Nautilus Article
Talking points
6.13.14
Q. What do you say to the fact that the article quotes that people regularly exposed to daily sun have a lower risk of getting melanoma and also have a higher survival rate if they do?
A. It is a well-established fact that UV radiation from sun or indoor tanning can cause cancer and numerous studies have demonstrated that exposure to UV radiation causes DNA damage in skin cells that can lead to skin cancer (melanoma and non-melanoma).
1,2
The relationship between the amount of UV exposure, skin type, and risk for melanoma is complex and is influenced by both genetic and environmental factors. While there have been some studies on the protective effects of sun exposure on melanoma, these studies do not prove a direct causal effect of sun exposure and lower melanoma risk. Bottom line, the risk of skin cancer, including melanoma exists in all skin types and UV exposure is an avoidable risk factor to the development of skin cancer.
3,4
Since everyone is at risk for skin cancer, the Academy recommends that people reduce their risk by seeking shade, covering up and wearing broad-spectrum, water-resistant sunscreen of SPF 30 or higher regardless of their skin type. To avoid vitamin D insufficiency, healthy diet and dietary supplementation is safe and effective means to obtain vitamin D. The Centers for Disease Control (CDC) and Cancer Council Australia specifically advise outdoor workers to practice strong sun protection. http://www.actcancer.org/sun-smart/outdoor-workers.aspx
http://www.cdc.gov/niosh/topics/uvradiation
Q: How do you respond to the article’s assertion that Cancer Council Victoria are “urging many people to dump the sunscreen and hat to catch some rays”?
A: The Cancer Council Victoria (CCV) has stated that their position on this issue was taken completely out of context in the article. The CCV stated that they would never recommend people “dump” sun protection in the summer nor would they recommend anyone get “several hours of sun a week all year”.
Q: What do you say to the article’s insinuation that the American Academy of Dermatology is colorblind sun protection advice and that scientific issues mixed with a race sensitivity.
A: The AAD bases its recommendations solely on scientific evidence. People of color, while at a lower risk for skin cancer, do develop skin cancers related to excessive sun exposure. 5,6 The Academy regularly reviews scientific evidence as soon as it is available and develops clinical practice guidelines, measures and appropriate use criteria (AUCs) for physicians. The Academy also actively works to identify gaps that require further basic and clinical research.
7
1 Lim HW, James WD, Rigel DS, Maloney ME, Spencer JM, Bhushan R. Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: time to ban the tan. J Am Acad Dermatol. 2011 May;64(5):893-902.
2 O'Leary RE, Diehl J, Levins PC. Update on tanning: More risks, fewer benefits. J Am Acad Dermatol. 2014 Mar;70(3):562-8.
3 American Cancer Society. Cancer Facts and Figures 2014.
http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2014/index
4 Agbai ON, Buster K, Sanchez M, Hernandez C, Kundu RV, Chiu M, Roberts WE, Draelos ZD, Bhushan R, Taylor SC, Lim HW.
Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am
Acad Dermatol .
2014;70(4):748-62.
5 Agbai ON, Buster K, Sanchez M, Hernandez C, Kundu RV, Chiu M, Roberts WE, Draelos ZD, Bhushan R, Taylor SC, Lim HW.
Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am
Acad Dermatol. 2014 Apr;70(4):748-62
6 Hu S, Parmet Y, Allen G, et al. Disparity in melanoma: a trend analysis of melanoma incidence and stage at diagnosis among whites, Hispanics, and blacks in Florida. Arch Dermatol 2009;145:1369-74.
7
Ryan C, Korman NJ, Gelfand JM, Lim HW, Elmets CA, Feldman SR, Gottlieb AB, Koo JY, Lebwohl M, Leonardi CL, Van
Voorhees AS, Bhushan R, Menter A. Research gaps in psoriasis: opportunities for future studies. J Am Acad Dermatol. 2014
Jan;70(1):146-67.

Q. What do you have to say about this quote from the article?
“ By the early 2000s, research began to suggest a link between vitamin D and lower disease rates for cancers including breast, prostate, and non-Hodgkin’s lymphoma, along with autoimmune diseases such as multiple sclerosis.
1 The need for sun especially affects darkly colored people since the skin pigment melanin, which protects against damaging ultraviolet solar radiation, also slows vitamin D production. Vitamin D deficiencies leach calcium from muscles and bones, causing pain, weakness, fractures, osteoperosis, and osteomalacia. Called rickets in babies and children, the bone-deforming illness not seen since Victorian times began cropping up from Britain to
Australia—and the U.S. too—in darker populations, many of them recent migrants from equatorial zones.”
