Sun safety is a personal issue for Andrew Levine, CEO of Hunt Valley-based cosmetics company JADS International.
"My mother had skin cancer, my brother had skin cancer, I even had a dog with skin cancer," he said. "Skin cancer is one of the really preventable cancers out there, but people don't know when to get out of the sun or to put on more sunscreen."
Levine has designed a new product line, manufactured in the Westminster area, called Sunburn Alert; a collection of stickers and wristbands that are sensitive to the ultraviolet, or UV radiation from the sun. Such radiation both causes sunburn and leads to cancer. By using the stickers or bands, according to Levine, people will have a way to gauge how much solar radiation they are absorbing and take action to prevent skin damage, either by applying more sunscreen, covering up or just getting out of the sun.
"These are calibrated to start changing color before a person with very pale skin, or a child, will start to burn," he said. "If you put your sunscreen on, you put it on the skin and the sticker. The idea is, if the sticker starts to fade from a dark royal blue to a lighter blue, that means is your sunscreen is losing its strength ... you will reapply your sunscreen until the sticker eventually gets to a light yellow color, which means you have met your maximum exposure for the day."
Levine hopes to develop fun, kid-friendly sticker designs later this year and has been partnering with organizations like the Shade Foundation, which focuses on children's sun safety to provide new resources for parents who want to keep their children safe in the outdoors.
"The Shade Foundation is committed to educating children about how to protect themselves from skin cancer," Executive Director Lawrence Young said. "By partnering with JADS International, we hope to provide families with another tool to stay sun-safe."
The cost of fun in the sun
There is a need for resources for fighting skin cancer, which is the most common form of cancer in the U.S., with 3.5 million cases of the most common types — squamous and basal cell carcinomas — diagnosed annually according to the American Cancer Society.
It also estimated that more than 70,000 people will be diagnosed in 2015 with the more rare, but also more dangerous and aggressive melanoma type of skin cancer.
In 2011, the most recent year for which the Centers for Disease Control and Prevention has statistics, 9,128 people died from melanomas. In Maryland, about 159 people die from melanomas annually, according to the Environmental Protection Agency and the state has the seventh highest rate of newly diagnosed melanomas among white people, whose fair skin places them at the greatest risk.
The statistics are all the more tragic considering the primary cause of skin cancers — exposure to UV radiation from sunlight or tanning beds — is something people have a great deal of control over, according to Dawn Holman, a behavioral scientist with the CDC's Division of Cancer Prevention and Control's Epidemiology and Applied Research Branch.
"Our message is really to tell people to use some protection whenever they go outside," she said. "We don't tell people to avoid the sun, we want people to enjoy the sun, but be diligent in using sun protection, not just sunscreen. Sunscreen is designed to be used in conjunction with other sun protection."
Seeking shade outdoors, especially during peak sun hours of 10 a.m. through 4 p.m., covering up using hats and long sleeves and using full spectrum sunscreen of at least SPF 15 that protects against both UVB and UVA rays are all recommendations of the CDC for preventing harmful sun exposure.
Those that are not often outside in the summer, such as the average American office worker, should take particular care when it comes to sun safety, according to Holman. Intermittent sun exposure, such as going to the beach for the weekend or a camping vacation is correlated with sunburns, she said, and sunburns strongly increase the chances of developing melanoma.
Cumulative sun exposure meanwhile, such as someone who regularly works outdoors might receive over the course of the summer, or even a lifetime, is more strongly correlated with the development of basal and squamous cell carcinomas, according to the National Cancer Institute's "Skin Cancer Prevention for health professionals." The risk is greater for those with fairer skin, who do not tan well, or who burn easily, according to that document.
The relationship between sunburns and melanoma may be even stronger in children. According to "The Surgeon General's Call to Action to Prevention Skin Cancer," getting even one sunburn as a child increases your chances of developing melanoma by 91 percent compared with children who were never sunburned. Although the very study this statistic is based upon, which examined 51 other studies that looked at melanoma risk, cautioned against weighing a single burn too heavily.
"Measurement of sunburns as 'ever' or 'never' sunburned as a child, adolescent, adult, or during one's lifetime may appear to be simpler; however, such categorization loses valuable information and should not be over interpreted," the study's authors wrote. "Combining all number of sunburns into 'ever' assumes the risk for [melanoma] of one sunburn is equivalent to 20 sunburns."
Beneath the skin
Any time the skin is getting tanned, it is a sign that some kind of damage is taking place, Holman said. She went on to say, however, that it is difficult to know based on current research if those who wear proper sun protection and yet grow tan over the course of the summer months are also increasing their risk for developing skin cancer to a substantial degree.
"The data on this has really come from indoor tanning," she said. "We don't have great data looking at the level of tan that someone gathers over the course of the summer."
One thing that is fairly clear is that the amount of UV radiation that causes skin to tan can also cause premature aging of the skin, according to Ann Boyles, a registered nurse and community educator for Carroll Hospital. When discussing sun safety with people at schools or in the community, she uses skin damage as a more immediate, graspable marker for the harmful side of sunshine.
