National Cancer Institute  U.S. National Institutes of Health

Cancer Trends Progress Report – 2007 Update

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Sun Protection
Prevention: Behavioral Factors

Only 56 percent of adults say they protect themselves from the sun.

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Sun Protection and Cancer

The number of new cases of melanoma skin cancer has increased between 1975 and 2004, with an estimated number of 60,000 new cases in 2007. More than one million people are diagnosed with basal cell and squamous cell (non-melanoma) skin cancer in the United States every year. Basal and squamous cell cancers are the two most common types of skin cancers in the country. Although forty to fifty percent of Americans who live to age 65 will have these two types of skin cancer at least once, most of these cancers and melanoma skin cancers can be prevented.. Studies suggest that reducing unprotected exposure to the sun and to artificial light from tanning beds, tanning booths, and sun lamps can lower the risk of skin cancer. Avoiding sunburns, intermittent high intensity exposure, and other damage from these sources—especially in children and teens—reduces the chances of getting melanoma skin cancer. All of these types of skin cancers are most common in light-skinned people, although they also occur in people with darker skin

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Percentage of adults aged 18 and older who reported that they practice usually or all the time at least one of three sun protection behaviors (use sunscreen, wear protective clothing, or seek shade) when they go outside on a warm sunny day for more than 1 hour.

We supplemented and modified our question on hat use (as part of protective clothing) to more accurately distinguish from baseball caps (that do not fully protect the face, neck, and ears) from other types of fully protective hats. We accomplished this by using graphic illustrations of different hats and by asking a separate question about baseball cap and sun visor use.

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Period – 1992–2005

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Trends – Falling from 1992–1998, rising between 1998–2000, recently stable between 2000–2003, and falling slightly between 2003–2005. Trends are similar for both men and women except that womens' practices were stable during the last period 2003–2005, while mens' practices of these behaviors fell between 2003 and 2005.

Protective clothing: The percentage of people who usually or always use at least one sun protective article of clothing (fully sun protective hat or long-sleeve shirt) is falling.

Shade: The percentage of people who usually seek shade fell between 1992–1998, then rose between 1998–2000, fell again between 2000–2003, and appears to be rising in the most recent period 2003–2005.

Sunscreen: The percentage of people who usually use sunscreen rose slightly after 1992, was stable from 1998–2000, and rose between 2000–2003. Most recently between 2003–2005, sunscreen use is falling more steeply than any of the earlier rises. In 2000, we began to track the level of sun protective factor (SPF), which is more in line with the intent of the Healthy People 2010 goal for sunscreen use. There also was a rise between 2000–2003 for those using sunscreen with an SPF of 15 or higher, but that trend is falling during the most recent period.

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Most Recent Estimates

In 2005, 56 percent of adults said they usually practice at least one of three sun protection behaviors:

  • 30 percent reported usually applying sunscreen, and 27 percent usually applied sunscreen with an SPF of 15 or higher
  • 18 percent reported usually wearing some type of fully sun protective clothing; if baseball caps are added to the fully sun protective hats, then usual use of at least partial sun protective clothing is about 38 percent
  • 33 percent usually sought shade

Only 43 percent of young adults aged 18–24 used one or more sun protective methods, whereas 58 percent of those 25 years of age and older reported using one or more methods. Among men 18 and older, only 47 percent reported usually using one or more methods of sun protection, in contrast to 65 percent of women 18 and older.

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Healthy People 2010 Target

Increase to 75 percent the proportion of adults who usually or always apply sunscreen with an SPF of 15 or higher, wear protective clothing, or seek shade.

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Groups at High Risk for Getting Too Much Sun

Younger adults and men are less likely to use some form of sun protection (use sunscreen, wear protective clothing, seek shade). Adults with lower incomes and less education are less likely to use sunscreens.

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Key Issues

In general, increased exposure to the sun—especially without adequate use of sunscreen and protective clothing—increases the chances of getting skin cancer. Recently, however, the competing need for vitamin D for bone health, general health, and possibly for helping to prevent certain other forms of cancer has been raised. Vitamin D is most efficiently made from exposure to sunlight but also can be obtained through the diet, primarily through fortified foods and supplementation.

