Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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The consequences of the statement "Sun Exposure is not a major cause of Melanoma"
- Ashley J Cooper (27 July 2008)
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Acral Lentiginous Melanoma - no sun on toes.
- Andrew Burd (28 July 2008)
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A correction
- Sam Shuster (28 July 2008)
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Time to go and get that hat
- Richard Quinton, Simon HS Pearce, John L Sievenpiper (28 July 2008)
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Use your head… and put a hat on it!
- Marc D. Moncrieff, Jennifer Garioch (29 July 2008)
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melanoma: no fun in the sun
- David G Samuel (29 July 2008)
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Mad Dogs and Englishmen
- Eddie Vos (30 July 2008)
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Diagnosis is the problem
- John N Burry (31 July 2008)
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Sun exposure is the cause of some melanomas
- Giovanni Codacci-Pisanelli, Roma, Italy, 00161 (31 July 2008)
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UV is not a major cause of melanoma: a reply.
- Sam Shuster (7 August 2008)
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Re: melanoma: no fun in the sun
- David G Tucker (7 August 2008)
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Not a subject for 'debate'!
- peter j mahaffey (28 August 2008)
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Ashley J Cooper, Consultant Dermatologist Kent and Canterbury Hospital, CT5 0XY
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Dear BMJ, As a Consultant Dermatologist running two-week wait cancer clinics and dealing with between four and eight melanomas per week (and numerous other skin cancers) at our multidisciplinary team meeting across the whole county, I find Dr. Shuster's arguments that melanoma is not related to sun exposure irresponsible and beyond rational thought. I do not believe the references quoted in his article are a fair representation of the body of scientific evidence available to us; and when mixed with selectivity and conjecture, cannot be relied upon to form concrete opinion. His statements regarding increased malignant diagnosis of 'benign' moles are frankly dangerous, and doesn't help the patient in the clinic presenting with a changing atypical naevus, or a diagnosed melanoma representing with local metastatic spread. Does he expect us to tell patients who are histologically diagnosed with a melanoma that it is a benign disease and the Histopathologist is wrong? His interpretations regarding research on sunbed use and ultraviolet A phototherapy are misguided. I find Scott Menzies' excellent observations far more compelling, as i expect most Dermatologists in the World would. I am not averse to good debate or clinical research; but melanoma aside, I am concerned that the Public Health message of Dr Shuster's article when transmitted into the lay press via the BMJ will only cause the 'epidemic' of nonmelanoma skin cancer (and, in my opnion, melanoma) to increase, whether it is believed to be real or not. We spend a lot of our time trying to convince the habitual sun worshippers to cover up when we remove their multiple basal cell and squamous cell carcinomas. If we are now to tell them that "ultraviolet light may protect against some forms of cancer including melanoma", i will go and get my hat. Dr Ashley Cooper East Kent Competing interests: None declared |
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Andrew Burd, Professor of Plastic, Reconstructive and Aesthetic Surgery The Chinese University of Hong Kong
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I have just finished writing a short update review on Cutaneous Melanoma for a local journal and a point of note is the ethnocentricity of the melanoma debate. I have no doubt that sun exposure but also major attacks on the immune system such as critical life events are involved in the superficial spreading and nodular melanomas in Caucasians but what about the acral-lentiginous type? Although this accounts for only 2% of Caucasian melanomas it accounts for more than 50% in our local Chinese population and I have yet to see anyone sunbathing in Hong Kong with their feet in the air! Malignant Melanoma is a fascinating but also potentially terrible disease, but whatever the mechanism it is the melanocyte that is the cause. As an aside, melanocytes, in health and disease are possibly responsible for more personal and inter-personal distress than any other single cell type. Nevertheless I would rather have my melanocytes than not have them, and whilst I have them, I will restrict their exposure to electro-magnetic radiation whether it be from the sun, (moon or stars would parse nicely but...) medical lasers or coal fires. Competing interests: None declared |
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Sam Shuster, Emeritus Professor of Dermatology Norfolk and Norwich University Hospital
