With the number of melanoma cases among young adults on the rise, adherence to preventative measures could be critical to stemming the tide of increased incidences of this deadly skin disease.
Millennials could be bracing for an uptick in melanoma cases, according to a recent study.1 But, more aggressive adherence could reverse that trend.
Dermatology Times® sat down with Steven R. Feldman, MD, PhD, Professor of Dermatology, Pathology and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, North Carolina to get some perspective on the science behind the study, what that could mean for the incidence of this deadly skin cancer in young adults, and what they can to prevent further gains.
Dermatology Times® (DT): What is happening with melanoma rates in millennials? Are they going up or down? We’ve seen conflicting data.
Steven Feldman, MD (SF): According to an article published in 2019, the number of cases of melanoma for all ages increased steadily from 50,000 in 2001 to 61,000 in 2006—roughly a 20% increase over 5 years, or 4% per year.1 And it kept rising to 72,000 in 2011 and 83,000 in 2015. In 2015, there were 67 cases reported in children, 251 in adolescents, and 1973 in young adults. That’s roughly 2000 cases out of the 80,000 reported cases. So, while it's going up, it's an increased relative risk. But the absolute risk is a really small number.
One of the big problems in melanoma incidence is that there may be a difference between the number of real melanomas—the ones that would actually hurt somebody—and the number of cases that get called melanoma.
Robert Swerlick, MD, Professor and Alicia Leizman Stonecipher Chair of Dermatology at Emory University, wrote an editorial2 about a study out of the University of Pittsburgh.3 And the main finding of that study, he said, was that they found increasing numbers of thin melanomas, especially in younger people, screened by primary-care physicians. For decades, Swerlick has been talking about the unintended consequences of increased scrutiny. That increased surveillance intensity can result in increased detection of what he calls histologically worrisome, biologically benign conditions.
DT: What’s the solution to this apparent overdiagnosis?
SF: It'd be nice to do a controlled study and follow large numbers of people for many years to decide whether there really is an increased death rate or not. That’s what needs to be done, but it would not be easy. It would take a lot of time and money to do it. And the bottom line is, if you're trying to prevent melanomas in young people, and if the numbers went up 20% over 10 years, the numbers are still so small that it would take very large studies. It may not even be practical to try to tell if you can reduce that small risk. The U.S. Preventive Services Task Force has highlighted that there isn't a lot of science to support skin cancer screening.
DT: And can you predict what will happen with melanoma rates among millennials in the next few years?
SF: I suspect that if there has been a move towards greater labeling of lesions as melanoma, that it's happened already, and there might not be much further increase in apparent incidence stemming from how pathologists describe the lesions they see.
And I think the tanning bed craze hit its peak. I don't see big-time growth in how much UV people are going to be getting in tanning beds. So, I don't think that's going to contribute to any further increase in melanoma rates.
However, some people go to a tanning bed a few times to look darker, but other people go there like an addiction. There’s good evidence that UV exposure causes release of endorphins from the skin. And in these frequent tanners, there's strong evidence that these narcotic-like molecules being released by the UV light are causing an addiction to light. Telling those folks about skin cancer 20 to 30 years down the road is probably not going to change their behavior either.
It may be that UV has a relaxing effect, and release of nitric oxide from the skin can reduce blood pressure a little bit. If you're causing even a small increase in blood pressure across the entire population, you might be causing more morbidity and mortality via heart disease than you’re preventing by preventing the skin cancers.
DT: When we’re talking about improving adherence to prevent melanoma among millennials, is the main issue long-term adherence, or just getting them to use sun protection in the first place?
SF: Great question. Adherence to physician recommendations is recognized as a problem. But despite that recognition, it is still dramatically underappreciated. We think about making diagnoses and recommending treatments. We don't spend nearly enough time working towards getting people to actually make the behavioral changes that we recommend. It’s an enormous issue across medicine. And it's extraordinarily complex. Getting people to do something once is hard enough. Getting them to create a habit and do it persistently over the long term is a much higher hurdle.
DT: Are there other messages that dermatologists should be sending to millennials?
SF: Since most skin cancers happen on the face, head, and neck, wearing a big hat probably goes a long way to reducing skin cancer risks in those areas. And then for people who are super fair and burn easily, encouraging them to protect themselves so that they don't get enough sun to burn might reduce melanoma risks. Those would be 2 reasonable things that people could do and still enjoy their lives to the fullest.
Feldman reports no relevant financial interests.
1. Paulson KG, Gupta D, Kim TS, et al. Age-specific incidence of melanoma in the United States. JAMA Dermatol. 2020;156(1):57-64. doi:10.1001/jamadermatol.2019.3353
2. Swerlick RA. Melanoma screening—intuition and hope are not enough [published online ahead of print, 2022 Apr 6]. JAMA Dermatol. 2022;10.1001/jamadermatol.2022.0082. doi:10.1001/jamadermatol.2022.0082
3. Matsumoto M, Wack S, Weinstock MA, et al. Five-year outcomes of a melanoma screening initiative in a large health care system [published online ahead of print, 2022 Apr 6]. JAMA Dermatol. 2022;e220253. doi:10.1001/jamadermatol.2022.0253