Prevalence of sun-protective behaviour and intentional sun tanning in German adolescents and adults: results of a nationwide telephone survey.

BACKGROUND: The incidence rate of melanoma in the Caucasian population is rising worldwide. One of the major environmental risk factors for melanoma is the exposure to ultraviolet (UV) radiation. To prevent skin damage caused by UV exposure, several organizations recommend wearing protective clothing, staying in the shade, avoiding the outdoors during midday and using sunscreen. OBJECTIVE: To provide representative data on factors associated with sun-protective behaviours and intentional sun exposure during summertime in the German population. METHODS: A population-based sample of 3000 German residents aged 14-45 years (response: 32.1%) was interviewed via telephone from October to December 2015. Survey participants provided data on the use of recommended sun-protective measures on a sunny summer day and their intentional sun exposure during summertime. Data were weighted by age, sex, educational level and federal state to ensure the national representativeness of the sample. RESULTS: Wearing long-sleeved clothes was the most frequently reported protective measure (53.9%), while wearing headgear was the least common (17.9%). Significantly lower frequencies of almost all recommended sun-protective measures were identified for males, participants between 14 and 25 years, those with an immigrant background and those with low levels of education. Using sun protection was positively associated with female gender (OR = 1.62), higher levels of education (ORhigh = 1.27), sunburn during childhood (OR = 1.33) and paying attention to healthy nutrition (OR = 1.64; all P < 0.05). Sun tanning behaviour was associated with female gender (OR = 1.42), younger age, lower level of education, sunbed use (OR = 5.24) and smoking status (OR = 1.50; all P < 0.001). CONCLUSION: As individual sun-protective measures are easy to implement and provide effective protection against high-risk UV exposure, campaigns on skin cancer prevention in Germany should put a stronger focus on young adults, men, less educated individuals and those with immigration background.

First evaluation of the Behavioral Addiction Indoor Tanning Screener (BAITS) in a nationwide representative sample.

BACKGROUND: Evidence suggests that indoor tanning may have addictive properties. However, many instruments for measuring indoor tanning addiction show poor validity and reliability. Recently, a new instrument, the Behavioral Addiction Indoor Tanning Screener (BAITS), has been developed. OBJECTIVES: To test the validity and reliability of the BAITS by using a multimethod approach. METHODS: We used data from the first wave of the National Cancer Aid Monitoring on Sunbed Use, which included a cognitive pretest (August 2015) and a Germany-wide representative survey (October to December 2015). In the cognitive pretest 10 users of tanning beds were interviewed and 3000 individuals aged 14-45 years were included in the representative survey. Potential symptoms of indoor tanning addiction were measured using the BAITS, a brief screening survey with seven items (answer categories: yes vs. no). Criterion validity was assessed by comparing the results of BAITS with usage parameters. Additionally, we tested internal consistency and construct validity. RESULTS: A total of 19·7% of current and 1·8% of former indoor tanning users were screened positive for symptoms of a potential indoor tanning addiction. We found significant associations between usage parameters and the BAITS (criterion validity). Internal consistency (reliability) was good (Kuder-Richardson-20, 0·854). The BAITS was shown to be a homogeneous construct (construct validity). CONCLUSIONS: Compared with other short instruments measuring symptoms of a potential indoor tanning addiction, the BAITS seems to be a valid and reliable tool. With its short length and the binary items the BAITS is easy to use in large surveys.

[Prevalence, risk groups, and reasons for sunbed use in Germany]. / Prävalenz, Risikogruppen und Motive der Solariennutzung in Deutschland.

BACKGROUND: Ultraviolet (UV) radiation of sunbeds has been classified carcinogenic by the International Agency for Research on Cancer (IARC). Unlike in other countries the available data on the important risk factor has been lacking until recently in Germany. OBJECTIVES: The SUN-Study 2012 (Sunbed-Use: Needs for Action Study) aimed at identifying epidemiological prevalence data concerning this completely preventable risk factor. MATERIALS AND METHODS: A total of 4,851 participants aged 14-45 years were selected from the German population in a representative manner and were surveyed via standardized telephone interviews. The survey period was split into a summer and a winter wave in order to take possible season effects into account. RESULTS: Four out of 10 Germans aged 14-45 years (39.2 %; 95 % CI 37.8-40.6 %) have ever used a sunbed. Within the last year 14.6 % (95 % CI 13.6-15.6 %) visited a sunbed. Current users reported six visits per year on average and every twentieth reported a family history of cutaneous malignant melanoma in first-degree relatives. More than 5 % of minors currently used sunbeds despite the nationwide ban, mostly at unsupervised locations. Half of those minors did not know about the legal ban of sunbed use for minors. CONCLUSIONS: Our study proves that sunbed use which is an important risk factor for skin cancer is widely used. Moreover, considerable information deficits about health risks exist among the German population.

