No Safe Tan

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By David Watts

During her junior year of high school, 17-year-old Kasey Shriver noticed a small but unsightly dark blemish between her shoulder blades. The lesion was visible above the back of her prom dress, so her mother took her to the doctor to have it removed.

Then the call came that changed everything. The biopsy had shown that Kasey had an aggressive cancer of the skin called malignant melanoma. Additional tests revealed that the cancer had already spread to a lymph node under her left arm. Kasey had joined a sharply rising number of young women in the U.S. diagnosed in recent years with melanoma, a potentially deadly cancer of color-producing skin pigment cells called melanocytes. Her doctors agree that early overexposure to ultraviolet radiation (abbreviated “UV radiation”) likely caused her melanoma.

Kasey had used tanning beds since she was 14 years old. The multisport athlete and honor student took pride in eating well, exercise and hard work. She and her mother believed that her brown skin was an attractive emblem of that healthy lifestyle. What Kasey learned after her diagnosis about UV radiation and melanoma was quite different from what she thought she knew.

UV radiation is a well-recognized “class I” human carcinogen, the highest category of proven cancer-causing substances (along with asbestos, tobacco and radon), as designated by the World Health Organization, U.S. Food and Drug Administration and U.S. Department of Health and Human Services. UV radiation is invisible, present in small amounts in sunlight and in substantial amounts in tanning bed emissions.

UV radiation in small doses is not all bad. Brief exposure to shorter burning wavelengths of UV (termed UVB) radiation in sunlight catalyzes vitamin D formation by the outer layer of skin. Conversely, UVB exposure in excess of a few minutes breaks down vitamin D and causes both tanning and sunburn. Longer wavelengths of UV (termed UVA) penetrate deeper and age skin but have no effect on vitamin D and minimal effect on tanning. Both UVB and UVA radiation cause cataracts, DNA mutations, cancers of the skin and eyes, decreased skin immunity and even flares of herpes.

Indoor tanning devices emit mostly UVA (UVB causes too much burning). Actual amounts of UVA and UVB in tanning beds vary widely, but average two to four times greater than in sunlight at noon. UVA levels up to 15 times as intense have been measured in “high pressure” units. Users of these devices can quickly accumulate hazardous doses of UVA, often with deceptively few visible short-term effects. The intensity of UV radiation in tanning devices is not regulated by law, so consumers must be vigilant.

Tanning and sunburn are both “damage control” reactions of skin cells harmed by UV radiation. Pigment is formed in an effort by cells to repair the injury. A burn fades in days and a tan in weeks, but both leave irreversible damage hidden beneath normal-appearing skin. In time, accumulated mutations can lead to uncontrolled cell growth and cancer. Since a tan is a signal that damage has occurred, there is no such thing as a safe or healthy tan.

Proponents of indoor tanning tout protection from sunburn as a benefit of exposure to “controlled” doses of UV radiation. However, fully two-thirds of respondents in a recent study of 198 tanning bed users reported skin burns, and one of five indoor tanning sessions resulted in a burn, indicating that UV overdoses are quite common. FDA guidelines for exposure limits are often not understood or followed by operators, who may sometimes be marginally trained part-time high school students working at minimum wage. One painful burn doubles the risk of melanoma.

The often-mentioned “base tan” from tanning beds yields a very low sun protection factor (SPF) of only 2–4. Even a dark tan is surprisingly ineffective in protecting skin cells from further UV injury. A false sense of protection often leads to later unexpected sunburn. The American Academy of Dermatology recommends sunscreen with an SPF of at least 15 to adequately prevent sunburn. Incidentally, you can get melanoma without ever having had sunburn.

Indoor tanning advocates argue that tanning beds are healthy because they cause vitamin D production by skin, and higher vitamin D levels may help prevent other internal cancers. In fact, tanning devices emit mostly UVA, which has no effect at all on vitamin D. However, UVA does contribute strongly to DNA damage, skin cancer and aging. Oral vitamin D supplements are a far safer and less expensive choice to boost winter vitamin D levels.

Young women are currently setting attendance records at tanning salons. An estimated one million tanning sessions are sold per day in the U.S., with approximately 70 percent of customers being young females. Nearly a third of female Caucasian teens in the U.S. have tanned indoors in the last year, and one in six tan frequently. Use increases with each year of adolescence (8.5 percent for 14-year-olds, 13.6 percent for 15-year-olds, 20.9 percent for 16-year-olds and 26.8 percent for 17-year-olds). Tanning addiction is well documented in all age groups.

Teenage girls and young women are specifically targeted by tanning advertisements. One-half of school newspapers surveyed in a Colorado study featured ads promoting multiple-session tanning packages, including “back-to-school specials” and “prom/homecoming specials.” Advertisements are bringing back old tobacco ad strategies, downplaying health risks and emphasizing social acceptance and attractiveness, possible health benefits and psychologic effects.

