■ Having actinic keratosis. cataracts, macular degeneration, and immune ■ Having past treatment with radiation. system depression.3 ■ Having a weakened immune system. ■ Being male. Risk Factors Melanoma skin cancer ■ Risk factors for nonmelanoma and melanoma can- Having a fair complexion, which includes the following: cers are not the same; each is described below.4 ■ Fair skin that freckles and burns easily, Nonmelanoma skin cancer does not tan, or tans poorly. ■ Blue or green or other light-colored eyes. ■ Being exposed to natural sunlight (ultraviolet ■ radiation or UVR) or artificial sunlight (such as Red or blond hair. ■ from tanning beds) over long periods of time. Being exposed to natural sunlight or artificial sunlight (such as from tanning beds) over long ■ Having a fair complexion, which includes the following: periods of time. ■ Having a history of many blistering sunburns as ■ Fair skin that freckles and burns easily, does not tan, or tans poorly. a child. ■ Having several large or many small moles. 2 | Chapter 7 Maryland CoMprehensive CanCer Control plan ■ Having a family history of unusual moles carcinoma. Advanced disease is often associated 1 (atypical nevus syndrome). with high morbidity in the instance of nonmela- ■ noma skin cancer because the vast majority of Having a family or personal history of 2 melanoma. cases occur on sun-exposed sites such as the head, ■ Being white and male. neck, and hands such that surgery and postopera- 3 tive radiation may produce severe morbidity with in addition, skin cancer is the most common cancer often permanent debilitation. 4 in solid organ transplant patients (especially Maryland has several major hospitals that transplants that require more immune suppres- perform solid organ transplantation. These 5 sion such as kidney and heart).5 transplant patient populations are known to have 6 an increased incidence of aggressive squamous Burden of Skin Cancer cell cancers. The incidence of nonmelanoma skin 7 in Maryland cancers increases over time of immunosuppres- sion and is the most common cancer in transplant 8 Melanoma patients. Skin cancers in these patients have The incidence and mortality of melanoma skin more accelerated growth, recur locally, and more 9 cancer has been increasing in Maryland over rapidly become metastatic.7 10 the last ten years. In certain years Maryland’s melanoma incidence rates have exceeded the Disparities 11 national rate. Figure 7.1 demonstrates how the ■ Many counties in Maryland have incidence incidence rates have continued to climb over the 12 and mortality rates greater than 25% above the past decade and how each increasing decade of US rate (Figure 7.2, Figure 7.3). These height- life is associated with an increased risk of skin 13 ened rates may be attributed to Maryland’s cancer. diverse geography, ranging from coastlines to Maryland has a unique challenge: more than 14 mountains, which allows residents to partake 50% of Maryland counties exceed the national in a wide variety of outdoor activities and 15 melanoma incidence rate for the time period sun-exposure-based occupations. 2002-2006 by 25% or more (Figure 7.2). Some of ■ The melanoma mortality rate for Maryland these counties surround the Chesapeake Bay and males is more than twice as high as for females. are known to have economies based on farming, In 2006, the male mortality rate was 4.8 per fishing, and tourism, which can be associated 100,000 population compared with 1.8 per with prolonged sun exposure. The Eastern Shore 100,000 for females (Table 7.1). (representing the eastern Maryland peninsula of ■ Maryland continues to have a lower percentage the Chesapeake Bay) has high rates of melanoma of melanoma cases diagnosed at the local mortality (Figure 7.3) even in areas with lower stage relative to US data. In 2006, 84.3% of rates of melanoma incidence (for example, all melanoma cancer cases in the US were Dorchester and Somerset Counties). diagnosed at the local stage.8 In contrast, only Nonmelanoma 59.1% of melanoma cases in Maryland were Per recommendations from the National Program diagnosed at the local stage. This disparity of Cancer Registries, cancer registries in the US may be partially due to the large number of collect data on new cases of malignant melanoma Maryland melanoma cases that remain unstaged and some cases of nonmelanoma carcinomas. at diagnosis, which measured 27.5% in 2006, an 9 However, these registries do not collect basal and improvement from 38.9% unstaged in 2002. squamous cell carcinomas. Nonmelanoma skin ■ Blacks or African Americans have lower cancer comprises 95% of skin cancers; therefore, five-year
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