You may not know this about me, but I also had skin cancer two years ago.
A well-meaning colleague introduced me to a crowd a while back by saying Kirstin is a 3-times cancer survivor, and I dismissed that and felt that, as it was the “lightest” of skin cancers, basal cell carcinoma, this did not hold equal significance compared with my breast cancers.
Maybe because I was “battle-hardened” already, and there was no “ordeal” involved this time. Treatment was pretty straight forward, I had Mohs micrographic surgery, where you receive a local numbing injection, and a specialist dermatologist takes off layer by layer of this little scaly area I had in the middle of my forehead at my hairline, tests it right there, and if any malignant cells are still present continues with the layering until all margins are clean. I received a bandage, told not to get the area wet for a week, and that was that.
Nevertheless, it was still malignant cancer, and if this is an initial diagnosis, can still be terrifying. First thoughts are that you can no longer enjoy our gorgeous sunshine, and experience the comforting tingle of having your exposed skin brushed by its warming rays. I learnt that this type of skin cancer can be the result of damage from sun exposure that happened many years back, even as way back as childhood.
I grew up in sunny South Africa and do recall, as a fair-skinned, freckled kid, that I did sunburn. I belong to the generation that still played outside all day long and only came home for dinner, looking worse for wear. Applying sunscreen was a nuisance, and even though my mother would try, I simply was not around enough for her to pay attention to making sure I did not outstay the time period before the lotion became ineffective.
Typical for me though, I was faced again with the desire to do some in-depth research on skin cancer, and everything that goes with it, needing to apply what I found to my own proactive prevention plan.
I would like to share my findings with you here, and shed some clarity on everything skin cancer-related, including what you can do these days to make a measured decision when you way up your options how to maximize sun protection and minimize associated health risks, considering that many sunscreens contain potentially harmful ingredients.
Why is UV radiation harmful?
Let me begin by clarifying what about the sun is so damaging to our health.
UV radiation is part of an electromagnetic light spectrum which radiates from the sun and reaches the earth. We cannot see this radiation, as its wavelengths are shorter than visible light. UV radiation can be harmful because it can cause genetic mutations that can lead to skin damage, premature aging and cancer. According to the World Health Organization (WHO), and the US Department of Health and Human Services, UV radiation is considered a human carcinogen.
There are different types of UV radiation, the most well known being UVA and UVB rays. There are others, such as UVC rays, but as they are absorbed by the ozone layer and do not penetrate the earth’s atmosphere, they are not of significance to us in this context (they are for Australians, faced with a hole in the ozone layer above their country).
As the Skin Cancer Foundations states, we used to believe that only shortwave UVB rays are damaging to our skin, but over the past years this view has been revised. Long wave UVA rays, even though less intense, are much more prevalent and account for up to 95% of UV radiation reaching the earth.
What distinguishes them is that these UVA rays are present with equal intensity all year round, and besides being the leading cause for skin wrinkling and premature aging, research over the last 20 years has shown that they do damage the basal skin cells in the outermost layer of the skin, the epidermis. Damage accumulates over time. Maybe that is why I was diagnosed with basal cell skin cancer in my late 40’s, even though as an adult I have been pretty protective over my skin, mainly also for vanity purposes, having seen how older women can look like if they have kissed the sun too much, as we would say in German.
The problem is that our youth are increasingly affected by skin-related disorders, including cancer. UVA rays are the main rays used in tanning salons. UVA radiation in tanning booths are much more intense than your average beach day exposure, the dosage can be as much as 12 times higher than that of our sun!
According to the Skin Cancer Foundation, those using tanning beds regularly are 2,5 times at risk for squamous cell skin cancer, and 1,5 times at risk for basal cell skin cancer (and I will elaborate on the types of skin cancer further on). More frighteningly, the risk for melanoma, the deadliest type of skin cancer, increases in our youth who regularly frequent tanning booths by up to 75%!
I have a teenage daughter too who is in the phase of believing that a tan is a desirable thing to look “healthy” and cool. And I remember being in that phase too myself when I was her age. It’s what our society dictates to us, or the young, that a tan is a sign of a healthy body. In fact, a tan is an injury to our skin’s DNA. The skin darkens as it tries to reduce further damage to its genetic structure.
UVB rays, on the other hand, are the main cause of red sunburns and they account for the main damage to our epidermis, or outer skin layer. They differ from UVA rays in that their intensity varies by season and location, being at their strongest in the US from May to October and in particular between 10 AM and 4 PM. However, if reflected off shiny surfaces like water or snow, or at high altitudes like in the mountains, their damaging effect is almost doubled, as up to 80% of their rays bounce back, in effect exposing the skin twice.
