5/28/2019 Controversies and Challenges in Sunscreen DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Photoprotection Darrell S. Rigel, MD MS Controversies and Challenges in Sunscreen Photoprotection Darrell S. Rigel, MD MS DISCLOSURES Clinical Professor Neutrogena – C, A, H, I New York University Medical Center P&G – C New York, NY LaRoche Posay - H Beiersdorf – A, H, I Duplicate Melanoma – USA 2019 1/451/45 or 1/55 Lifetime Risk Invasive MM Why is this issue important? 1/74 1/100 1/150 1/250 1/600 1/1500 1930 1950 1980 1985 1993 2000 2010 2018 Rigel et al, NYU Melanoma Cooperative Group, 2019 Distribute Melanoma – USA 2019 1/35 1/451/45 Melanoma – US 1/55 Lifetime Risk 2019 Invasive MM 1/74 Not1/100 • Invasive = 96,480 1/150 ProjectedProjected 1/250 1/600 1/1500 •In-situ = 95,830 1930 1950 1980 1985 1993 2000 2010 2019 2025 Do Rigel et al, NYU Melanoma Cooperative Group, 2019 1 5/28/2019 Melanoma – USA 2019 US Annual Change in Melanoma Incidence Rate 6% 5.4% 5.5% Lifetime Risk 1/231/23 5% Invasive and Insitu Males Females 192,310 total cases MM 4% 3.1% 3% 2.4% 2% 1.8% 1% 0.1% 0% 1930 1950 1980 1985 1993 2000 2019 1975-86 1987-2005 2006-10 Rigel et al, NYU Melanoma Cooperative Group, 2019 Siegel et al, Ca J Clinicians, 2019 Duplicate US Annual Change in Melanoma Incidence Rate US Annual Deaths2 from Melanoma 6% 5.4% 5.5% 10000 9000 or 5% 7910 Males Females 8000 4% 3.7% 7000 3.1% 6000 3% 5000 2.4% 4000 2% 1.8% 1.8% 3000 1% 2000 0.1% 1000 0% 0 1975-86 1987-2005 2006-10 2011-15 Siegel et al, Ca J Clinicians, 2019 ACS Distribute US Annual Deaths2 from Melanoma US Annual Deaths2 from Melanoma 10000 10000 8450 9000 8110 9000 8110 7910 7910 8000 8000 7000 7000 6000 6000 5000 Not 5000 4000 4000 3000 3000 2000 2000 1000 1000 0 0 Do ACS ACS 2 5/28/2019 US Annual Deaths2 from Melanoma US Annual Deaths2 from Melanoma 10000 10000 8650 8650 8700 8450 8450 9000 8110 9000 8110 7910 7910 8000 8000 7000 7000 6000 6000 5000 5000 4000 4000 3000 3000 2000 2000 1000 1000 0 0 ACS ACS Duplicate US Annual Deaths2 from Melanoma US Annual Deaths from Melanoma 10000 10000 9180 8790 8790 8650 8700 8650 8700 8450 8450 9000 8110 9000 or8110 7910 7910 8000 8000 7000 7000 6000 6000 5000 5000 4000 4000 3000 3000 2000 2000 1000 1000 0 0 ACS ACS Distribute US Annual Deaths from Melanoma US Annual Deaths from Melanoma 9710 9480 9480 10000 9180 10000 9180 8790 8790 8650 8700 8650 8700 8450 8450 9000 8110 9000 8110 7910 7910 8000 8000 7000 7000 6000 6000 5000 Not 5000 4000 4000 3000 3000 2000 2000 1000 1000 0 0 Do ACS ACS 3 5/28/2019 US Annual Deaths from Melanoma US Annual Deaths from Melanoma 9940 9940 10130 9710 9710 9480 9480 10000 9180 10000 9180 8790 8790 8650 8700 8650 8700 8450 8450 9000 8110 9000 8110 7910 7910 8000 8000 7000 7000 6000 6000 5000 5000 4000 4000 3000 3000 2000 2000 1000 1000 0 0 ACS ACS Duplicate US Annual Deaths from Melanoma US Annual Deaths from Melanoma 9940 10130 9940 10130 9710 9730 9710 9730 9480 9480 9320 10000 9180 10000 9180 8790 8790 8650 8700 8650 8700 8450 8450 9000 8110 9000 or8110 7910 7910 8000 8000 7000 7000 6000 6000 5000 5000 4000 4000 3000 3000 2000 2000 1000 1000 0 0 ACS ACS Distribute US Annual Change in Melanoma