1. Susman, Ed

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WASHINGTON, DC-People who work outdoors, whether in the high mountain ski slopes or on the humid agricultural fields, have increased risks of developing skin cancers, including melanoma, researchers reported at the 74th annual meeting of the American Academy of Dermatology.

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At a skin screening clinic at a Utah ski resort, 21 skin cancers were found among 262 people, mostly workers at the resort, reported Amir Varedi, BS, a medical student at the University of Utah, Salt Lake City, in his poster discussion presentation.


Of those patients screened, the researchers identified 15 basal cell carcinoma, two squamous cell carcinoma and four melanoma. They also identified 58 actinic keratosis, and 22 dysplastic nevi cancers, Varedi said. "We advertised that we would be doing the screening for about a month or two and then when we would show up there would be people waiting," he told Oncology Times. "We were very surprised that we had almost 10 percent of the people screened with skin cancer.


"As we continue to educate these workers at ski resorts, and screen them and refer them, we are hoping to see these rates go down," he said. The researchers conducted seven screening programs between 2011 and 2015 at two ski resorts in Utah, both at elevations greater than 8,000 feet. About 54 percent of the people screened were women; 96 percent of those screened were white.


Varedi noted Utah has the highest incidence rate of melanoma among any state (34.6 annual incidence per 100,000 persons and is among the top 10 states for rates of all skin cancer diagnoses.) "Many factors contribute to this, including a predominantly fair-skinned population, high altitude, and an active outdoor year-round lifestyle," he said. "Free skin cancer screenings are one strategy for promoting early detection of melanoma and other skin cancers in resort employees, whose employment necessitates extended time in the sun with cumulative exposure to ultraviolet radiation during peak hours at high altitudes and reflection from the snow."


Sun Safe on the Slopes

The study is a partnership between the Huntsman Cancer Institute, Utah Cancer Action Network, and local ski resorts to provide community outreach, prevention education, and skin cancer screening to employees through the program, Sun Safe on the Slopes.


"The Sun Safe on the Slopes program serves an at-risk population with health concerns not previously being addressed. The screening yielded an alarming rate of 8 percent of participants with presumed skin cancers," Varedi said. "Periodic skin cancer screening, as well as preventative on-site education, can contribute toward earlier detection and decreased incidence of skin cancer in this high-risk population. This program could be incorporated into outdoor recreation facilities where employees have prolonged ultraviolet exposure."


In commenting on the study, Susan Weinkle, MD, past-president of the American Society for Dermatologic Surgery, told Oncology Times, "It is important to look at sun exposure and the risk of skin cancer in the work environment. It's well-known that fair-skinned people at high altitudes [and] people that have an outdoor lifestyle have a higher risk of skin cancer.


"Most people on the ski slopes are covered up-they wear gloves, they wear helmets, they wear goggles, but in spring when it is warmer and they uncover, there is risk for sunburn and we know clearly that sunburning is much more harmful than low sun exposure."


Melanoma in Underserved Patients

In a second study at the meeting, researchers at the Caridad Center in Boynton Beach, Fla., found a high rate of melanomas at the state government-funded clinic that works with an underserved, underinsured population.


Audrey Jacobson, MD, a post-doctoral student at the University of Miami Miller School of Medicine, said she and colleagues performed a chart review of patients who had undergone excision of suspicious lesions that were then biopsied. Of the 38 patients in the study, 68 lesions were excised between January 2010 through March 2015.


There were 48 malignant lesions in that group: 58.3 percent were basal cell carcinoma, 22.9 percent were diagnosed as squamous cell carcinoma, and 14.6 percent were melanoma, Jacobson said in her poster discussion presentation.


"Almost 15 percent of the tumors we excised in this study were melanoma," she said. "Melanoma should only account for about 2 percent of diagnoses, so we do need some further research to determine why our sample had such a high rate of melanoma."


This high rate was also puzzling to Weinkle, also an affiliate dermatologist at the University of South Florida, Tampa. "Quite honestly, I find these numbers difficult to understand. The number of skin cancers found in this sample just seems atypically high. It is surprising to find seven melanomas among 38 patients. That is disproportionately high. This seems to be a bit skewed."


Jacobson said there are multiple reasons for the high numbers. "Basal cell carcinoma or squamous cell carcinoma may not look as worrisome to many patients and they may not present to our clinic," she said. "Maybe they know that melanoma is more worrisome, so there could be selection bias on the part of the patients."


She noted most of these patients generally work the farms and in the cane fields in South Florida. The Caridad Center cares for patients whose incomes fall below the U.S. poverty line. "It is really important for these patients to get care because access to specialty care such as dermatology is so hard to get even for people with insurance," Jacobson said.


"Communities such as the one described in this study exist in various forms across the U.S. and globe," she said. "Our results highlight the need for further investigation into skin cancer in uninsured, minority populations. In particular, socioeconomic factors, specific barriers to care, and cultural differences need to be described to better prevent, diagnose, and treat skin cancer in these at-risk populations."


Weinkle said people may associate sunburning with recreational activities such as going to the beach, skiing, golfing, but that people who work outside may not think in terms of sun protection.


"Outdoor work can lead to skin cancer so sun protection is important," she said. "Any suspicious lesion should be checked by a dermatologist. It is important to stress the sun exposure in a work environment."


Ed Susman is a contributing writer.