state/national statistics: basic epidemiology of skin cancer presented by: chris johnson, mph...
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State/National Statistics:Basic Epidemiology of
Skin Cancer
Presented by: Chris Johnson, MPHEpidemiologist, Cancer Data Registry of Idaho
Cancer Awareness, Screening, and Prevention Alliance (CASPA) May 18th, 2010 7-8:30 a.m.
Huckleberry Room Central District Health Department.
Outline
• Skin• Skin Cancer
– SCC and BCC– Melanoma
• Melanoma– Risk Factors– Incidence– Stage– Survival– Mortality– Lifetime Risks– Prevention
The Skin
• The skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. It helps regulate body temperature, stores water and fat, and produces vitamin D.
• The skin has two main layers: the outer epidermis and the inner dermis.
Skin Cancer
• Cancer may develop in any of the cell types:– Squamous Cell Carcinoma (SCC)– Basal Cell Carcinoma (BCC)– Melanoma
• Skin cancer is the most common form of cancer in the United States.
Squamous and Basal Cell Carcinomas
• The American Cancer Society estimates that substantially more than 1 million unreported cases of basal cell and squamous cell cancers occur annually in the US. This number is roughly equivalent to the total of all other cancer sites.
• Death rates from basal cell and squamous cell carcinomas are low.– When detected early, approximately 95% of these carcinomas can
be cured. – However, these cancers can cause considerable damage and
disfigurement if they are untreated.• Basal cell and squamous cell carcinomas are more than 10 times as
common as melanoma but account for less morbidity and mortality. – SCC may account for 20% of all deaths from skin cancer.
• SCC and BCC are not reportable to CDRI unless regional or distant stage or on a mucous membrane. – There were 5 reportable SCC and BCC skin cases in 2007 in Idaho.
• We do not know how many total cases of SCC and BCC there are per year in Idaho, but estimate it to be over 5,000.
Melanoma of the Skin• Melanoma is one of the most common cancers and the
most serious type of cancer of the skin.• Melanoma accounts for less than 5% of skin cancer
cases but causes a large majority (about 75%) of skin cancer deaths.
• The American Cancer Society estimates that about 68,720 new cases of malignant melanoma will be diagnosed in 2009, and 8,650 will die from the disease in the US.
• In some parts of the world, especially among Western countries, melanoma incidence is on the rise.– In the United States, melanoma incidence has more
than doubled in the past 30 years.• All in situ and invasive melanoma cases are reportable
to CDRI.
Melanoma Risk Factors
• Light skin color, hair color, or eye color.– Rates are more than 10 times higher in whites than in
African Americans. • Family history of skin cancer. • Personal history of skin cancer. • Intermittent exposure of untanned skin to
intense sunlight. • Severe (blistering/peeling) sunburns early in
childhood. • Presence of atypical or numerous moles (greater
than 50).• Freckles, which indicate sun sensitivity and sun
damage.
Ultraviolet Radiation
EARTH SURFACE
UV Radiation Wavelengths• Ultraviolet radiation (or UV radiation)— Electromagnetic radiation
with wavelengths between 100 and 400 nanometers. These rays are emitted from the sun and are not visible. They inflict increasingly more damage upon a recipient as the wavelength decreases. Based on its effects, UV radiation is subdivided into three wavelength ranges named UV-A, UV-B and UV-C:– UV-A covers the wavelength range 320-400 nm. UV-A is not absorbed
by the ozone layer. UV-A are present with relatively equal intensity during all daylight hours throughout the year, and can penetrate clouds and glass. Does not cause sunburn, does cause tanning. Recent research suggests its role in melanoma.
– UV-B covers the wavelength range 280-320 nm. UV-B is more energetic than UV-A, and is partially absorbed by the ozone layer. UV-B rays cause sunburn, tanning, and have been shown to cause SCC and BCC. UV-B also has the beneficial effect of vitamin-D production.
– UV-C covers the wavelength range 100-280 nm. UV-C is the most dangerous form of UV radiation, but is completely absorbed by the ozone layer. Artificial UV-C (for example emitted by electric discharges) is a threat for certain occupational group, like welders.
UV Exposure• More than 90% of skin cancers in the US are attributed
to UV-B exposure.– Other causes of skin cancer include arsenic, other chemical
exposures.• Human exposure to UV-B depends upon an individual's
– location (latitude and altitude)– the duration and timing of outdoor activities (time of
day, season of the year = angle of the sun)– and precautionary behavior (use of sunscreen,
sunglasses, or protective clothing).