Death Rate US Annual Deaths from Melanoma 9940 10130 9710 9730 3% 9480 9320 10000 9180 2.3% 8790 8650 8700 8450 2% 9000 8110 7910 1.1% 0.8% 8000 7230 1% 0.5% 0.4% 2012-16 7000 0% -0.2% 6000 -1% 1975-88 1989-2005 2006-11 5000 Not -2% 4000 -3% 3000 -4% 2000 Males Females 1000 -5% -5.2%-5.0% 0 -6% Do ACS Siegel et al, Ca J Clinicians, 2019 4 5/28/2019 US Lifetime Risk for Invasive Melanoma - 2019 Primary vs Secondary Prevention Non-Hispanic Whites 4% 3.7% Primary = Protection Secondary = Early Detection 3% 2.7% 2% 1 in 27 1% 1 in 40 0% Male Female Siegel et al, Ca J Clinicians, 2019 Impact Incidence Impact Mortality Duplicate What can we conclude from this data? Secondary prevention efforts appear to or be making an impact Primary prevention not as impactful What Causes Melanoma? The overwhelming majority Focus of our efforts on primary caused by UV exposure prevention – behavioral change (Sunscreen usage a component) Distribute Melanoma vs. Latitude USA UV and Melanoma Risk • Sunlight is the major environmental risk factor for 100 melanoma • Examine if S-shaped curves describe the relationship Hawaii between solar UV doses and MM incidence and the % of MM that can be directly related to UV exposure Atlanta Seattle Connecticut • Analysis indicates that S-shaped associations describe NotDetroit Utah Los Angeles MM incidence/100K San Jose NM the data well (P < 0.0001). San Francisco Iowa 10 • Conclusion: 50 45 40 3035 25 20 15 Latitude (deg N) ─ Between 89 and 95% of the annual CM cases are caused by solar UV exposure. ─ Avoidance of UV radiation will reduce the incidence of MM. Do SEER 2015 Juzeniene et al. Int J Hyg Environ Health. 2014 5 5/28/2019 Sunburn, Skin Aging and Skin Cancer are Caused by Same Are ALL melanomas Wavelengths of Sunlight caused by UV exposure? Sensitivity No, but the vast UVB UVA majority are! Wavelength (nm) 1. ISO 17166/CIE S007/E. 2. de Gruijl FR, Van der Leun JC. Health Phys. 1994;67(4):319-325. 3. Kligman LH, Sayre RM. Photochem Photobiol. 1991;53(2):237-242. Duplicate or Does Sunscreen Usage Lower Skin Cancer Risk? 34 Distribute Reduced melanoma risk after regular Sunscreen Use Clinically Shown to Prevent Squamous- sunscreen use Cell Carcinomas • 1,621 randomly selected residents of Nambour Daily sunscreen application and betacarotene supplementation in prevention of basal- cell and squamous-cell carcinomas of the skin: a randomised controlled trial (Queensland) Australia, age 25 to 75 years, were Adèle Green, Gail Williams, Rachel Neale, Veronica Hart, David Leslie, Peter Parsons, Geoffrey C Marks, Philip Gaffney, Diana Battistutta, Christine Frost, Carolyn Lang, Anne Russell randomly assigned to daily or discretionary sunscreen application to head and arms • Sunscreen used daily vs discretionaryNot use over 4 year RESULTS: • Treated for 5 years then followed for 10 years time period 40% fewer SCC lesions in • Use of an SPF 16 product, subjects using daily SPF 16 weight of product brought in sunscreen (p<0.05) every 3 months measured Green et al, J Clin Oncol, 2011 Do Lancet. 1999;354(9180):723-9. 6 5/28/2019 Reduced melanoma risk after regular Sunscreen Usage and Melanoma Risk sunscreen use All Melanomas 1 1 0.75 0.5 Relative Relative Risk 0.25 0 J Clin Oncol. 