Types of Skin Cancer
Let me shed some light on the different types of skin cancer. There are three common types of malignant skin cancers, and I will highlight those below. Two lesser common ones include Merkel Cell Tumor (not related to the current German Chancellor, by the way) and a long name one, Dermatofribrosarcoma Protruberans, but my attention in this blog is on the more easily pronounceable ones that you probably have heard mentioned before.
Basal Cell Carcinoma
This is the most common type, and the one I was diagnosed with on two parts of my face. According to the American Academy of Dermatology, here are its trademarks:
- It is generally flesh colored or slightly pinkish
- It can be a patch or a slight bump
- It usually shows up after years of sun exposure or indoor tanning
- Most commonly found on your head, neck, rims of ears and arms, but they can show up anywhere on your body
- They are unlikely to spread to other organs, but can invade local surrounding tissue and lead to visual disfigurement, or damage to nerves or surrounding bones
Squamous Cell Carcinoma
This is the second most common form of skin cancer. It shares many of the trademarks of basal cell cancer, but can also be identified as a sore that will not heal properly. It can grow deep into the skin, and has only been shown to spread to other areas (metastasize) in those with a severely compromised immune system.
This is the most serious and aggressive form of skin cancer, and can potentially be fatal if not discovered and treated early. Its trademarks are often referred to as the ABCDE’s.
A-symmetrical mole or dark spot
B-order irregularity with poorly-defined, ragged outlines
C-olor can range from tan to brown to black and even white, red or blue
D-iameter is often around 6 mm,
E-volution – it can change color, size and shape over time and can itch or bleed
Unlike most basal and squamous cells cancers, melanomas often require extensive treatment besides surgical removal, which can include chemotherapy, radiation, immunotherapy or vaccines. Your healthcare team may include a dermatologist, surgeon and oncologist.
Now before you try and hastily find a mirror to examine the spot that has been worrying you, let me add that most of us have about 30-50 non-cancerous moles and spots scattered over various parts of our bodies. They may fall into any of these categories:
Actinic Keratoses (AK)
These are also referred to as dysplasias, and are generally pre-cancerous changes in our skin that could potentially become cancerous (mainly squamous cell), but don’t necessarily do. However, they still need to be watched monthly for any changes. They are dry, scaly patches that can develop in the later years of our lives after our 40’s (did I just refer to myself as aging?), and also after years of sun exposure. I have a few of those, and other than turning darker if exposed to sunlight, they are doing just fine. I have had two removed on my back simply because I did not like the dark patches, preferring the lighter scarring that remains after they were easily removed by my dermatologist after a local numbing gel was applied.
These are little growths that may never develop into cancer, and most of us have lots of those, me included. They can be flat, raised, smooth, rough, round, oval and range from pink to tan to reddish brown. The most important thing here is to watch for visible changes using any of the above trademarks. If that is the case, alarm bells should go off. There are abnormal moles, called dysplastic nevi, which are irregular and are easily mistaken for skin cancer, but are just moles. Best practice: check and follow your gut feel. Remember, dermatologists are just humans, and misdiagnoses can be made. If you have an odd feeling about a mole or any spot, listen to your body’s message and double check again.
What can cause skin cancer?
Here are some common causes of skin cancer:
- Excessive UV exposure over a prolonged period of time
- Excessive use of tanning booths
- Impaired immune system
- Exposure to excessive radiation
- Contact with toxic chemicals on a consistent basis, especially occupational exposure (this suppresses the immune system)
- Nutritional deficiencies including Vitamin D (more on that later on) and Niacinamide (Vitamin B3 or Niacin)
When am I at a higher risk for getting skin cancer?
If you are fair skinned with freckles (but darker-skinned people can get skin cancer too), have a history of severe sunburns dating back to childhood or early adulthood, or if you have certain genetic disorders and damaged DNA from UV radiation that the body cannot repair.
Skin Cancer Prevention
Before I list 12 ways in which you can practice pro-active prevention, I simply have to include these guidelines when selecting sunscreen lotions, as there is so much controversy out there, and many people are utterly confused at what product they should buy, or whether they should lather up at all.
Sunscreen lotions need to fulfill two main roles: they need to adhere to the skin to be effective, and they need to stay effective and not break down too quickly under the effects of the sun’s rays. They can be categorized into two main groups, chemically-based or mineral-based.