UV Exposure
UV-B Exposure - Sunburn
– 33.7% of U.S. adults report having had a sunburn in 2004 (BRFSS).• In Idaho, 48.4% of white adults reported having
had a sunburn in 2008.
– Parents or caregivers reported that 72% of adolescents aged 11--18 years have had at least one sunburn, and 43% of white children aged <11 years experienced a sunburn in the past year.
SunburnPercentage of Adults who had a Sunburn in Last 12 Months
2008 Idaho BRFSS
0
10
20
30
40
50
60
70
80
90
100
Statewide HD 1 HD 2 HD 3 HD 4 HD 5 HD 6 HD 7
Per
cent
Percent
Sunburn
Percentage of Adults who had a Sunburn in Last 12 Months2008 Idaho BRFSS
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
18-24 25-34 35-44 45-54 55-64 65+
Per
cent
Percent
Synopsis of Melanoma in Idaho
• In 2007, there were 341 invasive cases of melanoma and 43 melanoma deaths among Idaho residents.
• Melanoma is the 5th most common cancer in Idaho in terms of incidence and 16th most common site for cancer deaths.
Melanoma Incidence 2007Geography Rate Count Population
Health District 1 24.1 56 208,085Health District 2 21.1 25 101,665Health District 3 28.7 64 242,205Health District 4 25.3 98 418,489Health District 5 24.4 44 173,435Health District 6 12.5 19 162,621Health District 7 11.9 20 189,645State of Idaho 23.3 341 1,496,145SEER Whites 2000 23.6 14,823 60,510,818SEER All Races 2000 20.4 15,988 78,139,539Rates are per 100,000 and age-adjusted to the 2000 US Std Population (19 age groups - Census P25-1130) standard.
Incidence by Race/EthnicityMelanoma of the Skin Incidence, 2004-2006, Combined NPCR & SEER
1.3
1.7
4.3
5.0
1.0
1.2
4.8
4.9
19.6
28.5
15.9
24.1
0.0 5.0 10.0 15.0 20.0 25.0 30.0
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Asi
an/
Pac
ific
Isla
nder
Am
eric
an
Indi
an/
Ala
ska
Nat
ive
Bla
ckW
hite
,H
ispa
nic
Whi
te,
non-
His
pani
cA
ll R
ace
s
Age-Adjusted Rate per 100,000
Incidence by AgeMelanoma of the Skin Incidence, 2004-2007, Age-Specific Rates
Combined NPCR & SEER
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
<1
01-0
4
05-0
9
10-1
4
15-1
9
20-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
70-7
4
75-7
9
80-8
4
85+
Age Group (in years)
Rat
e p
er 1
00,0
00
Male
Female
Incidence of Invasive Melanoma by Site on
Body and Sex, United States, 2004—2006
Idaho Melanoma Incidence
1998 - 2007
Legend
Idaho Counties
Age-Adjusted Rate per 100,000
0.0 - 11.6
11.7 - 17.5
17.6 - 23.0
23.1 - 27.8
Fewer than 10 cases
Health_Districts
SEER Summary Staging 2000• Cancer staging is the process of describing the
extent of the disease or the spread of the cancer from the site of origin.– In situ – noninvasive; basement membrane of
epidermis is intact (Clark’s level I)– Localized – papillary/reticular dermis invaded (Clark’s
level II-IV)– Regional – subcutaneous tissue invaded (Clark’s
level V), satellite nodules <= 2 cm from primary tumor, regional lymph nodes involved
– Distant – extension to underlying cartilage, bone, skeletal muscle, metastasis to skin or subcutaneous tissue beyond regional lymph nodes or visceral metastasis
Incident Cases by Stage
Melanoma Cases by StageNon-Hispanic Whites
100,575 852
11,616 804,987 329,987 42
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NPCR & SEER 2004-2006 Idaho 2004-2006
Per
cen
t o
f T
ota
l C
ases
Unstaged
Distant
Regional
Localized
Melanoma Trends
Trends in Melanoma Incidence by StageSEER 9 Registries, Whites
0.0
5.0
10.0
15.0
20.0
25.0
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
Year of Diagnosis
Ag
e-A
dju
sted
Rat
e p
er