"We have a machine called a skin analyzer. It doesn't detect skin cancer, but it does detect sun damage to your face," she said. "It has a black light, and … then there is a mirror in there. When you look into that mirror, the sun damage shows up as dark brown patchy areas that are different than your skin color."
Since some sun exposure may be unavoidable, and a person cannot go back in time to prevent a childhood sunburn, keeping an eye out for skin changes is also an important part of preventing skin cancer, according to Boyles.
"The important thing is to become familiar with your own skin and body," she said. "Any changes that you notice in your skin — dryness, patchy areas, something that's new that looks different, or something that has been there that is changing — that is something you want to have checked out either by your primary care doctor or your dermatologist."
Sunburn Alert stickers are an innovation keeping with the times, according to Dr. Henry Taylor, acting health officer at the Carroll County Health Department, another tool — like the Fit bit, or the Apple Watch — that allows people to track their own health and wellness behaviors.
"I think it's really good for people to learn as much as they can about what affects their health and do whatever they need to live a healthier lifestyle," he said. "At the same time, I would caution people that, it is complicated, and a lot of people do waste a lot of money on fancy gadgets or pills, It's possible for people to waste time and energy and distract themselves by finding the magic bullet."
Single source solutions, like using only sunscreen and not wearing a hat, are too inflexible, and Taylor said it would also be a mistake to focus too much on preventing skin cancer if you don't remember to wear your seat belt. He said he believes the Sunburn Alert stickers could have a valuable role to play as another nudge that reminds people to engage in sun-safe behaviors.
"I know that I am healthier and behave better when I track my sleep and my exercise," he said. "When I am getting too busy and not taking care of myself, I need those reminders because it's easy to forget to do those things we know we should be doing when our station makes it difficult.
The limitations of evidence and public health
When it comes to the science behind sun exposure and skin cancer, there are some things researchers know almost for certain.
There is solid evidence, for instance, that sun exposure —specifically exposure to UV light — increases a person's risk for developing either squamous or basal cell carcinomas, the most common but less aggressive forms of skin cancer, and there is fair evidence that such exposure increases the risk of developing the less common but more aggressive melanoma skin cancer. That's all according to the National Cancer Institute's "Skin Cancer Prevention for health professionals, which was last updated to reflect the current state of scientific evidence on May 14.
That same review of the evidence, however, found there was "inadequate evidence to determine whether the avoidance of sunburns or the use of sunscreen alters the incidence of cutaneous melanoma," and made similar conclusions concerning the prevention of squamous and basal cell carcinomas.
If the science is "inadequate," why do public health officials, the Surgeon General and others make recommendations as if it is? Part of the answer has to do with the inherently probabilistic nature of science. Another part of the answer relates to the problem of sending a coherent message that applies to a diverse population, according to Dr. Henry Taylor, acting health officer at the Carroll County Health Department.
"Uncertainty [in the science] affects the way we develop policy differently than what we say in public health messages or what people may be told by their own health care provider," Taylor said. "The people in the groups that make policy recommendations, who are different from the scientists, often feel they have to give some clear statement in order to get a particular group of people to go ahead and do what needs to be done."
The actual risk of developing skin cancer for any one individual will depend on myriad factors — skin type, family genetics and behaviors that amplify or mitigate the effects of sun exposure — that cannot be captured by a general public health message, according to Taylor, and recommendations from a person's doctor should always take precedence over public health messages. At the same time, he said, public health officials are constantly trying to assess the latest science to adjust advice accordingly.
There is also the fact that science is always evolving because, in part, no one study can take into account every factor that can complicate the results when it comes to something as complex as skin cancer.
"It's hard to separate out those factors that are directly related to causing skin cancer, from something we call intervening factors," Taylor said.
Taylor's father-in-law died of melanoma, which he said means his wife is 12 times more likely to develop melanoma, just because of that genetic relation. At the same time, his wife's family also had a summer house on the beach.
"Their whole family had a lot of sun exposure because it was a time when sun tans were considered stylish and attractive," he said. "The fact that they lived at the beach is affecting the degree of sun exposure in people that had a genetic tendency to skin cancer."
Ultimately, Taylor said public health recommendations are attempts to net the best results over the widest population despite imperfect scientific knowledge of what causes and what prevents disease, as well as imperfect knowledge about who will eventually develop a cancer.
According to the National Cancer Institute review, for instance, using sunscreen has few downsides: "The harms of sunscreen use are poorly quantified but are likely to be small, including allergic reactions to skin creams and lower production of Vitamin D by the skin with less sun exposure."
Not using sunscreen, however, will definitely increase your exposure to UV radiation, which will increase you chances of developing skin cancer. According to Taylor, that makes the public messaging about sunscreen use a good bet.
"This is about probabilities. It's taking a gamble, it's a role of the dice," Taylor said. "What situation you choose to take the risk in, and whether something else has weighted the dice against you. All of that is going to effect your chances of developing skin cancer."