Chemical sunscreens protect the skin by absorbing UV rays before they penetrate the skin, while they themselves of course get absorbed by the skin first. Their protective action is via a chemical reaction. As they get absorbed, they need to adhere to the skin, and this requires other additives to enhances their penetration. This results in a cocktail of active and inactive ingredients that have the potential to bioaccumulate in the body. They can be measured in blood, urine and even breast milk. The 6 main chemical ingredients in question are:
Oxybenzone, Octinoxate, Homosalate, Octisalate, Octocrylene and Avobenzone
Concerns have been raised, and validated by several lab animal studies, that these ingredients can
- Lead to biochemical changes
- DNA mutations
- Endocrine (Hormone) disruptions such as infertility, mimicking own hormones, interfering with own hormones
- Organ system toxicity such as allergic reactions
- Ecotoxicology (environmental toxicity)
In particular, Oxybenzone has been widely studied and shown to even damage coral reefs (excessive bleaching) around the globe, particular in areas such as Hawaii and the Caribbean with heavy tourist traffic. Scientists have found deformed DNA of coral in their larval stage, hindering them from proper developing. Residue has also been found in fish and other seafood, affecting the food chain we humans also feed off of. Studies have identified UV filters such as oxybenzone, octocrylene, octinoxate and another ingredient, ethylhexyl salicylate (ES) in almost all water sources around the world and have commented that these filters are not easily removed by common waste water treatment plant techniques.
The US Center for Disease Control and Prevention regularly finds oxybenzone in 96% of the US population. According to David Andrews, senior scientist at the EWG (Environmental Working Group), a not-for-profit educator and advocacy organization for clean products, they have also found that teenage boys with higher levels of oxybenzone have lower testosterone levels, although it is noted that this was not a controlled study, and was not measured with multi-day exposure.
So now you may ask with these concerns, what are the risk factors to our health? Is there evidence that this increases our risk for disease, including cancer?
According to the EWG in their Guide to Sunscreens, the evidence of potential hazards of sunscreen ingredients have not been reviewed recently. Many ingredients were evaluated in the 1970’s, and not much information is available on their potential to cause cancer, as the Danish Environmental Protection Agency found in a study in 2015. Studies exist that suggest that many chemical ingredients interact with our hormones, but that the risk to humans from this interaction has not yet been evaluated.
Let’s look at what many believe is a safer option – mineral-based sunscreens.
Mineral sunscreens are physical blockers, they act by forming a barrier on top of the skin which reflect UV rays away from the skin. The two main minerals mostly used are titanium dioxide and zinc oxide, and they are generally less irritating to the skin. They leave a residue on the skin, some of you may remember the typical white noses of surfers, this was pure zinc oxide which is very effective at blocking UVA rays. Today most of them have been refined to spread on more evenly and be less sticky.
Now you may have heard the controversy surrounding nanoparticles, so let me shed some light on this debate. Nanoparticles are extremely small particles (one video I came across in my research explained them as the size of an orange in relation to the earth, I think that about sums it up nicely). Natural nanoparticles are all around us, just think of the dust surrounding you. Modern technology has begun to manufacture them for various applications, e.g in transportation, healthcare, new energies and even buildings. The question is whether these particles stay enveloped in their material, or can escape into the environment and attach themselves elsewhere, and whether that can be harmful to our health.
Somehow nanoparticles have been linked to both titanium dioxide and zinc oxide, yet I want to clarify that 1) of course these minerals have natural nanoparticles and 2) they are not confined to only these two minerals.
The issue with nanoparticles overall is that we simply don’t know enough about their performance as they vary so much in shape, size and surface area coverage. So what does this have to do with sunscreens? It affects the efficacy of the sun protection, the larger a nanoparticle the higher the potential for better UV protection. At this point, manufacturers do not need to disclose the qualities of particles used in their sunscreens. Zinc oxide has larger nanoparticles, thus offering better coverage than titanium dioxide which is more clear when spread on the skin and thus offers thinner coverage.
EU-based as well as US-FDA based studies concluded that nanoparticles in zinc dioxide did not penetrate the skin in dosages that can harm cells, although the study could not fully establish if the zinc measured in the bloodstream was actually due to insoluble nanoparticles or simply zinc ions.
Titanium dioxide nanoparticles are referred to as a photocatalysts, when exposed to UV radiation they have the potential to form free radicals that can damage cells. Nanoparticles in minerals are much more susceptible to this than larger sized particles.
As a consumer then, we need the guarantee that sunscreen manufacturers use specific forms of nanoparticles that are optimal to staying stable when exposed to UV radiation, so-called sunscreen-grade minerals.
Claims made by manufacturers of having “non-nanoparticle” sunscreens should be viewed with a sceptic eye, they can be misleading as there are nanoparticles in almost all materials, whether natural or man-made.
The EWG has urged to FDA to evaluate the safety of nanosized particles against organ toxicity, lung health and skin penetration. Inhaled nanoparticles from loose powder make up and sunscreen sprays with titanium dioxide can be potentially dangerous to the lungs, as these dainty organs cannot effectively clear them, they can travel in the bloodstream and cause potential organ damage.
There is also a question of how safe ingested nanoparticles are, for example from mineral-based lip sunscreens. Titanium dioxide has been used as colorants in the food industry, for example to color doughnuts and M&M’s. Similarly, the effects of nanoparticles on the environment, such as from sunscreen wash off, has also not been fully assessed. So far, there is evidence of damage to coral reefs and accumulation in fish.