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I will respond to this later, together with any others that may arrive. In the meantime I’d like to correct an error in the published text. I wrote: “This view is supported by the findings of the Eastern region of England that the increase in new "melanomas" during 1991-2004 was entirely due to benign naevi (Levell et al, personal communication)” This should have been “This view is supported by the findings of the Eastern region of England on the increase in new "melanomas" during 1991-2004 (Levell et al, 2007)", and the full reference is Levell N, Beattie C, Greenberg D "Why has melanoma mortality remained unchanged when incidence is increasing: success, over-treatment and/or misdiagnosis? Br J Dermatol July 2007 157 (suppl 1) 103. Sam Shuster, Emeritus Professor of Dermatology. Competing interests: None declared |
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Richard Quinton, Consultant & Senior Lecturer in Endocrinology Endocrine Unit, Royal Victoria Infirmary, Newcastle-on-Tyne, Simon HS Pearce, John L Sievenpiper
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Dear Sir, Dr Cooper finds Scott Menzies' "excellent observations far more compelling, as [he expects] most Dermatologists in the world would". He is also concerned about Dr Schuster's article translating into an "epidemic of nonmelanoma skin cancer. Finally, he professes to be unaware of "evidence that ultraviolet light may protect against some forms of cancer". We would therefore direct Dr Cooper to the BMJ Lesson-of-the-week that we recently co-authored (1), along with its accompanying editorial by Mike Hollick (2). Therein Dr Cooper will find that the evidence linking major cancers, including breast, prostate, pancreas and colon to UVB light under-exposure to is a actually rather stronger than is the evidence linking melanona (quantitatively responsible for an order of magniture fewer deaths) to UVB over-exposure. This debate highlights how the more we as specialty physicians diverge from the common stem of general internal medicine that nurtured us, the greater the risk of us missing the bigger picture when an issue transcends specialty boundaries. Incompletely justified high-profile media campaigns about sunlight and melanoma risk may well produce short-term gain, in respect of a fall in non-melanoma skin cancer, but is this an ethically justifiable end- point of itself? We physicians need to be open and honest with our patients and, if called upon to do so, the general public. Where our opinion is founded largely upon our own personal experience (however extensive), but where the hard evidence is incomplete and/or indirect, this needs to be made clear to our interlocutors, else we doctors may in future years forfeit the professional trust bestowed on us. Yours sincerely, Dr Richard Quinton
1. Sievenpiper JL, McIntyre EA, Verrill M, Quinton R, Pearce SHS. 2008 Lesson of the Week: Unrecognised severe vitamins D deficiency. BMJ. 336: 1371-1374. 2. Hollick MF. 2008 Deficiency of sunlight and vitamin D: fortification of foods and advice on sensible sun exposure are urgently needed. BMJ 336: 1318-1319. Competing interests: None declared |
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Marc D. Moncrieff, Consultant Plastic Surgeon Norfolk & Norwich University Hospital, Colney Lane, Norwich. NR4 7UY, Jennifer Garioch
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Sir, We were disappointed to read Sam Shuster's article in the BMJ and would like to emphasise that this is not a view shared by the lead clinicians of the Norfolk & Norwich University Hospital skin cancer MDT. There is very good epidemiological evidence that melanoma is related to UV exposure that Dr Shuster has not cited. Marks1 has shown that the public health campaign in Australia has shown not only a decrease in the incidence of melanoma but also an increase in the detection of early, treatable lesions. Despite this positive progress, Queensland, a tropical region, has the dubious honour of having the World's highest incidence of melanoma. Is it Dr Shuster's assertion that the white Anglo-Saxon/Celtic majority living in this area somehow have inherited genetically unstable melanocytes? Alternatively, is it his assertion that Queensland has a particularly overzealous and poorly trained group of pathologists? The role of intermittent, high intensity exposure has been suggested as the mechanism by which UV light induces malignant change in melanocytes2. Intermittent ionising radiation is a well-recognised and well-documented model for inducing other cancers, most notably sarcomas3. Shuster suggests that melanomas do not occur in anatomical sites with this pattern of exposure, yet the most common location are the trunk and lower limb for males and females respectively. It is these same areas that are commonly sunburnt during the holiday season, particularly in childhood. We do not advocate that UV light is the sole cause of melanoma and Professor Burd does well to highlight the occurrence acral lentiginous melanoma in non-white populations on non-exposed areas. However, the incidence of melanoma in these populations is very rare. Quniton et al suggest that UV light may have a protective effect against some cancers. If this were as