100,
000
Localized Rate
Advanced Rate
Ratio
Cancer Survival
Site % Survival Site % SurvivalAll Sites 66.2% Kidney and Renal Pelvis 66.1%Thyroid 97.4% Larynx 62.5%Prostate 95.8% Colorectal 62.3%Testis 94.0% Leukemia 51.6%Breast 90.9% Ovary 44.4%Melanoma of the Skin 87.6% Myeloma 34.6%Hodgkin Lymphoma 86.3% Brain - malignant 32.4%Corpus Uteri 83.6% Stomach 25.8%Bladder 75.9% Esophagus 16.1%Non-Hodgkin Lymphoma 70.5% Lung and Bronchus 13.9%Cervix 69.2% Liver and Bile Duct 8.6%Oral Cavity and Pharynx 67.7% Pancreas 5.9%
5-Year Relative Cancer Survival, 2000-2007 Idaho Cases
Melanoma Survival by Stage
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
1 2 3 4 5 6 7 8 9 10
Years Survival
Per
cen
t R
elat
ive
Su
rviv
al
Localized SEER 1997-2007
Localized Idaho 1997-2007
Regional SEER 1997-2007
Regional Idaho 1997-2007
Distant SEER 1997-2007
Distant Idaho 1997-2007
Melanoma Mortality 2004-2008Geography Rate Count Population
Health District 1 3.7 43 1,014,918Health District 2 2.7 15 507,235Health District 3 3.4 37 1,166,718Health District 4 3.5 62 2,018,142Health District 5 2.9 26 855,843Health District 6 2.9 21 809,462Health District 7 2.9 22 923,282State of Idaho 3.2 226 7,295,600US Whites 2006 3.1 8,250 241,574,020US All Races 2006 2.7 8,441 298,754,819Rates are per 100,000 and age-adjusted to the 2000 US Std Population (19 age groups - Census P25-1130) standard.
Leading Causes of Mortality and Melanoma - Males
4.7
22.6
25
25.8
27.3
38.8
48.4
57.5
58.2
120.4
183.4
191
822.4
4.1
18.4
27.5
23.6
18.0
44.0
67.5
55.2
47.9
113.2
249.2
221.1
927.50
0 100 200 300 400 500 600 700 800 900 1000
Melanoma of the Skin
Alzheimers
Diabetes Mellitus
Prostate Cancer
Suicide
Cerebrovascular Diseases
Lung Cancer
Accidents and Adverse Effects
Chronic Obstructive Pulmonary Disease and Allied Cond
Other Cause of Death
Diseases of Heart
All Malignant Cancers
All Causes of Death
Age-Adjusted Rate per 100,000
US 2006
Idaho 2008
2.2
14.5
21.8
22.3
27.7
28.6
37.1
39.2
39.9
111.9
126
147.5
630.4
1.7
14.5
23.4
20.1
24.3
25.4
40.2
42.2
35.8
96.2
160.9
153.7
654.1
0 100 200 300 400 500 600 700
Melanoma of the Skin
Colon and Rectum
Breast Cancer
Diabetes Mellitus
Alzheimers
Accidents and Adverse Effects
Lung Cancer
Cerebrovascular Diseases
Chronic Obstructive Pulmonary Disease and Allied Cond
Other Cause of Death
Diseases of Heart
All Malignant Cancers
All Causes of Death
Age-Adjusted Rate per 100,000
US 2006
Idaho 2008
Leading Causes of Mortality and Melanoma - Females
Mortality Trends
0
0.5
1
1.5
2
2.5
3
3.5
4
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
Year
Ag
e-A
dju
sted
Rat
es
Idaho
US
Risks of Developing and Dying from Melanoma
If your currentage is:
30 1 in 689 1 in 257 1 in 124 1 in 69 1 in 45 1 in 3540 1 in 404 1 in 149 1 in 76 1 in 47 1 in 3750 1 in 229 1 in 91 1 in 51 1 in 3960 1 in 140 1 in 62 1 in 4470 1 in 95 1 in 5580 1 in 87
If your currentage is:
30 1 in 4463 1 in 1974 1 in 1001 1 in 493 1 in 284 1 in 20340 1 in 3486 1 in 1270 1 in 546 1 in 299 1 in 21050 1 in 1938 1 in 627 1 in 317 1 in 21660 1 in 870 1 in 355 1 in 22870 1 in 515 1 in 26680 1 in 370
Melanoma in Males
Then your risk of developing melanoma by a particular age is:
By age 40 By age 50 By age 60 By age 70 By age 80 Ever
Then your risk of dying from melanoma by a particular age is:
By age 40 By age 50 By age 60 By age 70 By age 80 Ever
Risks of Developing and Dying from Melanoma
If your currentage is:
