THE ULTRAVIOLET DOSE DEPENDENCE OF NON-MELANOMA SKIN CANCER INCIDENCE

Abstract— We correlate annual ultraviolet dose estimates with age specific and age adjusted incidence data for non-melanoma skin cancer in the United States, United Kingdom, Canada and Australia. We first examine (1) a reciprocity or photographic model in which incidence rates (R) are related to exposure (E) which is the product of age (T) and annual dose (D). We also test several models which violate reciprocity including models identified by the labels: (2) Dose potency; (3) Double cause; (4) Age-exposure and (5) separable. Our analyses together with the recent National Cancer Institute study favors the age-exposure model and/or the double cause models. All models lead to biological amplification factors (defined as the ratio of the percent increase in skin cancer incidence due to a 1% increase in dose) greater than unity. For the U.S. we find the biological amplification to be approximately 1.8 for the population center but greater in regions of higher UV annual dose, and less in regions of lower annual UV dose.     

UV radiation: balancing risks and benefits

We use action spectra published by the International Commission on Illumination to examine diurnal, seasonal and latitudinal variations in erythemally weighted (sunburning) UV-a health risk, and vitamin D-weighted UV-a health benefit. Vitamin D-weighted UV is more strongly dependent on ozone and solar zenith angle. Consequently, its diurnal, seasonal and geographic variability is more pronounced than for erythemally weighted UV. We then investigate relationships between the two quantities. An algorithm is developed and used to relate vitamin D production to the widely used UV index, to help the public to optimize their exposure to UV radiation. In the summer at noon, there should at mid-latitudes be sufficient UV to photosynthesize optimal vitamin D in approximately 1 min for full body exposure, whereas skin damage occurs after approximately 15 min. Further, while it should be possible to photosynthesize vitamin D in the winter at mid-latitudes, the amount of skin that must be exposed is larger than from the hands and face alone. This raises the question of whether the action spectrum for vitamin D production is correct, since studies have reported that production of vitamin D is not possible in the winter at mid-latitudes.     

ULTRAVIOLET-RADIATION and SKIN CANCER. EFFECT OF AN OZONE LAYER DEPLETION

The effect of changes in the ozone layer on the incidence of skin cancer was explored using data for Norway. Attempts were made to arrive at a relationship between the "environmental effective UV-dose" and the skin cancer incidence. Norway is well suited for this purpose because of the large variation in the annual UV-dose from north to south. Furthermore we have a well developed cancer registry and a homogeneous population with regard to skin type. Four different regions of the country, each with a broadness of 1 degree in latitude (approximately 111 km), were selected (located around 69.5, 63.5, 60 and 58.5 degrees N). The annual effective UV-doses for these regions were calculated, assuming normal ozone conditions throughout the year and the action spectrum proposed by CIE, which extends up to 400 nm. The incidence rate (in the period 1970-1980) of malignant melanoma and non-melanoma skin cancer (mainly basal cell carcinoma) increased with the annual environmental UV-doses. For both these types of cancer a quadratic dose-effect relationship seems to be valid to a first approximation. The present data indicate that the incidence of skin cancer would increase by approximately 2% for each percent ozone reduction.     

Solar radiation, vitamin D and survival rate of colon cancer in Norway

Solar radiation contributes significantly to the status of serum calcidiol (25-hydroxyvitamin D3, 25-(OH)D3) in humans, even at the high latitudes of northern Norway. Thus, in late summer the serum concentration of calcidiol is roughly 50% larger than that in late winter, when the solar radiation in Norway contains too little ultraviolet radiation to induce any synthesis of vitamin D3 in human skin. This seems to influence the prognosis of colon cancer. We here report that the survival rate of colon cancer in men and women, assessed 18 months after diagnosis, is dependent on the season of diagnosis. A high serum concentration of calcidiol at the time of diagnosis, i.e. at the start of conventional therapy, seems to give an increased survival rate. This agrees with cell and animal experiments reported in the literature, as well as with epidemiological data from some countries relating colon cancer survival with latitude and vitamin D3 synthesis in skin. One possible interpretation of the present data is that, the level of calcidiol, or its derivative calcitriol (1alpha,25-dihydroxyvitamin D3, 1alpha,25-(OH)2D3), may act positively in concert with conventional therapies of colon cancer.     