A. Regarding the association of vitamin D and disease, the National Academy of Sciences Institute of Medicine
(IOM) has concluded that while evidence links a person’s vitamin D level to their bone health, the evidence linking vitamin D with other health benefits is inconsistent, inconclusive, and insufficient.
8 A recent systematic review on vitamin D and ill heath showed that intervention studies did not show an effect of vitamin D on disease occurrence, including colorectal cancer.
9
In addition, existing data suggests that cases of rickets in the United States are most frequently in cases of exclusively breast-fed or darker-skinned infants. While some studies have documented an increase in the reported cases of rickets in the US and Australia, these studies also highlight that rickets remains a rare condition in infants and children.
10,11 Given this the American Academy of Pediatrics has had a long-standing recommendation for vitamin D supplementation for all infants that mirrors the recommendations from the
IOM.
12
Based on currently available scientific evidence that supports a key role of calcium and vitamin D in skeletal health, the IOM Recommended Dietary Allowance (RDA)* for vitamin D is 13 : o 400 IU (International Units) for Infants/Children 0-1yr o 600 IU for children, teenagers and adults 1-70yr o 800 IU for adults 71+ yr
*The RDA is intake that covers needs of 97.5% of the healthy normal population.
Vitamin D can be safely and easily obtained from a healthy diet that includes foods naturally rich in vitamin D, foods/beverages fortified with vitamin D, and/or vitamin D supplements.
Because of the known side effects of UV exposure, vitamin D should not be obtained from unprotected exposure to ultraviolet (UV) radiation.
14
8
Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, Durazo-Arvizu RA, Gallagher JC, Gallo RL, Jones G,
Kovacs CS, Mayne ST, Rosen CJ, Shapses SA. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011;96(1):53-8.
9 Autier P, Boniol M, Pizot C, Mullie P. Vitamin D status and ill health: a systematic review. Lancet Diabetes Endocrinol. 2014
Jan;2(1):76-89
10 Thacher TD, Fischer PR, Tebben PJ, Singh RJ, Cha SS, Maxson JA, Yawn BP. Increasing incidence of nutritional rickets: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2013;88(2):176-83.
11 Robinson PD, Högler W, Craig ME, Verge CF, Walker JL, Piper AC, Woodhead HJ, Cowell CT, Ambler GR. The re-emerging burden of rickets: a decade of experience from Sydney. Arch Dis Child. 2006;91(7):564-8.
12
Wagner CL and Greer FR. Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents Pediatrics
2008;122(5):1142 -1152.
13 Institute of Medicine. 2011 Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National
Academies Press.
14 American Academy of Dermatology. Position Statement on Vitamin D. http://www.aad.org/Forms/Policies/Uploads/PS/PS-Vitamin%20D%20Postition%20Statement.pdf

Q. What is the AAD’s recommendation for sun exposure?
A. Unprotected sun exposure is the most preventable risk factor for skin cancer. More than 3.5 million new cases of skin cancer will be diagnosed in the United States this year, affecting 2 million people.
15 At current rates, one in five Americans will develop skin cancer in his or her lifetime 16,17 . Approximately 75 percent of skin cancer deaths are from melanoma, and the incidence of melanoma has been rising at an alarming rate for at least 30 years.
18
To reduce your risk of skin cancer, the American Academy of Dermatology recommends seeking shade when the sun is at its strongest, covering up exposed skin with protective clothing, such as a long-sleeved shirt and pants, sunglasses and a wide-brimmed hat, and applying a broad-spectrum, water-resistant sunscreen with an
SPF 30 or higher to all exposed skin.
Q. Does this recommendation for sun exposure change depending on the skin type of the individual?
A. While skin type is an important factor that contributes to a person's risk for melanoma, non-melanoma skin cancers, photo-aging and vitamin D deficiency, there are many other variables, such as sun exposure, geographic location, family history, etc., that additionally impact a person's risk for skin cancer. The Academy is committed to educating the public on how to reduce their risk of skin cancer and ultimately save lives. Since everyone is at risk for skin cancer, we recommend that people reduce their risk by seeking shade, covering up and wearing broad-spectrum sunscreen regardless of their skin type.
Q: Why does the Academy not subscribe to the original Fitzpatrick scale of skin color?
A. Anyone, regardless of skin color or ethnicity, can develop skin cancer and photoaging, so it is important that everyone practice sun safety. Because US population is increasingly multicultural, determining Fitzpatrick skin type could potentially quite difficult and lead to inaccurate classification for untrained individuals.