important they suggest, Australians would be some of the healthiest around. An inspection of the readily- available statistics reveals that cancers of the breast, colon & prostate kill with montonous regularity in Australia and New Zealand as they do in Western Europe4. A more rational explanation is likely to be that vitamin D deficiency is a surrogate marker for poorer socioeconomic status and chronic malnutrition in general, both well established risk factors for many diseases, including cancer. What is more, the mortality from melanoma in these countries is not "...quantitatively responsible for an order of magnitude fewer deaths" but is actually the fourth most fatal cancer of the entire population. Quinton et al may be less dismissive of melanoma if they were to consider that in England & Wales, melanoma is the third most common cancer in the 16-40 year-olds5, the very cohort that are contributing taxes to pay for our government-sponsored positions. No skin cancer specialist would suggest that uv light is to be completely avoided, rather the sunburn it can cause. The Australians have taken a lead in educating the public about uv-related skin cancers and have demonstrated its effectiveness6. Perhaps its time we put our hats on and followed them. Marc Moncrieff MD FRCS(Plast.) - Lead Surgeon Jennifer Garioch MD FRCP - Chairperson & Dermatologist Skin Cancer MDT, Norfolk & Norwich University Hospital Foundation NHS Trust 1. Marks R. The changing incidence and mortality of melanoma in Australia. Recent Results Cancer Res. 2002;160:113-21 2. Gilchrest BA, Eller MS, Geller AC, Yaar M. The pathogenesis of melanoma induced by ultraviolet radiation. N Engl J Med. 1999;340(17):1341 -8 3. Laskin WB, Silverman TA, Enzinger FM. Postradiation soft tissue sarcomas: an analysis of 53 cases. Cancer 1988;62:2330-2340 4. http://info.cancerresearchuk.org/cancerstats/geographic/world/commoncancers/?a=5441 (Last accessed 28th July 2008) 5. http://info.cancerresearchuk.org/healthyliving/sunsmart/skincancer/malignantmelanoma/ (Last accessed 28th July 2008) 6. Marks R. Campaigning for melanoma prevention: a model for a health education program J Eur Acad Dermatol Venereol. 2004;18(1):44-7 Competing interests: None declared |
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David G Samuel, F1 general surgery Prince Charles Hospital CF47 9DT
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As a newly qualified doctor who spent 8 weeks last year studying at the Sydney Melanoma centre I was dumbfounded by the claims made against a link between sun exposure and melanoma. Having spent time with endless patients reporting hours of sun exposure and sunburn in earlier years and now presenting with cancerous lesions I believe that Dr Shuster may benefit from a similar "elective" in order to change his mind on the melanoma theory! Rubbishing the claims that the high incidences of melanoma do not occur in sun bathed areas seems bizarre. I have not heard of epidemics of melanoma occurring amongst the Eskimo populations or the Shetland island inhabitants. It does seem strange that the rates are higher in sunny Oz does it not?! I also feel that by writing his article, Dr Shuster has also undone many years of hard work and public awareness campaigns to encourage people to act responsibly in the sun. I only hope that his clinics are not over- run by worried sunbathers in years to come as that little mole becomes and itchy, bleeding, ulcerated lesion! Claims that melanoma is now mis-diagnosed and inaccurately categorised histopathologically are also misled. The Sydney centre has a team dedicated to assessing only melanoma biopsies. Day in, day out their eyes see the subtle differences between benign and cancerous lesions. I can speak from first hand experience that the dangers of melanoma are real! Seeing young patients, many in their twenties and thirties dying from metastatic melanoma is a humbling experience and has certainly made me reach for the Factor 50 on a sunny day! I admit that sun exposure is not the only factor involved in developing lesions, and genetics may increase the risk of melanoma but surely the experiences of this team who, after all see slightly more melanoma cases than in sun bathed Britain, as well as the self reported behaviours of patients who admit to over exposing themselves to the sun and burning regularly cannot all be wrong? Recent cases of "sun bed" related melanoma also raises the theory of UV linked hypotheses to the skin surface and increases credibility of a "sun" link. I only hope that Dr Shuster enjoys the summer sun if it ever arrives - I for one will continue to tread carefully and follow the slip, slap slop message by donning the Factor 50! Competing interests: None declared |
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Eddie Vos, maintains www.health-heart.org Sutton (Qc) Canada J0E 2K0