Noninvasive Optical Imaging of UV‐Induced Squamous Cell Carcinoma in Murine Skin: Studies of Early Tumor Development and Vitamin D Enhancement of Protoporphyrin IX Production

Better noninvasive techniques are needed to monitor protoporphyrin IX (PpIX) levels before and during photodynamic therapy (PDT) of squamous cell carcinoma (SCC) of the skin. Our aim was to evaluate (1) multispectral fluorescent imaging of ultraviolet light (UV)‐induced cancer and precancer in a mouse model of SCC and (2) multispectral imaging and probe‐based fluorescence detection as a tool to study vitamin D (VD) effects on aminolevulinic acid (ALA)‐induced PpIX synthesis. Dorsal skin of hairless mice was imaged weekly during a 24‐week UV carcinogenesis protocol. Hot spots of PpIX fluorescence were detectable by multispectral imaging beginning at 14 weeks of UV exposure. Many hot spots disappeared after cessation of UV at week 20, but others persisted or became visible after week 20, and corresponded to tumors that eventually became visible by eye. In SCC‐bearing mice pretreated with topical VD before ALA application, our optical techniques confirmed that VD preconditioning induces a tumor‐selective increase in PpIX levels. Fluorescence‐based optical imaging of PpIX is a promising tool for detecting early SCC lesions of the skin. Pretreatment with VD can increase the ability to detect early tumors, providing a potential new way to improve efficacy of ALA‐PDT.     

Sun Exposure over a Lifetime in Australian Adults from Latitudinally Diverse Regions

Spatio‐temporal patterns in sun exposure underlie variations in skin cancer incidence and vitamin D deficiency, indicate effectiveness of sun protection programs and provide insights into future health risks. From 558 adults across four regions of Australia (Brisbane (27°S), Newcastle (33°S), Geelong and the Western Districts of Victoria (37°S) and Tasmania (43°S)), we collected: self‐report data on time‐in‐the‐sun from age 6 years; natural skin color and ethnicity; silicone skin casts (for cumulative skin damage); and serum for vitamin D status. Ambient ultraviolet radiation (UVR) at the location of residence, with time‐in‐the‐sun, was used to calculate a “UVR dose” for each year of life. Individuals maintained their ranking compared to their peers for time‐in‐the‐sun in summer compared to winter and across ages (Spearman rho 0.24–0.84, all P < 0.001). Time‐in‐the‐sun decreased with age in all birth cohorts, and over calendar time. Summer time‐in‐the‐sun increased with increasing latitude (P < 0.001). Seasonal variation in vitamin D status had greater amplitude and vitamin D deficiency increased with increasing latitude. Temporal patterns are consistent with effectiveness of sun protection programs. Higher relative time‐in‐the‐sun persists from childhood through adulthood. Lower summer time‐in‐the‐sun in the warmest location may have implications for predictions of UVR‐related health risks of climate change.     

Solar Ultraviolet Radiation Measurements in One of the Most Populous Cities of the World: Aspects Related to Skin Cancer Cases and Vitamin D Availability

A number of studies published in the scientific literature have shown the relationship between sun exposure and nonmelanoma skin cancer (NMSC) and vitamin D synthesis. However, the paucity of medical data, particularly in developing countries, hampers a global assessment of the impact of sun exposure on NMSC and vitamin D. To improve knowledge on this subject, this paper presents UV index (UVI) measurements performed in São Paulo City (SPC) in the period 2005–2008. It was found that 65% of the UVI measured 2 h around local noon during the summer show very high (8 < UVI < 10) and extreme (UVI > 11) levels according to the World Health Organization (WHO) classification. During the winter, 40% of the measurements around noontime show high or very high levels. In spite of worrisome recent statistics from SPC, showing that NMSCs make up about 28% of over a million of new cases of cancer in 2008, sun protection is not considered a real problem in these urban areas. UV measurements also show that every month of the year UV levels are high enough to ensure vitamin D production in human skin from incidental sun exposure.     