[Prevention of skin cancer: considerations on strategic communication]. / Prävention von Hautkrebs : Kommunikationsstrategische Überlegungen.

In recent decades the numbers of cases of skin cancer have been increasing worldwide in light skinned populations. In Germany skin cancer is the most common form of cancer. To reduce the burden of skin cancer protection from ultraviolet radiation (primary prevention) and early detection (secondary prevention) of the disease play a decisive role. In this context information to the population about preventive behavior and the support of informed decision-making in skin cancer screening are important aspects in communication. This paper gives an overview about communicational aspects in the promotion of skin cancer prevention. In the development of communicational interventions it is important to identify the relevant target groups. Relevant key opinion leaders have to be included in the information process. Additionally, interventions should be based on a theoretical framework and be designed for the respective target group. Furthermore, different forms of communication and communication tools are provided for the realization of an information intervention. To appraise the intervention elements of summative and formal evaluation are available. The current results provide important findings about different effects of communicational aspects on knowledge and behavior of the population; however, due to the complexity of information interventions a particular effect cannot be explained by a single communicational element.

[Collection and processing of personal data to evaluate cancer screening programmes - results of a survey of the German population in light of the bill 'early detection of cancer and cancer registries']. / Erfassung und Verarbeitung von persönlichen Daten zur Evaluation von Krebsfrüherkennungsprogrammen - Ergebnisse einer Bevölkerungsbefragung im Kontext des Krebsfrüherkennungs- und -registergesetzes.

In a representative German sample, 62.1% of participants of cancer screening interventions indicated willingness to provide personal data for data-linkage with cancer registries. An agreement of over 90% is deemed necessary to conduct a meaningful population-based evaluation. The 'early detection of cancer and cancer regis-tries' bill proposed a procedure based on the use of pseudonyms only. This way personal consent is not required but participants are granted the right to object.

Sunbed use in Germany: trends, user histories and factors associated with cessation and readiness to change.

BACKGROUND: Sunbed use is considered carcinogenic in humans. Studies that examine behavioural patterns related to sunbed use over time are needed for developing skin cancer prevention strategies. OBJECTIVES: To explore age-related trends in the initiation age, to investigate individual histories of sunbed use and to identify characteristics associated with cessation. METHODS: We analysed cross-sectional data of 4851 sunbed users and nonusers from a representative sample of Germans, aged 14-45 years, interviewed in 2011/2012. Biographical data were reconstructed based on reported tanning frequency/duration and changes in sunbed use over time. We used survival analysis to model the initiation age and created birth cohorts to assess age-related trends. Characteristics associated with sunbed use cessation were identified using logistic regression. RESULTS: Among sunbed users, median sunbed exposure was 180 min per year. Annual exposure remained constant in 85·6% of this subgroup with no changes over time during periods of sunbed use. Age at initiation decreased significantly across birth cohorts from 25 to 19 years (25th percentile; cohorts 1966-75 to 1986-93). Characteristics associated with sunbed use cessation included educational level [odds ratios (OR) 1·53 and 1·71 for medium and high education, respectively], greater awareness of skin cancer risk (OR 2·41) and immigrant background (OR 0·54; all P < 0·01). CONCLUSIONS: Initiation of sunbed use at an increasingly younger age suggests the need for interventions targeted at young adults. Approaches that increase general skin cancer risk awareness and that are sensitive to participants' educational level and immigrant background may also be helpful.

UVA-induced DNA double-strand breaks result from the repair of clustered oxidative DNA damages.

UVA (320-400 nm) represents the main spectral component of solar UV radiation, induces pre-mutagenic DNA lesions and is classified as Class I carcinogen. Recently, discussion arose whether UVA induces DNA double-strand breaks (dsbs). Only few reports link the induction of dsbs to UVA exposure and the underlying mechanisms are poorly understood. Using the Comet-assay and γH2AX as markers for dsb formation, we demonstrate the dose-dependent dsb induction by UVA in G(1)-synchronized human keratinocytes (HaCaT) and primary human skin fibroblasts. The number of γH2AX foci increases when a UVA dose is applied in fractions (split dose), with a 2-h recovery period between fractions. The presence of the anti-oxidant Naringin reduces dsb formation significantly. Using an FPG-modified Comet-assay as well as warm and cold repair incubation, we show that dsbs arise partially during repair of bi-stranded, oxidative, clustered DNA lesions. We also demonstrate that on stretched chromatin fibres, 8-oxo-G and abasic sites occur in clusters. This suggests a replication-independent formation of UVA-induced dsbs through clustered single-strand breaks via locally generated reactive oxygen species. Since UVA is the main component of solar UV exposure and is used for artificial UV exposure, our results shine new light on the aetiology of skin cancer.