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The sun fearing side of the debate appears to miss the fact that humans cannot live healthily without ample vitamin D3, only obtained from marine liver fat or from the sun over 45 degrees above the horizon. The idea of Mad Dogs and Englishmen going out in the mid day sun*) has merit since there may be a reason we're a naked species, some with light skin and rosy cheeks, to allow endogenous manufacture of vitamin D3 .. and since we're a species not licking its fur for 'UV-B damaged cholesterol', a.k.a. vitamin D3. Without that vitamin/hormone for which a receptor in all cell types, calcium homeostasis and normal cell expression is not possible, an effect certain for bone health and probable for cancer development prevention. Sun protection factor creams prevent evidently harmful burning but also the generation of vitamin D, a ticking time bomb since health is more than skin deep. *) http://www.health-heart.org/MadDogsAndEnglishmen.wav Competing interests: None declared |
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John N Burry, retired dermatologist PO Box 7177 Hutt St Adelaide 5000 South Australia Australia
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Melanoma is a deadly cancer. There is no doubt about the diagnosis if the
tumour metastasises. The problem for the clinician and the histopathologist is
to make the diagnosis before there is metastasis. Melanoma may evolve from
naevi. Changes in naevi have led to the diagnosis of dysplasia which it is
maintained is evidence of early malignancy. Samuel has complete faith that
histopathologists are able to see the "subtle differences between benign and
cancerous lesions". Perhaps Cooper has the same faith when he see "between
four and eight melanoma per week" at a clinic in the south of England. Shuster
doubts the "subjective histopathological criteria used to diagnose melanoma
which have become too vague for use and are commonly found in benign
disease". It is obvious in Australia that melanoma is caused by sunlight. To
argue that it is not because of confusion in histopathological diagnosis is not to
sort out the confusion but to add to it. John N Burry retired dermatologist
Competing interests: none |
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Giovanni Codacci-Pisanelli, Medical Doctor - Research Assistant Roma, Italy, 00161, Roma, Italy, 00161
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I think there is no doubt that sun exposure is a major cause of melanoma in specific situations, namely the anglosaxons that moved to Australia. It remains questionable whether similar relevance may be attributed to populations that remained in the same areas for thousands of years, for example, southern europeans living on the border of the mediterranean sea. Furthermore, the assumption that sun exposure for recreational reasons causes melanoma while constant exposure for occupational reasons does not appears paradoxical. The sun does damage several substances that are exposed to it for a long time, from car paint to plastic. What we frequently see in Italy in elderly persons who worked all their life under the sun are skin carcinomas. I would like to propose three subjects for discussion,
Competing interests: None declared |
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Sam Shuster, Emeritus Professor of Dermatology Norfolk and Norwich University Hospital
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As editorial limitation did not allow the text and references for a full exposure of the poor evidence used to promote UV as the cause of melanoma, the misdiagnosis of benign moles as melanomas, and the failure to balance the potential benefits of UV against the unproved risk of melanoma, a reply is needed to the responses which continue to rely on common misconceptions Firstly, melanomas are not more common in the main sites of sunburn and sun exposure1 Over 50% of melanomas in Prof Burd’s Chinese patients’ arrive underfoot, although he has “…yet to see anyone sunbathing with their feet in the air”2. Retain that image to hold the fact. Statements to the contrary3,4 rely on making the actual distribution appear sun related, by “correcting” the observed data for site, distribution of melanocytes, naevus cells or surface area. This is unacceptable, because we don’t know melanoma’s cell of origin, and instead of hard evidence on naevus cell and melanocyte distribution, we just have mole counts and one limited early 50’s study, which did not distinguish epidermal from follicular melanocytes. Proponents of the “correction” haven’t even noticed that it makes the role of sun even less convincing, because it increases by at least tenfold the facial density of basal and squamous cancers, the bench- mark of sun induced tumours, with which melanoma has to be compared. So, for the moment, we have to talk simple site distribution, and that puts melanoma well out of the sun. The question isn’t whether UV has some effect on melanoma, but whether it is a major cause; that is why the tumours in XP are important. But the alleged 1000 fold risk in XP4 is based on incomplete data5, and when total tumour count is used, the melanoma risk is only 5% of that for basal and squamous basal cell cancers. Some responders objected to the observation that the melanoma scare arose as benign moles became misdiagnosed as melanomas6,7, , and is the most likely explanation of why the once dangerously mortal melanomas have become benign. This is not surprising as they weren’t around in the early 80’s when we older