The epidemiology of UV induced skin cancer.

There is persuasive evidence that each of the three main types of skin cancer, basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma, is caused by sun exposure. The incidence rate of each is higher in fairer skinned, sun-sensitive rather than darker skinned, less sun-sensitive people; risk increases with increasing ambient solar radiation; the highest densities are on the most sun exposed parts of the body and the lowest on the least exposed; and they are associated in individuals with total (mainly SCC), occupational (mainly SCC) and non-occupational or recreational sun exposure (mainly melanoma and BCC) and a history of sunburn and presence of benign sun damage in the skin. That UV radiation specifically causes these skin cancers depends on indirect inferences from the action spectrum of solar radiation for skin cancer from studies in animals and the action spectrum for dipyrimidine dimers and evidence that presumed causative mutations for skin cancer arise most commonly at dipyrimidine sites. Sun protection is essential if skin cancer incidence is to be reduced. The epidemiological data suggest that in implementing sun protection an increase in intermittency of exposure should be avoided, that sun protection will have the greatest impact if achieved as early as possible in life and that it will probably have an impact later in life, especially in those who had high childhood exposure to solar radiation.     

OZONE DEPLETION AND INCREASE IN ANNUAL CARCINOGENIC ULTRAVIOLET DOSE

An increase in skin cancer incidence due to an increase of solar ultraviolet (UV) radiation is one of the best quantitated effects of stratospheric ozone depletion. Until now, estimates of effective UV dosages could not be based on spectral data on carcinogenicity. Instead the spectral dependence of sunburn or mutations was used. These data contained little information on longwave ultraviolet radiation (UVA: 315-380 nm). Recently, in hairless mice, experimental data have become available on the carcinogenic effectiveness of the ultraviolet, including UVA. From these new data we can estimate the effect of ozone depletion on the ambient annual carcinogenic UV dose. We find that a 1% decrease in ozone yields a 1.56% increase in annual carcinogenic UV; this value is not strongly dependent on geographical latitude. From this result, combined with the dose-response relationship for UV carcinogenesis, we conclude that for a 1% decrease in total column atmospheric ozone an increase of 2.7% in non-melanoma skin cancer is to be expected.     

Low Sun Exposure and Vitamin D Deficiency as Risk Factors for Inflammatory Bowel Disease,With a Focus on Childhood Onset

The incidence and prevalence of inflammatory bowel disease (IBD) are increasing worldwide. Some ecological studies show increasing incidence with increasing latitude. Ambient ultraviolet radiation varies inversely with latitude, and sun exposure of the skin is a major source of vitamin D. Vitamin D deficiency is common in patients with IBD. Sun exposure and vitamin D have immune effects that could plausibly reduce, or be protective for, IBD. One quarter of new IBD cases are diagnosed in childhood or adolescence, but most research is for adult‐onset IBD. Here, we review the evidence for low sun exposure and/or vitamin D deficiency as risk factors for IBD, focusing where possible on pediatric IBD, where effects of environmental exposures may be clearer. The literature provides some evidence of a latitude gradient of IBD incidence, and evidence for seasonal patterns of timing of birth or disease onset is inconsistent. High prevalence of vitamin D deficiency occurs in people with IBD, but cannot be interpreted as being a causal risk factor. Evidence of vitamin D supplementation affecting disease activity is limited. Further research on predisease sun exposure and well‐designed supplementation studies are required to elucidate whether these potentially modifiable exposures are indeed risk factors for IBD.     