30 1 in 520 1 in 224 1 in 133 1 in 93 1 in 69 1 in 5740 1 in 389 1 in 178 1 in 112 1 in 79 1 in 6350 1 in 320 1 in 154 1 in 97 1 in 7360 1 in 282 1 in 134 1 in 9170 1 in 229 1 in 12180 1 in 193
If your currentage is:
30 1 in 22775 1 in 5692 1 in 2633 1 in 1322 1 in 663 1 in 39940 1 in 7526 1 in 2953 1 in 1392 1 in 677 1 in 40250 1 in 4767 1 in 1675 1 in 730 1 in 41760 1 in 2480 1 in 828 1 in 43970 1 in 1122 1 in 48180 1 in 636
Melanoma in Females
Then your risk of developing melanoma by a particular age is:
By age 40 By age 50 By age 60 By age 70 By age 80 Ever
Then your risk of dying from melanoma by a particular age is:
By age 40 By age 50 By age 60 By age 70 By age 80 Ever
Preliminary Results from CDC Melanoma Monograph
• Many papers, many authors
• A few preliminary results:• Socio-economic status (SES)• Physician per county population
– Relationship to incidence differs by stage at time of diagnosis
Melanoma & SES
• SES measures contribute substantially to variation in cutaneous melanoma incidence and mortality.
• Patients with higher SES measures are more likely to be diagnosed with melanoma.
• However, patients with lower SES measures are more likely to have an advanced stage at diagnosis, and worse outcomes, including higher mortality.
• Complex relationship between:– socioeconomic factors, environmental risk factors and sun
exposure behavior, – awareness of melanoma prevention, access to primary care and
melanoma screening, – potential variation in ultraviolet exposure related to differences in
outdoor recreation and leisure, a product of SES itself.
Melanoma & SESLocalized Stage Cutaneous Melanoma Incidence & SES
Incidence Density Ratios non-Hispanic Whites, Combined NPCR & SEER 2004-2006
0.6
1.0
1.4
75-<
85 v
s<
75
85+
vs
<75
10-<
20 v
s<
10
20+
vs
<10
35,0
00-
49,9
99 v
s<
35,0
00
50,0
00+
vs
<35
,000
Met
rop
oli
tan
vs u
rban
Ru
ral
vsu
rban
<5
vs >
10
5-10
vs
>10
% >= High schooleducation (race-
specific)
% Below poverty level(race-specific)
Median householdincome
Urban-rural status % Unemployed
County- (*Race) Based SES Measure
IDR
Melanoma & Physician DensityCutaneous Melanoma Incidence & Physicians per County Population
Incidence Density Ratios non-Hispanic Whites, Combined NPCR & SEER 2004-2006
0.6
1.0
1.4
Localized Stage Advanced Stage Localized Stage Advanced Stage Localized Stage Advanced Stage
Dermatologists per 10,000 Internal Medicine per 10,000 General Practitioner per 10,000
Estimated County Physician Density
IDR
Prevention of Melanoma
• Primary Prevention– Avoiding the disease in the first place
• Secondary Prevention– Screening– Early diagnosis and treatment
Primary Prevention• Skin cancer is largely preventable when sun protection measures
against UV rays are used consistently.• Preventing sunburn, especially in childhood, may reduce the lifetime
risk for melanoma.
Recommendations: – Avoid exposure to the midday sun (from 10 a.m. to 4 p.m.) whenever
possible. When your shadow is shorter than you are, remember to protect yourself from the sun.
– If you must be outside, wear long sleeves, long pants, and a hat with a wide brim.
– Protect yourself from UV radiation that can penetrate light clothing, windshields, and windows.
– Protect yourself from UV radiation reflected by sand, water, snow, and ice.
Sunscreen• Sunscreen's role in preventing skin cancer has been demonstrated
to be complex.• Using sunscreen has been shown to prevent squamous cell and
basal cell skin cancers. • Sunscreens May Not Reduce the Risk of Cutaneous Melanoma
– The evidence for the effect of sunscreen use in preventing melanoma is mixed.