If this leaves you confused as to which sunscreen lotion to purchase, you are not alone! Here are some tips to help you make other sun-protective decisions that are not limited to only applying a cream to your skin.
12 Proactive Prevention Steps
- Limit your sun exposure and seek shade, in particular between the hours of 10 am and 4 pm in mid-summer, regardless of which hemisphere you live in. Trees offer the best shade that is cooling too due to the condensation off their leaves.
- Cover up – use a hat, photoprotective swimwear and clothing, sunglasses. Australians are leaders in this field, out of necessity due to the very real hole in the ozone layer above their country. There, a tan indicates you are a naïve foreigner, my Aussie friends tell me.
- Shift your mindset around thinking a tan indicates health – it actually indicates a body frantically trying to prevent further genetic damage.
- Avoid tanning booths! If your teenager insists, try the reality-check method and show her (it usually is a “her”) realistic images of melanoma skin cancers in prominent places like the face, and place the stats (and maybe even the images) on your fridge: up to 12x more UV radiation than from the sun!
- Get to know your body! Observe your skin, every inch of it. That includes between your fingers and toes, and yes, the butt cheeks and genital areas too (amazing where you find little moles…). In particular the rims of your ears, back of neck and along the hairline (that’s where mine was hiding away) and on your entire scalp.
- See the same dermatologist once a year for a full body check-up. This is the best way to monitor any changes. Be prepared for them to check everywhere, but that is exactly what you need, a thorough inspection.
- Check your Vitamin D status as a deficiency can severely compromise your immune system which in itself has been shown to contribute to an elevated risk for cancer. Your levels should be at minimum in the 60’s ng/mL range. Strict sun protection can exacerbate Vitamin D deficiency. Get to know your skin type to assess best timing and allow some unscreened sun exposure on bare skin.
- Avoid sunscreens claiming they have SPF levels higher than 50. It misleads you into thinking that this offers long term protection and makes you stay in the sun longer.
- Avoid sunscreens that claim they contain Vitamin A (retinyl palmitate or retinol). The EWG states that it appears that tumors can develop sooner on skin coated with Vitamin A-enriched cream.
- Avoid sunscreen sprays and loose powder sunscreens (including SPF-enriched make up powder) as this spreads nanoparticles which may be harmful if inhaled consistently.
- Sunscreen lotions: A minimum SPF should be 30, to be reapplied every 60-80 minutes or more often if there is a lot of water exposure. Mineral-based sunscreens have come a long way in terms of ease of spreading and you will find a range of excellent “cleaner” brands on the market. Make sure it is a “broad-spectrum” product that protects against both UVA and UVB rays.
- Best Product Guide: the EWG’s Guide to Sunscreens, where they rate almost any product on the US and global market according to the quality of each ingredient, giving the product an overall score. They will also focus on inactive ingredients such as those ending in -parabens, phthalates, sodium laureth (and lauryl) sulfate and chemical fragrance that you should avoid. This online rating system gives excellent information in great detail so you can make the choice that is best for you.
Scinicariello, Franco, and Melanie C. Buser. “Serum Testosterone Concentrations and Urinary Bisphenol A, Benzophenone-3, Triclosan, and Paraben Levels in Male and Female Children and Adolescents: NHANES 2011–2012.” Environmental Health Perspectives 124.12 (2016): 1898–1904. PMC. Web. 23 July 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5132630/
Krause M, et al. “Sunscreens: are they beneficial for health? An overview of endocrine disrupting properties of UV-filters” Int J Androl. 2012 Jun;35(3):424-36. https://www.ncbi.nlm.nih.gov/pubmed/22612478
Schlumpf, Margret et al. “Fundamental Questions to Sun Protection: A Continuous Education Symposium on Vitamin D, Immune System and Sun Protection at the University of Zürich.” Dermato-endocrinology 2.1 (2010): 19–25. PMC. Web. 24 July 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084961/
Schneider SL, Lim HW. “Review of environmental effects of oxybenzone and other sunscreen active ingredients” J Am Acad Dermatol. 2018
Ruszkiewicz, Joanna A. et al. “Neurotoxic Effect of Active Ingredients in Sunscreen Products, a Contemporary Review.” Toxicology Reports 4 (2017): 245–259. PMC. Web. 24 July 2018. https://www.webmd.com/melanoma-skin-cancer/guide/skin-cancer#1
American Academy of Dermatology, Inc. https://www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/types-of-skin-cancer
Skin Cancer Foundation https://www.skincancer.org/skin-cancer-information/melanoma/types-of-melanoma
Cancer Treatment Centers of America https://www.cancercenter.com/skin-cancer/types/
EWG’s Guide to Sunscreens https://www.ewg.org/sunscreen/
Minatec – What are nanoparticles and nanomaterials?
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