For instance, an ad may portray tanning bed sessions as a convenient equivalent to “a day at the beach.” Attractive, smiling, fit and tanned models may be displayed in enjoyable social activities in an exotic locale. The ad is designed to create the impression that beautiful, healthy, popular people tan. Ironically, the models themselves typically take great care to protect their skin from aging caused by UV exposure.

Consumers also receive misleading verbal information from tanning facility personnel. A 2012 congressional investigation revealed that nine out of 10 of the 300 tanning salons they contacted nationwide (including Nebraska) told investigators posing as clients that indoor tanning had NO health risks. When specifically asked about skin cancer, over half dismissed the known risks as “myth,” “rumor” and “hype.” Four out of five salons claimed indoor tanning was good for the health of a teenage girl. Several said tanning would prevent cancer, treat depression and low self-esteem and aid in weight loss.

The tanning industry even goes so far as to claim salons can cheaply treat medical conditions such as psoriasis. Physicians may use very small doses of specific UV wavelengths to lower the skin’s immunity in skin disorders like psoriasis, in which the immune system is hyperactive. Indoor tanning proponents contend that tanning beds are equivalent to medical phototherapy devices used by physicians. Unfortunately for unwary consumers, tanning bed emissions are instead quite variable, nonspecific and often too strong. Overdoses and burns can easily worsen psoriasis and increase the threat of skin cancer.

Science has closely linked melanoma risk to UV radiation exposure at younger ages. A collection of scientific studies in the “British Medical Journal” in 2012 found that in people of any age who had ever been exposed to tanning devices, their melanoma risk was 20 percent higher and climbed almost 2 percent for each additional session in a given year. When exposed under the age of 35, the risk almost tripled to 59 percent. In other words, the younger the tanning bed user, the higher the risk.

As the intensity of UV exposure goes up, the danger of melanoma rises. In a Minnesota study, users of extremely intense “high-speed” (UVB-enhanced) or “high-pressure” (UVA-dominant) tanning units had a 286–444 percent jump in melanoma, respectively. As expected, melanoma risk also went up markedly with higher total hours of exposure. Again, the higher the accumulated dose of UV radiation or the more powerful the tanning device, the greater the risk of melanoma.

New cases of melanoma are rising more rapidly than any other cancer, with an eightfold jump in young women since 1970, double the rate of young men. Researchers believe the difference is in part due to tanning bed use by young females. A recent study determined that three out of every four melanomas in patients under the age of 30 were related to tanning bed use. Melanoma is now the most common cancer of young adults, the second most common in teenagers and is a leading cause of death in these age groups. One American dies every 62 minutes of melanoma.

National momentum is building to protect minors from the high-dose UV radiation in commercial tanning devices. Six states prohibit any access by minors under the age of 18. Another 12 do so for children aged 14–17, and 17 other states require parental consent. Although Nebraska protects minors from tobacco, another well-known class I carcinogen, it currently has no restrictions on UV radiation used in commercial tanning. Nebraska does not require tanning facilities to be licensed.

To address growing concern about the link between soaring melanoma rates and artificial UV radiation exposure, a bill introduced by state Sen. Jeremy Nordquist of Omaha is currently under consideration by the Nebraska Legislature. LB 132 would ban commercial UV tanning by minors under the age of 18, with an important impact on our mounting melanoma public-health crisis.

Because of the clear evidence of harm to young people by tanning devices, LB 132 is widely supported by Nebraska physician groups. These include the Nebraska Medical Association and physician specialty groups representing family practice, internal medicine, pediatrics, oncology, dermatology, ophthalmology, ENT and obstetrics-gynecology.

Those seeking facts to make more informed decisions about indoor tanning are advised to find information sources that do not profit by influencing their choice. Finding guidance online may not be straightforward, since some websites (for example, the UV foundation and Vitamin D Council) have undisclosed tanning industry affiliations. However, websites such as the Skin Cancer Foundation and AIM at Melanoma are good examples of science-based, easy-to-use portals of important information.

Now aged 21, four years since her cancer diagnosis, Kasey is still at high risk for her cancer to reappear somewhere in her body. She sees her doctors every three months for tests and scans. Being a cancer survivor has become part of who she is, and she has resolved to help others benefit from her painful experience. She strongly supports tanning reform (she testified in support of LB 132), works with other young cancer survivors and is currently taking premedical courses in college.

If you have fair skin, red or blond hair, freckles or numerous moles, or if you burn easily, you are at higher risk for malignant melanoma. A history of sunburn or a family history of melanoma also increases your risk. Even if you have no risk factors, if you notice a new or changing spot anywhere on your body, please have it checked immediately by your doctor. It could save your life.

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