Q. What do you have to say about this quote from the article?
“ While the Academy of Dermatology declines to tailor its recommendations by skin color, the data reveal very different realities for different races. For example, the academy often emphasizes that skin cancer is on the rise. There has indeed been a 17 percent jump in melanoma rates for
Caucasians between the years 2000 and 2010. But the incidence for African Americans has not changed over this same time period, flat-lining at 1 case in 100,000—26 times lower, according to the U.S. CDC National Cancer Registry. Melanoma is mostly a white person’s disease affecting
“Caucasian populations residing in highly resourced, westernized countries,” according to a World
Health Organization 2012 report. In the U.S., melanoma is the sixth most common cancer for
Caucasians, but does not make the top 10 for African Americans.”
A. While skin cancer rates may vary among the population, it is important to recognize that all individuals have a risk of skin cancer. In fact, since the late 1980s, the incidence of MM has increased significantly among
Hispanics in California, increasing an average of 1.8% yearly in male Hispanics between 1988 and 2001, and
7.3% average yearly between 1996 and 2001.
19
Although skin cancer is less prevalent in people of color compared to the Caucasian population, it often presents at a more advanced stage, and thus the prognosis is worse compared to the Caucasian population. A study comparing low-level exposure to UVA and UVB in all population found DNA damage to the skin cell in all skin types, including in very dark skin. Since no skin type is immune to UVA/UVB-induced DNA damage which
6 Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006.
Arch Dermatol 2010; 146(3):283-287.
16 Stern RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol. 2010
Mar;146(3):279-82.
17 Robinson JK. Sun Exposure, Sun Protection, and Vitamin D. JAMA 2005; 294: 1541-43.
18 American Cancer Society. Cancer Facts and Figures 2014. http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2014/index
19 Cockburn MG, Zadnick J, Deapen D. Developing epidemic of melanoma in the Hispanic population of California. Cancer
2006;106:1162-8.

causes not only skin cancer but photoaging and UV related disorders of pigmentation, sun protection is necessary for people of all skin types, including people of color. 20
Melanoma can be difficult to diagnose in people of color because it can be hidden between the toes, on the sole, scalp and oral cavity. As a result, melanoma is often not diagnosed in people of color until after the cancer has spread, making treatment less effective. Melanoma in people of color is underreported and hence the incidence of melanoma in people of color is underestimated.
The Academy promotes skin cancer prevention strategies for all patients, regardless of ethnic background and socioeconomic status, leading to timely diagnosis and treatment. The Academy promotes public education campaigns to all communities to minimize the risk of skin cancer and UV related disorders for all.
Q. What is your recommendation for the use of sunscreen?
A. To reduce the risk of skin cancer and premature aging, dermatologists continue to recommend generously applying a water-resistant, broad-spectrum sunscreen – that protects against both types of ultraviolet radiation (UVA and UVB) – with an SPF 30 or higher. It should be emphasized that the use of sunscreen is only a component of total photoprotection practice, which include seeking shade, and wearing sun-protective clothing, hats and sunglasses.
The sun protection recommendations from the Cancer Council Australia remain consistent with this message.
21
Q. What about the limitations to producing Vitamin D for those who take these precautions?
A . The AAD recognizes that vitamin D production is essential. Without vitamin D, the body cannot use calcium and phosphorus — two minerals necessary for healthy bones. The American Academy of Dermatology
(Academy) does not recommend getting vitamin D from sun exposure (natural) or indoor tanning (artificial) because ultraviolet (UV) radiation from the sun and tanning beds can lead to the development of skin cancer.
In addition, the typical use of sunscreen still allows for most people to make vitamin D from the sun.
22
Getting vitamin D from a healthy diet, which includes naturally enriched vitamin D foods, fortified foods and beverages and/or vitamin D supplements, and practicing sun protection offer a healthier and safer alternative.
20 Tadokoro T, Kobayashi N, Zmudzka BZ, Ito S, Wakamatsu K, Yamaguchi Y, et al. UV-induced DNA damage and melanin content in human skin differing in racial/ethnic origin. FASEB J 2003;17:1177-9.
21 Cancer Council Australia. Preventing skin cancer. http://www.cancer.org.au/preventing-cancer/sunprotection/preventing-skin-cancer/
22 Kannan S, Lim HW. Photoprotection and vitamin D: a review. Photodermatol Photoimmunol Photomed 2014;30(2-
3):137-45.