Effectiveness of skin cancer screening programmes.

Skin cancer, nonmelanoma skin cancer (NMSC) and cutaneous malignant melanoma (CMM), is the most frequent cancer worldwide. It is amenable to early detection, and screening for skin cancer has the potential to reduce mortality and morbidity. However, there are no recommendations for population-based skin cancer screening programmes due to the lack of evidence for the effectiveness from epidemiological studies. In 2008 the first nationwide screening programme for NMSC and CMM in the world was established in Germany. The decision for implementing such a programme was based on the results and evidence of a pilot study that was conducted from 2003 to 2004. The pilot study revealed that a population-based screening programme for skin cancer is feasible and effective. Careful evaluation of the nationwide programme is crucial to generate strong evidence for long-term public health benefits.

Skin cancer screening participation and impact on melanoma incidence in Germany--an observational study on incidence trends in regions with and without population-based screening.

BACKGROUND: The SCREEN (Skin Cancer Research to provide Evidence for Effectiveness of Screening in Northern Germany) project involved population-wide skin cancer screening with whole-body examination by general physicians and dermatologists. It was conducted in the German state of Schleswig-Holstein (July 2003-June 2004), but not in the German state of Saarland. METHODS: The population-based registries of Schleswig-Holstein and Saarland provided data on melanoma incidence before, during, and after SCREEN to assess the association of skin cancer screening with incidence. RESULTS: Approximately 19% of the Schleswig-Holstein population participated in SCREEN (women: 27%, men: 10%). A total of 52% of all melanomas diagnosed during SCREEN in Schleswig-Holstein were detected as part of the project. Melanoma incidence increased during SCREEN (invasive melanoma in women: +8.9 per 100,000 (95% confidence intervals (CI): 6.1; 11.7); men: +4.0 per 100,000 (95% CI: 1.6; 6.4)) and decreased afterwards (women: -10.6 per 100,000 (95% CI: -13.3; -7.9); men: -4.1 per 100,000 (95% CI: -6.5; -1.7)). Similar changes were not observed in Saarland that had no such project. The differences between the two states were greatest among women, the group with the greater SCREEN participation. CONCLUSION: The SCREEN project had a substantial impact on melanoma incidence. This is consistent with the impact of effective screening for other cancers.

Effectiveness of information campaigns.

Skin cancer represents the most common type of cancer in the white population worldwide and the incidence has dramatically increased during the last decades. UV-radiation is believed to be the most important risk factor responsible for this trend. The prominent role of UV-radiation renders skin cancer most suitable for primary prevention, because the main risk factor can easily be avoided by sticking to simple rules for the behaviour in the sun or under artificial UV (e.g. sunbeds). Since UV-exposure cannot and should not be avoided totally especially due to the beneficial health effects of UV-irradiation like Vitamin D(3)-production, recommendations and information for the public should be as clear and as weighted as possible, through adequate messages, such as: "Love the sun and protect your skin". For that purpose the Association of Dermatological Prevention in Germany (ADP) developed the period of life programme (POLP) that defines certain age-specific target groups, with the aim to give well adapted prevention messages to the population during lifetime. Evaluation of primary prevention campaigns in Germany showed that due to continuous intervention programs during the last 16 years changes in the "sun-behaviour" of the population have been achieved leading to a reduced but sufficient exposure to solar UV-irradiation. This will then contribute to the aim of decreasing morbidity and mortality of skin cancer.

[Prevention of skin cancer. Necessity, implementation and success]. / Prävention von HautkrebsNotwendigkeit, Durchführung und Erfolg.

Including malignant melanoma, basal cell carcinoma, and squamous cell carcinoma, skin cancer is the cancer with the highest incidence worldwide. Its incidence is increasing more rapidly than that of all other kinds of cancer. It is necessary to slow down this trend through preventive steps in order to reduce morbidity and mortality rates and to decrease the financial burden on the health systems. This goal could be achieved through primary (prevention of risk factors) and secondary prevention (early diagnosis and screening). This essay describes the necessity, realization, and success of these kinds of intervention programs. It especially portrays the procedures in Germany as they have been practiced for the last 15 years by the Society of Dermatology Prevention and German Cancer Aid.