Key messages of the First North American Conference on UV, Vitamin D and Health held on March 8, 2006, and a June 16, 2007 Position Statement released by the Cancer Council Australia along with several other organizations include guidelines for when sun protection is required. These two sets of guidelines still conform with the present World Health Organization (WHO) guidelines that recommend sun protection when the UV index is 3 (moderate) or higher. The First North American Conference on UV, Vitamin D and Health further remarked, "The known risks associated with unprotected UVB exposure must be weighed against its benefits as a source of vitamin D. For example, it is possible that just a few minutes a day of unprotected sun exposure will increase vitamin D status, but for some may also increase the risk of skin damage. Factors such as age, diet, skin pigmentation, geographic location and intensity of the sun will affect the amount of sun exposure needed to produce adequate vitamin D. More research is needed in this area before any more specific recommendations can be made."

Most recently, there have been two National Institutes of Health-sponsored conferences in May and September of 2007 and a recent NCI study published in November 2007 pertaining to the effects of vitamin D on health and cancer. The NCI study found a protective effect of vitamin D status on colorectal cancer mortality but no effect on total cancer mortality. An accompanying editorial by co-sponsors of the May NIH conference on vitamin D and cancer cautioned that while vitamin D likely has many health benefits besides its benefits for bone health, health professionals and the public should not rush to judgment that vitamin D is a solution for good health nor should they consume high amounts of vitamin D. More definitive data on both benefits and potential adverse effects of high doses are required before making major recommendations. Finally in October 2007, the American Institute for Cancer Research (AICR) and World Cancer Research Fund (WCRF) in the second edition of their expert panel report concluded that their review of cohort studies provided limited evidence suggesting that foods containing vitamin D or vitamin D status are protective for colorectal cancer.

Some research suggests that people apply less than an adequate amount of sunscreen and fail to reapply it appropriately. This, coupled with research showing that those who use sunscreen tend to increase time spent in the sun, is likely to result in more skin damage rather than sun protection. A recent Australian randomized clinical trial, the Nambour Skin Cancer Study, conducted by Adele Green and colleagues showed that 4.5 years of daily sunscreen application resulted in a statistically significant 38-percent reduction in incidence of squamous cell carcinoma compared with discretionary use. While an additional eight years of follow-up did not yield a statistically significant difference for basal cell carcinoma with daily sunscreen use, the late follow-up period showed a non-significant 25 percent decrease in BCC tumor incidence in the former sunscreen treatment group with confidence intervals narrowing.

Pending FDA regulations of sunscreens are important because present labeling information misleads the public about the protection they are getting. For example, a sunscreen must contain ingredients that block both UVA and UVB sun rays. Also, the SPF factor relates only to blockage of UVB rays and not to the sunscreen's ability to block UVA.

According to industry estimates, 28 million Americans are using some form of indoor tanning annually and there are about 25,000 tanning salons in the United States. In most states, indoor tanning facilities are unregulated with no lower age restriction for usage. Adolescence and childhood are particularly vulnerable periods for future development of skin cancer. National Health Interview Survey (NHIS) Cancer Control Supplement data in 2005 for the first time started tracking indoor tanning use by both adults and adolescents. Nearly 9 percent of 14- to 17-year-olds used tanning devices during the past 12 months; girls are seven times more likely than boys to use such devices. WHO recommends that access to tanning beds be restricted for those under the age of 18. As of March 31, 2007, only 18 states had enacted laws related to minors' access to tanning facilities (State Cancer Legislative Database, July 2007 Fact Sheet on Skin Cancers). Adults could also benefit from other future FDA regulations proposed for indoor tanning equipment/facilities. The NHIS 2005 Cancer Supplement, shows that 14 percent of adults 18 years of age and older (11 percent of males and 17 percent of females) have used indoor tanning devices in the past 12 months. Those using indoor tanning devices are primarily non-Hispanic whites (17 percent total; 12 percent males and 21 percent females).

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Additional Information on Sun Protection

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