Solar UV Exposure of Seafarers along Subtropical and Tropical Shipping Routes

Seafarers working on decks of vessels at low latitudes are exposed to extremely high solar UV radiation. Their risk of developing skin cancer may be enhanced. Solar erythemal UV irradiance and exposure were measured for the first time on merchant vessels going along typical international routes at low latitudes. The measurements taken at horizontal incidence on the observation deck, and on different parts of the seaman (head, shoulder, chest and back) doing typical outdoor work show the highest portion (40–80% of horizontal exposure) incident on the head. 2 years of measurements of solar UV and VIS/NIR irradiance taken on the mast top of the Research Vessel METEOR were added to the data base. Radiative transfer model calculations were performed along all the routes with satellite‐based input data of ozone and aerosol for clear sky health‐effective radiation including vitamin D3 (VD3). Measured data show extremely high noontime UV index values up to 19 with clear sky, and up to 22 due to cloud scattering. Eight hours erythemal exposure values are more than double of typical midlatitude summer values. Based on the results, an algorithm is presented to derive a seafarer's personal erythemal exposure according to his/her personal record of sea service.     

UV index forecasts and measurements of health-effective radiation

While erythemal irradiance as a potentially damaging effect to the skin has been extensively studied and short-term forecasts have been issued to the public to reduce detrimental immediate and long-term effects such as sunburn and skin cancer by overexposure, beneficial effects to human health such as vitamin D(3) production by UV radiation and melatonin suppression by blue visible light have attained more and more attention, though both of them have not become part of forecasting yet. Using 4years of solar radiation data measured at the mid-latitude site Lindenberg (52°N), and forecast daily maximum UV index values, an overall good correspondence has been found. The data base of solar UV radiation and illuminance has also been used to analyze effects of clouds and aerosols on the effective irradiance. Optically thick clouds can strongly modify the ratios between erythemal and vitamin D(3) effective irradiance such that direct radiative transfer modeling of the latter in future UV forecasts should be preferably used. If parameterizations of vitamin D(3) effective irradiance from erythemal irradiance are used instead, the optical cloud depth would have to be taken into account to avoid an overestimation of vitamin D(3) with parameterizations neglecting cloud optical depth. Particular emphasis for the beneficial effects has been laid in our study on low exposure. Daily doses of solar irradiation for both vitamin D(3) and melatonin suppression do not reach minimum threshold doses even with clear sky and unobstructed horizon during the winter months.     

Location and vitamin D synthesis: is the hypothesis validated by geophysical data?

The literature reports strong correlations between UV exposure and latitude gradients of diseases. Evidence is emerging about the protective effects of UV exposure for cancer (breast, colo-rectal, prostate), autoimmune diseases (multiple sclerosis, type II diabetes) and even mental disorders, such as schizophrenia. For the first time, the available levels of vitamin D producing UV or "vitamin D UV" (determined from the previtamin D action spectrum) and erythemal (sunburning) UV from throughout the USA are measured and compared, using measurements from seven locations in the USA are measured and compared, using measurements from seven locations in the US EPA's high accuracy Brewer Spectrophotometer network. The data contest longstanding beliefs on the location-dependence and latitude gradients of vitamin D UV. During eight months of the year centered around summer (March-October), for all sites (from 18 degrees N to 44 degrees N latitude) the level of vitamin D UV relative to erythemal UV was equal (within the 95% confidence interval of the mean level). Therefore, there was no measured latitude gradient of vitamin D UV during the majority of the year across the USA. During the four cooler months (November-February), latitude strongly determines vitamin D UV. As latitude increases, the amount of vitamin D UV decreases dramatically, which may inhibit vitamin D synthesis in humans. Therefore, a larger dose of UV relative to erythemal UV is required to produce the same amount of vitamin D in a high latitude location. However, the data shows that at lower latitude locations (<25 degrees N), wintertime vitamin D UV levels are equal to summertime levels, and the message of increasing UV exposure during winter is irrelevant and may lead to excessive exposure. All results were confirmed by computer modeling, which was also used to generalize the conclusions for latitudes from 0 degrees to 70 degrees N. The results of this paper will impact on research into latitudinal gradients of diseases. In particular, it may no longer be correct to assume vitamin D levels in populations follow significant latitude gradients for a large proportion of the year.     