Identification of a non-dividing subpopulation of mouse and human epidermal cells exhibiting high levels of persistent ultraviolet photodamage.

The distribution and persistence of cyclobutane pyrimidine dimers were investigated in mouse skin after chronic and acute exposures to ultraviolet-B radiation. We found that DNA damage accumulated in response to chronic irradiation and persisted in a unique set of epidermal cells located at the basal layer. Treatment with a tumor promoter caused the heavily damaged epidermal cells to divide and p53-immunopositive clusters to form within 24 h suggesting that these cells may be progenitors of the mutant p53 clusters associated with actinic keratoses and squamous cell carcinomas. In contrast to low fluence chronic irradiation, daily treatment with a higher fluence of ultraviolet-B produced extensive hyperplasia and considerably reduced penetration of photodamage. Exposure of chronically irradiated skin to an acute "sunburn dose" of ultraviolet-B also produced significant epidermal hyperplasia and resulted in complete loss of heavily damaged basal cells within 4 d postirradiation. The occurrence and distribution of cyclobutane dimers in human skin correlated well with putative sunlight exposure and resembled that observed in ultraviolet-B-irradiated mice. Heavily damaged basal cells were observed at various sites, including those receiving sporadic sunlight exposure, suggesting that these cells may play an important role in carcinoma formation in humans.

The velocity of ultrasound in human primary melanoma tissue - implications for the clinical use of high resolution sonography.

BACKGROUND: Ultrasonography with 20 MHz frequency can be used to estimate tumour thickness preoperatively in malignant melanoma (MM) of the skin. The vertical invasion depth is the single most important prognostic factor for localised MM, and its preoperative knowledge would be very useful for the planning of surgical procedures. Since ultrasonographic distance measurements directly depend upon the tissue specific ultrasound velocity, we determined the ultrasound velocity in primary melanoma. RESULTS: Ultrasound velocity was calculated from runtime differences of a 20 MHz ultrasound signal along a known distance either through water alone or through thick specimens of primary MM. The ultrasound velocities varied between 1553 m/s and 1588 m/s with a mean of 1564 m/s in four different MM specimens. The analysis of different parts of the specimens showed that the variation of the calculated velocities was larger between different specimens than within one individual specimen. CONCLUSIONS: The ultrasound velocity in MM tissue may be slightly lower than normally assumed, thereby explaining a part of the overestimation usually found in sonographic measurement of melanoma invasion depth. Additionally, the variation of ultrasound velocity between individual tumours may contribute to the impairment of the correlation found between sonometry and Breslow's measurement of MM invasion depth. For practical reasons, a setting of 1580 m/s will be appropriate for ultrasonography of primary malignant melanoma.

The dose dependence of cyclobutane dimer induction and repair in UVB-irradiated human keratinocytes.

UVB and UVA components of the solar spectrum or from artificial UV-sources might be important etiological factors for the induction and development of skin cancer. In particular, deficiencies in the capacity to repair UV-induced DNA-lesions have been linked to this phenomenon. However, until now only limited data are available on the biological and physical parameters governing repair capacity. We have, therefore, developed a flowcytometric assay using fluorescence-labeled monoclonal antibodies to study the dose-dependence of induction and repair of UVB-induced cyclobutane pyrimidine dimers in a spontaneously immortalized keratinocytic cell line (HaCaT). Our results show that the kinetics of recognition and incision of UVB-induced DNA lesions slows down by a factor of about 3 in a dose range of 100-800 J m-2. Furthermore, a thorough analysis of repair kinetics indicates that this reduction in repair capacity might not be dependent on saturation of enzymatic repair capacity (Michaelis-Menten) but may be caused by a UV-induced impairment of enzymes involved in DNA repair. Because this effect is evident in vitro at doses comparable to the minimal erythemal dose in vivo, our results might have significant impact on risk assessment for UV-induced carcinogenesis.

Effects of whole-body UVB irradiation on cytokine production by peripheral blood mononuclear cells from stage I melanoma patients.

