Not made in the shade: Too much sun

Summer means picnics, barbecues, swimming, days on the beach or boat – treasured experiences that cast away worries while families soak up the sun.

When it comes to sun exposure, most of us know that too much is definitely not good for us. Or do we?

According to an American Academy of Dermatology survey released last year, 76 percent of Americans agree that sun protection is a healthy and important habit, but only 41 percent regularly protect themselves, and 28 percent say they rarely or never use protections including sunscreen, protective clothing or umbrellas.

That’s alarming news in a state where many people are fair skinned, which increases skin cancer risk, and where nearly everyone craves sunshine after being cooped up all winter.

According to Centers for Disease Control data collected between 2013 and 2017, the most recent national survey available, New Hampshire has the nation’s third highest rates of melanoma, a lethal form of skin cancer – trailing only Utah and Vermont. As a percentage of the population, New Hampshire appears to have significantly more deaths related to melanoma than the Green Mountain State.

Between 1982 and 2017, melanoma rates more than doubled in the U.S., and they continue to rise globally.  All types of skin cancer, including basal cell and squamous cell carcinomas – cancerous skin growths that can be removed and usually don’t spread to other organs – are increasing as people are living longer and affecting all ages and races, according to the American Cancer Society.

Skin cancer is the most common cancer in the U.S.  The Cancer Society predicts that 11,540 Americans will die of skin cancer this year.

Dr. Evaa Alawami, a dermatologist at Concord Dermatology, says there's a false sense of security when it comes to warding off threats from the sun, especially in New Hampshire, where people are more likely to feel sun-deprived. But the trends are extremely concerning, even as death rates from melanoma have dropped nationally.  Alawani said her practice is seeing more serious skin cancer cases.

“We like to be outdoors. We have long winters,” said Alawami, who treats two main cohorts of patients for skin cancer: golfers and lake house owners with skin damage from frequent sun exposure and burning. “You can diagnose more than one type of cancer in one visit,” she said.

Last month Alawami saw two patients whose melanomas had spread to their lungs and brain.  In terms of percentage of dermatology patients with any form of skin cancer, “number-wise, they are up. We’re seeing more and more.” Melanomas are less common but have higher mortality rates. But various types of skin cancer are becoming more prevalent in older and middle-aged people, she said.

But it’s hardly an age-related health danger. Nor is it confined to any stereoptype – such as people with pale skin, freckles and light-colored hair, who are often considered the most at risk.  Alawami had a 21-year-old patient with a much darker skin tone who developed melanoma in one finger, just above the nail.  She recently diagnosed three patients with melanoma in their hands and feet.

According to data from the American Academy of Dermatology, melanoma incidence has begun to decline in adolescents and adults age 30 or younger, but continues to be the most common cancer in people age 15 to 29, according to the ACA. Skin cancer among children, especially young females, continues to be a serious concern and repeated sunburns at early ages raises the risk of skin cancer later on. In older populations, melanoma is increasing, according to cancer statistics. But incidence is complex to track. The rates also reflect trends toward earlier diagnosis and treatment.

Complicating the discovery of skin cancer is that many are tough for amateur eyes to distinguish from otherwise harmless marks, lumps and moles.  Melanoma frequently appears as a very dark raised spot, larger than a standard eraser on a pencil – but that’s not always the case, and it can be challenging to discern in very dark skin.  In children, it sometimes appears as a red, growing spot.

“It can appear at any age, in anybody,” Alawami said.  If you see something concerning or changing, the first expert to consult is your primary care provider, who can determine if it warrants a dermatologist's exam.

Dr. Nora Janeway, medical director at Health First Family Care Centers in Laconia and Franklin, says melanoma is a diagnosis she never wants to miss. As a primary care physician, Janeway refers patients to dermatologists when their skin spots or growths are unusual or increasing in size, and she notes their appearance so she can evaluate any changes over time.