Effect of column ozone on the variability of biologically effective UV radiation at high southern latitudes

Solar irradiance measurements from Ushuaia (Argentina) and Palmer and McMurdo Stations in Antarctica covering four seasons from mid-1993 through early 1997 have been analyzed and their variations compared with column ozone changes. UV irradiances were weighted for biological effectiveness using a published biological weighting function for dose-dependent inhibition of photosynthesis by phytoplankton from the Weddell Sea. All calculations involved integrated daily UV doses and visible exposures (weighted UV and unweighted visible irradiances, respectively). The results show that daily biologically effective total UV doses underwent large short-term variations at all three sites, with day-to-day increases up to 236% at Ushuaia, 285% at Palmer and 99% at McMurdo. Parallel changes in visible exposure indicated that the total UV changes were preponderantly due to variations in cloudiness. On a 12-month basis, daily biologically effective UV doses correlated strongly with visible exposures (R > or = 0.99). Anticorrelations of total UV with ozone, on the other hand, were poor (R > -0.11). The largest daily biologically effective UV doses, and their day-to-day increases, occurred as part of the normal variability related to cloud cover and were seldom associated with significant ozone depletion. UV dose/visible exposure ratios tended to reflect ozone depletion events somewhat more consistently than UV doses alone. With the Weddell Sea phytoplankton weighting function used in this study, antarctic ozone hole events were seldom readily discernible in the biologically effective UV record. The results suggest that, where the UV sensitivity of organisms was similar to that of the Weddell Sea phytoplankton, seasonal ozone depletion had no appreciable effect on annual primary productivity during the 1993-1997 period. Additional data on the geographical and seasonal variation of biological weighting functions are desirable for more comprehensive assessments of ozone depletion effects at high southern latitudes.     

An overview of the ultraviolet index and the skin cancer cases in Brazil

This study relates regional and seasonal UV index (UVI) variations, number of skin cancer cases and population skin-color distribution in Brazil. UVI calculations were performed using the UV Global Atmospheric Model (UVGAME), whose characteristics and validations are provided in thiis article. Health and racial data sets are based on the health and census data collected by Brazilian governmental agencies in the past. The discussion covers cultural customs and details of health and educational campaigns in Brazil. Despite lower UV levels in the South and Southeast regions, the results show a number of nonmelanoma skin cancer (NMSC) cases regions, where the white population is predominant. In general, in the southern regions about 50 new NMSC cases per 100000 inhabitants have been diagnosed each year. These rates decrease almost 40% in the Central-North regions and more than 80% in Northeast region, where miscegenation is common. In addition, the UVI evaluation is extended to other South American sites with singular characteristics, e.g. populous cities located in high altitudes or those affected by the Antarctic ozone hole in the extreme south of the continent.     

Seasonal erythemal UV doses in Belo Horizonte, Brazil

The ultraviolet radiation (UVR) emitted by the Sun causes many effects on the biosphere. On human beings they vary from the benefit of vitamin D synthesis to the harm of skin cancer induction. The biological dose depends on the effect, the exposure time to the Sun and the amount of UVR received. In this work we show that the measured incidence of erythemal dose (ED) in Belo Horizonte (19.92 degrees S, 43.94 degrees W, 858 m a.s.l., Brazil) for a cloudless day can vary from 7503 to 2926 J m(-2) in the summer-winter seasonal variation. In addition, supposing a linear relationship between the ED and the geophysical parameters of solar zenith angle cosine (cos(SZA)), column ozone and reflectivity from the ozone monitoring instrument overpass measurements, a model for the forecast of UVR incidence on a monthly-based period is developed. From this an annual ED of 1,451,099 J m(-2) is obtained.     

Basal Cell Carcinoma: What’s New Under the Sun

Basal cell carcinoma (BCC) is the most common skin cancer in white populations with an increasing incidence worldwide, thereby imposing an important public health problem. Its etiology is still unclear, but existing data indicate that the risk for BCC development is of multifactorial origin and results from the interplay of both constitutional and environmental factors. Yet, UV radiation (UVR) is believed to be the predominant causative risk factor in the pathogenesis of BCC. For years, BCC and squamous cell carcinoma (SCC) have been grouped together as “nonmelanoma skin cancer.” However, it seems that there are considerable biologic differences between BCC and SCC, and thus each type of epithelial cancer should be addressed separately. The present review provides an overview of the intriguing etiologic link of BCC with UVR and attempts a comprehensive review of recent epidemiologic and molecular evidence that supports this association.     

