Response to EPA and NOAA's New Global UV Index Guidelines, second round
William B. Grant, Ph.D., SUNARC (www.sunarc.org)
With input from:
Cedric F. Garland, Dr.P.H., F.A.C.E.
Department of Family and Preventive Medicine, 0631C
School of Medicine, University of California, San Diego
cgarland@ucsd.edu
and Gordon Ainsleigh, D.C., Auburn, Calif., drgordon@auburninternet.com
As a further response to the New Global UV Index Guidelines, I would like to draw the
attention of the skin cancer prevention community to the health benefits of UVB
radiation in just one field – internal cancer prevention - with the presentation of a list of
some of the key papers in the history of this field. Of course, there are many more health
benefits from UVB/vitamin D documented in the scientific literature, including greatly
reduced risk for multiple sclerosis, musculoskeletal disorders, and many other diseases
and conditions, but those are topics for another day.
Peller S. Carcinogenesis as a means of reducing cancer mortality. Lancet 1936; 2:552-6.
Peller S, Stephenson CS. Skin irritation and cancer in the United States Navy. Am J Med
Sci 1937; 194:326-333.)
Very likely the first scientific-based published mention of solar ultraviolet radiation
reducing the risk of cancer.
Apperly FL. The relation of solar radiation to cancer mortality in North America, Cancer
Res. 1941;1:191-5.
Another early published mention of solar radiation being associated with reduced cancer
mortality.
Ott J. Health and Light, Lecture and Film, presented before Cancer Control Society Third
Annual Cancer Convention, Los Angeles, 1975.
In the printed version of that lecture, he discusses some experiments conducted with C3H
mice under pink or full spectrum fluorescent lights. Those under the pink light lived less
than half as long as those under the full spectrum, and had many more and larger multilobe tumors. Such work was repeated by 6 major medical centers. Detailed reports were
written and submitted to the National Cancer Institute (NCI) and the American Cancer
Society (ACS). The reports were ridiculed and criticized, which prevented the
researchers from carrying out further work. The NCI wrote back that light is just not an
acceptable parameter for cancer research, since there was nothing in the literature to
support it. The ACS commented that cancer research is already very complicated and
adding another variable would only further confuse the issue. More about the ACS later.
(Note: for papers published after about 1970, abstracts may be found at
www.ncbi.nlm.nih.gov/PubMed)
Eisman JA, Martin TJ, MacIntyre I, Mosely JM. 1,25-dihydroxyvitamin D receptor in
breast cancer cells. Lancet 1979; 2:1335-1336.
Eisman JA, MacIntyre I, Martin TJ, Frampton RJ, King RJB. Normal and malignant
breast tissue is a target organ for 1,25-(OH)2 vitamin D3. Clin Endocrinol 1980;
13:267-272.
Eisman showed that breast cancer cells have receptors for activated vitamin D, and that
the growth of breast cancer cells is inhibited by adding vitamin D to the growth medium.
Garland CF, Garland FC. Do sunlight and vitamin D reduce the likelihood of colon
cancer? International Journal of Epidemiology 1980; 9: 227-31.
This is the first scientific paper to propose that the geographic variation in colon cancer
mortality rates could be explained by solar UVB production of vitamin D, and that
vitamin D reduces the risk of colon cancer.
Garland C, Shekelle RB, Barrett-Connor E, Criqui M, Rossof A, Paul O. Dietary vitamin
D and calcium and risk of colorectal cancer: a 19-year prospective study in men. Lancet
1985; 1: 307-9.
The first epidemiological study of individuals (observational study) showing the high
levels of vitamin D intake were associated with low incidence of a cancer.
Gorham ED, Garland CF, Garland FC. Acid haze air pollution and breast and colon
cancer mortality in 20 Canadian cities. Canadian Journal of Public Health 1989; 80:
96-100.
The first scientific study to propose that air pollution causes increased risk of both breast
and colon cancer.
Garland C, Comstock GW, Garland FC, Helsing KJ, Shaw EK, Gorham ED. Serum 25hydroxyvitamin D and colon cancer: eight-year prospective study. Lancet 1989; 2:
1176-8.
The first paper to show that low levels of serum vitamin D metabolites are associated
with elevated risk of colon cancer.
Garland FC, Garland CF, Gorham ED, Young JF. Geographic variation in breast cancer
mortality in the United States: a hypothesis involving exposure to solar radiation.
Preventive Medicine 1990; 19: 614-22.
The first scientific journal article, to my knowledge, to report an association between
stratospheric ozone thickness and increased risk of breast cancer.
Schwartz GG, Hulka BS. Is vitamin D deficiency a risk factor for prostate cancer?
(Hypothesis). Anticancer Res. 1990 Sep-Oct;10(5A):1307-11.
The first paper to hypothesize that prostate cancer is due to vitamin D deficiency.
Ainsleigh HG. Beneficial effects of sun exposure on cancer mortality. Prev Med 1993;
22:132-140.
The first literature review and the first risk:benefit analysis of the anticancer effects of
sun exposure.
Corder EH, Guess HA, Hulka BS, Friedman GD, Sadler M, Vollmer RT, Lobaugh B,
Drezner MK, Vogelman JH, Orentreich N. Vitamin D and prostate cancer: a
prediagnostic study with stored sera. Cancer Epidemiol Biomarkers Prev. 1993 SepOct;2(5):467-72.
The first study of individuals to report that lower levels of 25(OH)2D were associated
with higher risk of prostate cancer.
Lefkowitz ES, Garland CF. Sunlight, vitamin D, and ovarian cancer mortality rates in
U.S. women. International Journal of Epidemiology 1994;23:1133-6.