Ultraviolet (UV) radiation causes significant impairment of immunological function in human skin. The immunosuppressive effects of UV radiation are thought to be due to local release of cytokines by human keratinocytes, leading to impaired function of epidermal antigen-presenting cells (APC) and failure to induce cutaneous delayed-type hypersensitivity (DTH) reactions. Recent studies have shown that individuals susceptible to UV-induced suppression of DTH may be more prone to develop skin cancer including malignant melanoma (MM). Since the causal relationship between UV radiation and the induction of MM still seems obscure, we investigated the immunological reactions of peripheral blood mononuclear cells (PBMC) to whole-body irradiation with UVB in 15 stage I melanoma patients as compared to PBMC from normal volunteers matched for age, gender and skin type. Whole-body irradiation was performed with 0.8 minimal erythema dosages on five consecutive days. Peripheral blood was obtained before and after the procedure. Overall, there were no major effects of UVB irradiation on peripheral lymphocyte subsets and proliferation of PBMC from patients or normal controls, but UVB irradiation led to a significant increase in PWM-stimulated production of IL-6, IL-2R and TNF by PBMC. These changes were independent of the individual UVB dosages administered and appeared in both groups similarly. UVB irradiation did not lead to significant changes on IL-1 and IL-2 expression by PBMC. Our results suggest that PBMC participate in the cytokine response to UV, even in the absence of inflammatory reactions, but that this participation is not specific to MM patients.

Teaching non-specialist health care professionals how to identify the atypical mole syndrome phenotype: a multinational study.

The atypical mole syndrome (AMS) phenotype is the strongest known risk factor for cutaneous melanoma but recognition of the phenotype has been claimed to be problematic and to require specialist assessment. This study determined the ability of previously unskilled doctors and nurses in five countries to recognize the phenotype after brief training. The system used was the AMS scoring system. This incorporates melanocytic naevus counts, clinical atypia of naevi and distribution of naevi. The agreement in scoring between the dermatologist and trained personnel was determined in 986 patients; overall agreement in diagnosis was 94.5% (kappa 0.70, P < 0.0001). The kappa scores in different countries ranged from 0.65 to 0.77 for individual naevus characteristics, indicative of good agreement. Accurate diagnosis of the atypical mole syndrome phenotype is possible by non-specialists. This has implications for collaborative studies of naevi, for screening and for both primary and secondary prevention of melanoma.

Expression of complement regulator proteins in primary and metastatic malignant melanoma.

The expression of complement regulatory antigens C3b/C4b receptor, (CD35) membrane cofactor protein (CD46), decay accelerating factor (CD55), and homologous restriction factor 20 (CD59) was determined immunohistochemically on ten primary malignant melanomas, 16 metastatic lesions, and ten melanocytic nevi. All of the melanocytic nevi and 9/10 primary melanomas showed both expression of CD46 and CD59. In one primary melanoma lacking CD46, expression of CD35 could be detected. In metastatic melanoma, 9/16 metastases were CD46+/CD59+, two were CD46-/CD59+, one CD46+/CD59-, and four CD46-/CD59-. Additionally, CD55 could be detected in two CD46+/CD59+ metastases, and CD35 in one. Expression or lack of complement regulatory antigens did not correlate with the expression of GD2, GD3, HMB-45 or S-100. In conclusion, some cases of metastatic melanoma show loss of normal expression of complement regulatory proteins. This might have implications on the immune response or the efficacy of immune therapy in malignant melanoma.

Effects of chronic low-dose ultraviolet B radiation on DNA damage and repair in mouse skin.

Chronic exposure to sunlight causes skin cancer in humans, yet little is known about how habitual exposure to low doses of ultraviolet B radiation (UVB) affects DNA damage in the skin. We treated Skh-1 hairless mice with daily doses of suberythemal UVB for 40 days and analyzed the amount and distribution of DNA photodamage using RIAs and immunofluorescence micrography. We found that DNA damage accumulated in mouse skin as a result of chronic irradiation and that this damage persisted in the dermis and epidermis for several weeks after the chronic treatment was terminated. Although the persistent damage was evenly distributed throughout the dermis, it remained in the epidermis as a small number of heavily damaged cells at the dermal-epidermal boundary. Rates of DNA damage induction and repair were determined at different times over the course of chronic treatment in response to a higher challenge dose of UVB light. The amount of damage induced by the challenge dose increased in response to chronic exposure, and excision repair of cyclobutane pyrimidine dimers and pyrimidine(6-4)pyrimidone dimers was significantly reduced. The sensitization of mouse epidermal DNA to photoproduct induction, the reduction in excision repair, and the accumulation of nonrepairable DNA damage in the dermis and epidermis suggest that chronic low-dose exposure to sunlight may significantly enhance the predisposition of mammalian skin to sunlight-induced carcinogenesis.