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Sunlight and skin cancer in the UK

Recent decades have seen huge increases in the numbers of people in the UK being diagnosed with skin cancer. Excessive exposure to ultraviolet (UV) radiation is the most important modifiable risk factor for both malignant melanoma and non-melanoma skin cancer (NMSC).

Table 6.1 shows a summary of what we know about sunlight and skin cancer.

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The two types of NMSC, basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are both caused by chronic and repeated sun exposure, although the risk of BCC is also increased by sunburn1,2. Risk of melanoma has a stronger association with a history of sunburn or sporadic intense exposure to sunlight than with regular and prolonged exposure3,4.

Family history of skin cancer, high count of common or atypical nevi (moles), fair skin, red or blond hair, presence of freckles and high body surface area all affect the impact of UV exposure on skin cancer risk5,6.

A recent cohort study of women in Norway and Sweden reported a significantly elevated risk of melanoma among participants who used a sunbed at least once a month over the second, third or fourth decade of life compared with women who had rarely or never used a sunbed.6 Results were adjusted for the number of sunburn episodes during the corresponding period. Evidence for a causal association of sunbed use with NMSC is increasing.7.

Exposure to UV radiation has increased in recent decades in the UK population as people have increasingly sought a suntan by holidaying in hot countries and using sunbeds (Table 6.28).

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It is also expected that further depletion of the ozone layer will cause more skin cancer cases in the future9.

Skin cancer prevention campaigns advise people to avoid exposure to the sun at midday, cover up and use a high sun protection factor (SPF) sunscreen when necessary. There is controversy over whether the way people use sunscreen is effective and whether it increases risk by encouraging people to spend longer in the sun. Evidence from case-control studies is contradictory and prospective studies and clinical trials are necessary10.

Incidence and mortality of skin cancers

Each year, around 8,000 people are diagnosed with malignant melanoma in the UK. Incidence quadrupled in British males between 1975 and 2001, tripled in British females 11 and is increasing in most white populations worldwide. The increase in incidence of melanoma between successive birth cohorts is narrowing but incidence is still expected to increase substantially over the next decades12. NMSC is the most commonly diagnosed cancer in white populations worldwide, with BCC and SCC occurring at a ratio of about 4:1. Reliable statistics on the incidence of NMSC are difficult to obtain, but it is estimated that around 100,000 people are diagnosed with it each year in the UK13. Estimates suggest that the incidence of NMSC increased by an average of 3 to 8% per year in Europe, the US, Canada and Australia from the 1960s to the 1990s14. BCC rarely metastasises, while SCC can spread to other parts of the body. Treatment for NMSC can involve disfiguring surgery and nearly half of patients develop another NMSC within five years15.

For more detailed malignant melanoma statistics see the malignant melanoma section.

Vitamin D, sunlight and cancer

There is controversy over whether following sun protection advice could result in vitamin D deficiency, and increased risks of other diseases, including certain internal cancers. Evidence from human studies for an association between vitamin D levels in plasma or dietary vitamin D intake and increased risks of breast, colon or prostate cancers is inconclusive16. There is evidence that a small amount of exposure to sunlight is sufficient to maintain a healthy level of vitamin D. Photosynthesised vitamin D will not be stored by the body once the optimum level has been reached so there is no benefit from deliberate prolonged sun exposure.

References for sunlight and cancer risk

1. van Dam, R.M., et al., Risk factors for basal cell carcinoma of the skin in men: results from the health professionals follow-up study. Am J Epidemiol, 1999. 150(5): p. 459-68.
2. Zanetti, R., et al., The multicentre south European study 'Helios'. I: Skin characteristics and sunburns in basal cell and squamous cell carcinomas of the skin. Br J Cancer, 1996. 73(11): p. 1440-6.
3. Veierod, M.B., et al., A prospective study of pigmentation, sun exposure, and risk of cutaneous malignant melanoma in women. J Natl Cancer Inst, 2003. 95(20): p. 1530-8.
4. Elwood, J.M. and J. Jopson, Melanoma and sun exposure: an overview of published studies. Int J Cancer, 1997. 73(2): p. 198-203.
5. Tucker, M.A. and A.M. Goldstein, Melanoma etiology: where are we? Oncogene, 2003. 22(20): p. 3042-52.
6. Veierod, M.B., et al., A Prospective Study of Pigmentation, Sun Exposure, and Risk of Cutaneous Malignant Melanoma in Women. JNCI Cancer Spectrum, 2003. 95(20): p. 1530-1538.
7. Rivers, J.K., Is there more than one road to melanoma? Lancet, 2004. 363(9410): p. 728-30.
8. Office for National Statistics, Social Trends No 33, Summerfield C, Editor.2003, Office for National Statistics: London.
9. Health Development Agency, Cancer Prevention: A resource to support local action in delivering the NHS cancer plan. 2002, Health Development Agency. p. Chapter 6, pages 127-146.
10. de Vries, E. and J.W. Coebergh, Cutaneous malignant melanoma in Europe. Eur J Cancer, 2004. 40(16): p. 2355-66.
11. Cancer Research UK. Cancer statistics, malignant melanoma. 2005
12. Diffey, B.L., The future incidence of cutaneous melanoma within the UK. Br J Dermatol, 2004. 151(4): p. 868-72.
13. Holme, S.A., K. Malinovszky, and D.L. Roberts, Changing trends in non-melanoma skin cancer in South Wales, 1988-98. Br J Dermatol, 2000. 143(6): p. 1224-9.
14. Diepgen TL, Mahler V, The epidemiology of skin cancer. Br.J Dermatology, 2002.146(61) p.1-6
15. Nguyen, T.H. and D.Q. Ho, Non-melanoma skin cancer. Curr Treat Options Oncol, 2002. 3(3): p. 193-203.
16. Giovannucci, E., The epidemiology of vitamin D and cancer incidence and mortality: a review (United States). Cancer Causes and Control, 2005. 16(2): p. 83-95.