“Melanoma killed Bob Marley at the age of 36,” said Janeway. Nationwide, “what we’ve seen over the last decade is way more melanomas being diagnosed, but not a greater number of deaths” – a mercy that can be traced to greater awareness of skin cancer coupled with finding melanoma earlier. “More people are coming to the doctor, saying my mole looks strange or dark.  In the Lakes Region, I do see a lot of photo aging and photo damage – the combination of light-colored skin and sun overexposure, over many, many years.”

This definitely boosts skin cancer risk, according to American Academy of Dermatology, Alawami and Janeway. 

Nick VinZant, a senior research analyst for Quote Wizard, an insurance company that’s part of Lending Tree, Inc., assesses skin cancer risks. Statistics don’t tell the entire story, he said, but they hint at trends creeping up, or tips of expanding icebergs. Contrary to conventional wisdom, northerly states across the country have the highest skin cancer rates, which have moved slightly up since 2013, said Vin Zant, who lives in Washington, another outdoorsy state with a comparatively high incidence of skin cancer.

In 2013, New Hampshire had an average of 30.9 new cases of melanoma diagnosed for every 100,000 population. That jumped to 32.1 in 2017, which VinZant says is statistically significant. Nationwide, the new case average was 23.6 per 100,000 people in 2013. That rose to 28.4 four years later. A nearly 5 percent increase translates to a lot of cases when expanded to the entire U.S. population. The American Academy of Dermatology estimates that 7,180 people will die from melanoma this year.

In New Hampshire, between 2013 and 2017, 2,691 new cases of melanoma were diagnosed, and 1,053 melanoma-related deaths were reported, according to the CDC. During the same period, Vermont had 1,500 new cases and 68 deaths. But the Green Mountain state has a melanoma rate 5.5 percent higher than New Hampshire’s. 

“Melanoma is pretty directly related to sun exposure” as well as exposure to ultraviolet rays in tanning booths, VinZant said, Skin type and genetics are also big factors. The colder, more northern states in general have higher skin cancer rates because of demographics, less perception of risk and danger, and lagging use of sun protection. In sunnier, southerly states, combating the effects of the sun is an early, daily habit, including in Texas, where the new case rate was 13 percent in 2017.

In northern states, people "aren't preparing as well because they’re not as constantly exposed" to sun year round, Vin Zant said. Northern folks are more prone to getting sunburned when seasons change, and less likely to use sunscreen on cloudy days, even though the problematic rays get through.

State-to-state differences in melanoma and skin cancer rates do not appear to be related to difference in medical care or diagnosis between the states, Vin Zant said.

Adriane Burke, cancer programs director for the Division of Public Health at the New Hampshire Department of Health and Human Services, believes the state’s racial and ethnic makeup play a big role in the Granite State’s skin cancer picture.

“When we look at who gets skin cancer, it’s mostly non-Hispanic white people,” said Burke. New Hampshire is comprised of roughly 90 percent non-Hispanic whites - compared to 60 percent nationally. When comparing state rates of skin cancer for non-Hispanic whites, New Hampshire ranks 8th highest.

Other factors increase risk, according to the AAD and CDC. Experiencing five or more blistering sunburns between the ages of 15 and 20 boosts one’s risk for melanoma by 80 percent. Research shows that UV light from the sun and tanning beds can cause melanoma, and increase the likelihood of a mole becoming a melanoma. Use of tanning beds increases the risk, especially for women age 45 and younger.

Melanoma rates are 60 percent higher in men, who more often work outdoors and seldom bother with sun protection, according to national data.

Females are diagnosed with melanoma at much younger ages – a statistic Burke hopes is being curbed in New Hampshire. In 2015, HB136 made tanning booth use illegal for anyone under 18.  Their use declined between 2011 and 2015, but tanning booths are not policed for age violations, and it’s hard to know what’s happening now, Burke said.

She believes individual strategies go a long way to cutting skin cancer risk, including applying sunscreen, wearing long pants and long sleeve shirts, hats and sunglasses – and seeking shade under trees or an umbrella. According to the AAD’s report in 2020, 65 percent of Americans don’t know that shade protects them from the sun’s harmful rays.

The next frontier is playgrounds, Burke said. “We need to ensure that kids have shades structures over play structures. We see playgrounds that are fully out in the sun.”