From the Journals

Lifetime indoor tanning raises risk of cutaneous squamous cell carcinoma

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Prevention is the best medicine

“There is a saying that ‘when prevention works, nothing happens,’ ” wrote Boris D. Lushniak, MD, in an accompanying editorial. Dermatology plays an important role in public health, most notably skin cancer prevention, and the specialty’s efforts to educate the public and raise awareness about skin cancer and its causes are paying off, in combination with government initiatives to reduce exposure to UV radiation. The current study adds to the data on risk factors for skin cancer, and is distinctive in its focus on artificial sources of UV radiation, specifically indoor tanning sources. The relationship between indoor tanning and basal cell carcinoma or squamous cell carcinoma has not been well studied, “so this study fills an important gap,” he noted.

Research on indoor tanning and other skin cancer risk factors can help expand skin cancer prevention efforts and support goals such as the Healthy People 2020 goal of “reducing the proportion of adolescents in grades 9-12 who report using artificial sources of UV light for tanning, and reducing the proportion of adults aged 18 years or older who report using artificial sources of UV light for tanning,” he wrote.

The first-ever Surgeon General’s Call to Action to Prevent Skin Cancer, released in 2014, made skin cancer prevention a priority and offered specific strategies including providing more sun protection in outdoor settings, educating the public about UV exposure, promoting polices to help prevent skin cancer, reducing harm from indoor tanning, and increasing the collection of data related to skin cancer prevention.

The strategies seem to be working, Dr. Lushniak wrote. Based on data from the 2015 Youth Risk Behavior Surveillance System, a significant linear decrease in the use of indoor tanning devices by youth occurred between 2009 and 2015. “Oftentimes we do not appreciate or celebrate the successes of prevention. ... Let’s keep on track on that bold and noble mission of preventing skin cancer,” he added (JAMA Dermatol. 2019 Oct 2. doi: 10.1001/jamadermatol.2019.2680).

Dr. Lushniak is affiliated with the University of Maryland School of Public Health, College Park. He served as acting U.S. Surgeon General from 2013 to 2014, and as U.S. Deputy Surgeon General from 2010 to 2015. He had no financial conflicts to disclose.



Women who accumulated more indoor tanning sessions over time significantly increased their risk for squamous cell cancer over women who never engaged in indoor tanning, based on data from 159,419 women.

Previous research has examined associations between indoor tanning and cutaneous melanoma, but an association between indoor tanning and squamous cell carcinoma (SCC) has not been well studied, wrote Simon Lergenmuller, MSc, of the University of Oslo, and colleagues.

In a prospective cohort study published in JAMA Dermatology, the researchers surveyed 159,419 women from the Norwegian Women and Cancer study. Of these, 95,552 women (69%) reported ever use of indoor tanning. The average age at study inclusion was 50 years. During an average of 17 years’ follow-up, 597 women developed SCC.

Overall, the risk of SCC increased with increasing numbers of indoor tanning sessions. The adjusted hazard ratio for most tanning sessions versus no tanning sessions was 1.83. “The association between cumulative exposure to indoor tanning and SCC risk was the same regardless of duration of use and age at initiation,” the researchers wrote.

The risk of SCC was significantly higher both among women with 10 years or less of tanning bed use and among those with more than 10 years of use, compared with never users (HRs, 1.41 and 1.43, respectively). Similarly, researchers found a significantly higher risk of SCC among women who started indoor tanning at age 30 years or older and those who started younger than 30 years, compared with never users (HRs, 1.36 and HR, 1.51, respectively).

No significant association appeared between age at initiation of indoor tanning and age at the time of SCC diagnosis.

The study findings were limited by several factors including the variation in UV radiation among tanning devices, the lack of data on men, and the retrospective collection of UV exposure data that likely led to some misclassification, the researchers noted.

However, the results were strengthened by the large sample size and support the association between increased exposure to indoor tanning and increased risk of SCC, they wrote. “Avoidance of indoor tanning may help prevent not only melanoma but also SCC, and our results support the development of policies that regulate indoor tanning.”

The study was supported by the Institute of Basic Medical Sciences, University of Oslo, and the Norwegian Cancer Society. The researchers had no financial conflicts to disclose.

SOURCE: Lergenmuller S et al. JAMA Dermatol. 2019 Oct 2. doi: 10.1001/jamadermatol.2019.2681.

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