– The conflicting results may reflect the fact that sunscreen use is more common among fair-skinned people, who are at higher risk for melanoma;
– or, this finding may reflect the fact that sunscreen use could be harmful if it encourages longer stays in the sun without protecting completely against cancer-causing radiation.
• Some sunscreens only protect against UVB radiation.• Sunscreen also blocks vitamin D formation in the skin, a process
that some researchers believe also promotes cancer.
• To date, no criteria exist in the U.S. for measuring and labeling the amount of UVA defense a sunscreen provides. However, the FDA plans to introduce UVA standards within the next few years.
Recent Sunscreen Research• A recent meta-analysis found consistently that sunscreen users above 40
degrees latitude are at a higher risk of melanoma than people who don't use sunscreen, even when differences in skin color are taken into account.
• Wearing sunscreen decreased melanoma risk in studies closer to the equator.
• In the Northern hemisphere, 40 degrees draws a line between New York city and Beijing.
• The UV light that reaches the Earth's surface is composed of UVA (longer) and UVB (shorter) wavelengths. UVB causes sunburn, while they both cause tanning. Sunscreen blocks UVB, preventing burns, but most brands only weakly block UVA. Sunscreen allows a person to spend more time in the sun than they would otherwise, and attenuates tanning. Tanning is a protective response (among several) by the skin that protects it against both UVA and UVB. Burning is a protective response that tells you to get out of the sun. The result of diminishing both is that sunblock tends to increase a person's exposure to UVA rays.
• It turns out that UVA rays are more closely associated with melanoma than UVB rays, and typical sunscreen fails to prevent melanoma in laboratory animals.
Ultraviolet-B (UVB)-vitamin D-cancer hypothesis
• UVB-induced vitamin-D may decrease the rates of some cancers.• Several ecological and observational studies have examined the
hypothesis, in addition to one good randomized, controlled trial. • Results for breast and colorectal cancer satisfy the criteria best, but
there is also good evidence that other cancers do as well, including bladder, esophageal, gallbladder, gastric, ovarian, rectal, renal and uterine corpus cancer, as well as Hodgkin's and non-Hodgkin's lymphoma.
• Several cancers have mixed findings with respect to UVB and/or vitamin D, including pancreatic and prostate cancer and melanoma. Even for these, the benefit of vitamin D seems reasonably strong.
• The action spectrum of ultraviolet radiation mainly responsible for melanoma induction is unknown, but evidence suggests it could be ultraviolet A (UVA), which has a different geographic distribution than ultraviolet B (UVB).
Sun Exposure: UV-B• A number of public health organizations state that there
needs to be a balance between having the risks of having too much (skin cancer) and the risks of having too little sunlight (vitamin-D deficiency).
• There is a general consensus that sunburn should always be avoided.
• However, not all physicians agree with the assertion that there is an optimal level of sun exposure, with some arguing that it is better to minimize sun exposure at all times and to obtain vitamin D from other sources.
• Serum levels of 25(OH) D3 are below the recommended levels for a large portion of the general adult population and in most minorities, indicating that Vitamin D deficiency is a common problem in the United States.
Tanning Beds• Tanning beds primarily emit UVA. The lamps used in tanning salons
emit doses of UVA as much as 12 times that of the sun.• Use of sunbeds (with deeply penetrating UVA rays) has been linked
to the development of skin cancers, including melanoma.
• In July 2009, the IARC released a report that categorized tanning beds as “carcinogenic to humans.” The agency, which is part of the World Health Organization (WHO), previously classified tanning beds as “probably carcinogenic.” The change comes after an analysis of more than 20 epidemiological studies indicating that people who begin using tanning devices before age 30 are 75% more likely to develop melanoma.
• The World Health Organization recommends that no person under 18 should use a sunbed.
Secondary Prevention
• Self Skin Examinations• Medical Skin Examinations
Cost-Effectiveness of Screening for Malignant Melanoma
• Journal of the American Academy of Dermatology. 41(5, Part 1):738-745, November 1999.
• The cost-effectiveness ratio for a screening program of adults older than age 20 who were at high risk for skin cancer was about $30,000 per year of life saved.
• This is reasonably cost-effective compared with other accepted cancer screening strategies.
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