2011 Jan 20;29(3):257-63. doi: 10.1200/JCO.2010.28.7078. Epub 2010 Dec 6 Discretionary 2 Duplicate Sunscreen Usage and Melanoma Risk Sunscreen Usage and Melanoma Risk All Melanomas or Invasive MMs 1 1 1 1 0.75 0.75 0.5 0.5 0.5 Relative Risk Relative Risk Relative 0.25 0.25 0 0 Discretionary Daily Discretionary 2 Distribute Sunscreen Usage and Melanoma Risk Reduced melanoma risk after regular Invasive MMs sunscreen use • 1,621 randomly selected residents of Nambour (Queensland) Australia, age 25 to 75 years, were randomly assigned to daily or discretionary sunscreen 1 1 application to head and arms 0.75 • Treated for 5 years then followed for 10 years Not • Only 11 new MMs in daily group vs. 22 (p=0.051) 0.5 • 2 Invasive MMs in daily group vs.11 Relative Risk Relative • Conclusions: 0.25 0.27 – Melanoma risk significantly lowered by regular sunscreen use in adults 0 Green et al, J Clin Oncol, 2011 Do Discretionary Daily 7 5/28/2019 Sunscreen Use and Melanoma Risk Among Young Australian Adults Skin cancers in Australia prevented by regular sunscreen use • Assessed early-life sunscreen use and risk of cutaneous MM before age 40 • Estimated the proportion of skin cancers that would have • 629 cases and 240 controls occurred but were likely prevented by regular sunscreen use • Risk of MM was less with higher use of sunscreen in childhood (OR=0.60) and lifetime (OR=0.65) • Regular sunscreen use prevented around 14,190 persons from developing SCCs (PF 9.3%) and 1,730 from Melanoma • Protective association was stronger for people reporting blistering sunburn, receiving a diagnosis of melanoma at a younger age, or having many nevi. (PF 14%) • Total sun exposure inversely weighted by sunscreen use (as a measure of sun • Conclusions: exposure unprotected by sunscreen) was significantly associated with – Prevailing levels of sunscreen use probably reduced skin cancer melanoma risk (OR=1.80) incidence by 10-15% • Conclusion: – Sunscreen should be a component of a comprehensive sun protection strategy ⁻ Regular sunscreen use is significantly associated with reduced risk of cutaneous MM among young adults. Watts et al, JAMA Dermatol, 2018 Olsen et al, Aust N Z J Public Health. 2015 Duplicate How many melanomas might be prevented if more people How many melanomas might be prevented if more people applied sunscreen regularly? applied sunscreen regularly? Calculated the PF, the proportional difference between the observed number of melanomas arising under prevailing levels of 5% annual or increase in sunscreen use for 10 years (50% increase) British Journal of Dermatology Olsen et al, Br J Dermatol, 2017 14 DEC 2017 DOI: 10.1111/bjd.16079 Distribute How many melanomas might be prevented if more people How many melanomas might be prevented if more people applied sunscreen regularly? applied sunscreen regularly? Calculated the PF, the proportional difference between the observed number of melanomas arising under prevailing levels of 5% annual increase in sunscreen use for 10 years (50% increase) Estimated that cumulatively to 2031, 231,053 fewer melanomas would arise inNot the U.S.