dermatologists saw it happen under our own microscopes in the US and UK, as in Australia8. The need to reassess the effects of UV is important: evolution must have taught us how to live with the sun, and we cannot assume we know enough about its harmful and beneficial effects to set the balance of exposure; but I do agree with Moncrieff and Garioch1 that we should be cautious about the cancer protection studies: they could be just as unreliable as melanoma epidemiology. The field is now choked by epidemiological studies and their meta- analyses, that sure sign of doubt, could now spawn a new family of meta- meta analyses with the same uncertain outcome shown for the effect of sun screens and beds. The BMJ was quite wrong to ask “Where do you stand on this issue?” because this is not a matter for a “good debate”6: we will only resolve the melanoma problem if we forget our epidemiological preoccupation with UV and start again with some real science. I have no competing interests to declare, and my everyday work is not concerned with the diagnosis, treatment and prevention of melanoma. 1 Moncrieff M D, Garioch J. Use your head… and put a hat on it! (BMJ Rapid Responses 29 July 2008) 2. Burd A. Acral Lentiginous Melanoma - no sun on toes. (BMJ Rapid Responses 28 July 2008) 3. Bulliard Jl, De Weck D, Fisch T, Bordoni A, Levi F. Detailed site distribution of melanoma and sunlight exposure: aetiological patterns from a Swiss series. Ann Oncol 2007;18:789-94 4 Menzies S W. Is sun exposure a major cause of melanoma? Yes BMJ 2008 337: 763 5. Kraemer K, Lee, M, Andrews AD, Lambert C. The role of sunlight and DNA repair in melanoma and nonmelanoma skin cancer. Arch Dermatol 1994;130:1018-21 6. Cooper A J The consequences of the statement "Sun Exposure is not a major cause of Melanoma" . (BMJ Rapid Responses 27 July 2008) 7. Quinton R, Pearce SHS, Sievenpiper J L Time to go and get that hat (BMJ Rapid Responses 28 July 2008) 8 Samuel D G. melanoma: no fun in the sun (BMJ Rapid Responses 29 July 2008) 9. Burry J N. Diagnosis is the problem (BMJ Rapid Responses 31 July 2008) Competing interests: I have no competing interests to declare, and my everyday work is not concerned with the diagnosis, treatment and prevention of melanoma. |
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David G Tucker, Holistic Therapist ..& maverick Andover Hants sp10
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David Sammuel.... "I have not heard of epidemics of melanoma occurring amongst the Eskimo populations or the Shetland island inhabitants. It does seem strange that the rates are higher in sunny Oz does it not?!" You seem to be making the same kind of assumptions that many researchers do from a given outcome and this could be yet another big mistake... 1./ The increase incidence of skin cancers appears to coincide well with the increase use of sunscreens.That should be ringing loud bells!Check out the absorption of potentially toxic chemical cocktails through the skin and then there is no surprise at Melanoma increase perhaps? It has been reported that Oz has the highest use of sunscreen.... We have lived with the sun for millions of years....and now it has suddenly become 'dangerous' since the concept of sunscreens??....Please,the concept is insulting. 2./ Eskimos, or more correctly, Innuits, have a good intake of beneficial lipids,especially saturates and don't use toxic sunscreens I suspect!The imbalance of Omega 6 to 3 and detrimental other dietry habits, such as Soy ingestion, sugar and processed carbohydrate overload, are all possibly linked to the huge cancer increase in general. 3./As for the Shetland Islanders....see above! It is just criminal that Westernised allopathic medical disciplines generally seem to ignore the crucial aspect of what we ingest/absorb in relation to our health.What do people think we eat for?Hungry...'fill a gap'Please, lets think a little here! Competing interests: None declared |
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peter j mahaffey, consultant plastic & reconstructive surgeon bedford hospital mk42 9dj
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Its extraordinary that, after the trouble Meadows got himself into in giving statistical advice based on no proper evidence, that clinicians involved in any area of practice, never mind melanoma, can give such subjective opinions so freely. We most certainly do NOT know for sure that sunlight exposure is directly responsible for melanoma. As Schuster so rightly states, debate based on opinion is precisely what we don't need in this area. We need hard evidence, and our profession isn't always the best at offering advice on this basis. In 1847, Semmelweiss announced that hand washing could save many lives by limiting the spread of infection. He was pilloried by respected colleagues and in 1865 committed to an asylum. Quinton and colleagues are therefore to be applauded in urging us to look at the bigger picture in melanoma aetiology because it seems we have still not learned, over 150 years later, that it can be very dangerous to accept conventional wisdom. Competing interests: Clinician with significant melanoma caseload |
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