Vitamin D Fortification of Consumption Cow’s Milk: Health,Nutritional and Technological Aspects. A Multidisciplinary Lecture of the Recent Scientific Evidence

Vitamin D is essential in assuring bone health at all stages of life, but its non-skeletal effects are also essential: This vitamin impacts the physiology of the immune system, skeletal muscles and adipose tissue, glucose metabolism, skin, cardiovascular and reproductive systems, neuro-cognitive functions and cell division. The incidence of vitamin D deficiency is widespread worldwide, at any age, in young and healthy subjects, as well as in pregnant women and the elderly population, due to several factors, including inadequate sunlight exposure, skin pigmentation and coverage, adiposity, lifestyle and low dietary intakes. To overcome this problem, the fortification of foods that are consumed on a daily basis, such as milk, is strongly advisable. This opinion paper aims to discuss, in a multidisciplinary way, the current evidence supporting the importance of vitamin D in health and disease and the role of milk as an optimal carrier of this vitamin, to promote adequate intakes, highlighting its unique physico-chemical characteristics linked to both fat globule membrane and casein micelle structure. Moreover, it addresses the impact of industrial processing and storage of consumption milk on the stability of these structures, thus in determining vitamin D bioavailability and the achievement of adequate intakes.     

UV radiation and skin cancer in Norway

A distinct increase in skin cancer incidences is observed since the registration started in Norway in the 1950s. As UV radiation is assumed to be the main risk factor for skin cancer, hourly values of the UV irradiance were reconstructed for the period 1957–2005 for 17 of the Norwegian counties (58–70°N). For reconstruction, a radiation transfer model is run with total ozone amount and cloud information as meteorological input. Reconstructed hourly erythemally weighted UV irradiances for about 5 years are compared to measurements at four stations, two stations representing the north–south extension of Norway, and two stations at about 60°N representing the eastern inland – Western coastal contrasts. The agreement between reconstructed and measured UV varies between 0% for the northernmost site to 10–15% overestimation for the other locations. For clear sky, a reasonable agreement between reconstructed and measured data was found for all stations, while for overcast, an overestimation of 10–20% was found for all but the northernmost station. Both the cancer incidences and the reconstructed UV values have a distinct north–south increase. The UV increase towards south is mostly due to increasing solar elevation. The west to east increase is much smaller, and differences in UV are due to differences in both cloud optical thickness and total cloud amount. One additional outcome from this work is that long-term UV-data are reconstructed for Norway, data that can be used in further biological and medical studies related to UV effects.     

The Vitamin D Status Among Tibetans

UVB from the sun and intake from food are the only human sources of vitamin D. Tibet is a unique region for comparisons of these sources: (1) it lies at a low latitude and at a high altitude and has very large annual fluences of UVB; (2) the traditional Tibetan food is poor in vitamin D. Blood samples were taken from 63 persons of different age, with different occupations and staying at different places. UVB doses at these places were measured. The samples were analyzed by a standard radioimmune assay for determination of the serum concentration of 25 hydroxyvitamin D (25(OH)D). The main finding was that among nomads, there seems to be severe vitamin D deficiency (serum levels of 25(OH)D < 30 n m ). We tentatively propose that the low level of 25(OH)D of nomads is related to their clothing and sun exposure habits. For persons of other occupations (students, teachers and farmers) the levels are higher, although a significant fraction of these persons also have lower levels than 75 n m , by many regarded as a limit for insufficiency related to a number of negative health conditions. The annual dose of vitamin D-generating UVB is about five times larger in Lhasa than in Oslo. Despite this, the average vitamin D status seems to be similar, except in the case of nomads. This phenomenon is certainly related to food habits. In conclusion, the 25(OH)D status among nomads in Tibet appears to be alarmingly low. However, for people of other occupations the status is more normal.