The first paper to provide evidence that ovarian cancer is in part due to vitamin D
deficiency.
Freedman DM, Zahm SH, Dosemeci M. Residential and occupational exposure to
sunlight and mortality from non-Hodgkin's lymphoma: composite (threefold) casecontrol study. BMJ. 1997 May 17;314(7092):1451-5.
First paper to show that UVB reduced the risk of non-Hodgkin’s lymphoma.
Grant WB. An estimate of premature cancer mortality in the United States due to
inadequate doses of solar ultraviolet-B radiation Cancer 2002;94:1867-75.
This paper upped the number of cancers for which vitamin D was apparently a risk
reduction factor to 12, adding bladder, endometrial, esophageal, gallbladder, pancreatic,
rectal, and renal to the list of 5 previously identified. Estimated that 17-23,000
Americans die prematurely from 12 types of internal cancers annually due to insufficient
UVB/vitamin D.
The American Cancer Society responded that UVR was known to cause skin cancer so,
in essence, shouldn’t be considered for reducing the risk of cancer and, besides, there are
many more factors that are associated with cancer risk and risk reduction that were not
included in the analysis that might explain the geographic variation of cancer mortality
rates in the U.S., so the results in this paper were not useful for policy guidelines at this
time.
In response, I prepared this manuscript: Grant WB. A multifactor ecologic analysis of
the geographic variation in cancer mortality rates in the U.S.A., which is currently under
review. I added alcohol, smoking, urban residence, Hispanic heritage, and
socioeconomic status to the analysis and easily confirmed the single-factor results. In
addition, I identified urban residence as an additional risk factor for cancer, which I
attribute to reduced UVB exposure. Additional cancers associated with insufficient
UVB/vitamin D include Hodgkin’s lymphoma, laryngeal, testicular, and vulvar cancer.
The number of premature cancer deaths annually in the U.S. was increased to 47,000,
with half associated with geographical location and half with urban residence.
Grant WB, Garland CF. A critical review of studies on vitamin D in relation to colorectal cancer.
Nutrition and Cancer 2004;48:115-23.
This paper shows that dietary sources of vitamin D are, by themselves, unable to
significantly reduce the risk of colorectal cancer. It also shows that total vitamin D, from
diet, supplements, and UVB radiation, can be sufficient at the proper levels. Since colon
and rectal cancer mortality rates have geographic variations in the U.S. similar to those
for about a dozen other types of cancer (Devesa SS, Grauman DJ, Blot WJ, Pennello GA,
Hoover RN, Fraumeni JF Jr. Atlas of Cancer Mortality in the United States, 19501994. NIH Publication No. 99-4564, 1999. http://cancer.gov/atlasplus/new.html), and that
the pattern is highly correlated (inversely) with July UVB doses in the U.S. (Herman JR,
Krotkov N, Celarier E, Larko D, Labow G. Distribution of UV radiation at the Earth's
surface from TOMS-measured UV-backscattered radiances. J Geophys Res-Atmos
1999;104:12 059-12 076. http://toms.gsfc.nasa.gov/ery_uv/dna_exp.gif) in the U.S. –
solar UVB is THE primary source of vitamin D for most Americans (see, also,
www.sunarc.org).
Thus, suggesting that people avoid UVR during midday when the vitamin D production
potential is highest is akin to telling Americans that they should not drive cars faster than
30 miles/hour since 40,000 Americans die from auto accidents each year, or drink more
than one alcoholic beverage per day because some Americans get drunk and others die
from cancer and other diseases for doing so.
Robsahm TE, Tretli S, Dahlback A, Moan J. Vitamin D3 from sunlight may improve the
prognosis of breast-, colon- and prostate cancer (Norway). Cancer Causes Control.
2004 Mar;15(2):149-58.
This is the first paper to show that the seasonal variation in cancer detection (highest in
spring) is due to seasonal variations in vitamin D produced by solar UVB radiation. This
paper is important since it shows that vitamin D is important in reducing the risk of
cancer even at the stage of discovery.
Moore C, Murphy MM, Keast DR, Holick MF. J Am Diet Assoc. 2004 Jun;104(6):9803. Vitamin D intake in the United States.
Abstract
Mean intake of vitamin D in the United States was estimated from food and food plus
supplements and compared with recommended intake levels. US men, nonpregnant and
nonlactating women, and nonbreastfeeding children aged 1 year and older who
participated in the Third National Health and Nutrition Examination Survey (NHANES
III, 1988-1994) or the Continuing Survey of Food Intakes by Individuals 1994-1996,
1998 (CSFII 1994-1996, 1998) were included in the estimates. Intake of vitamin D from
food sources and dietary supplements was not meeting recommended levels. The lowest
intakes of vitamin D from food were reported by female teenagers and female adults. The
highest intakes of vitamin D from food sources were reported by male teenagers. Dairy
products were the primary sources of both vitamin D and calcium. Additional food
fortification as well as dietary and supplement guidance are needed for the general
population.
In conclusion, I would ask those counseling people on how to avoid skin cancer to also
include in the message the importance of obtaining adequate vitamin D, including from
UVB radiation – from solar radiation when available and from artificial UVR sources
when not - and that when considering solar UVR exposure, other factors are more
accurate than time of day in determining ultraviolet exposure and risk/benefit, such as
skin pigmentation, solar zenith angle at time of exposure, season, altitude, air clarity and
cloudiness, etc., and that the risk of skin cancer can be reduced by having an abundance
of fruit and vegetables in the diet and/or antioxidants not smoking in order to help combat
the free radicals generated from UVR exposure.