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Melanoma Fact Sheet
Advisory Board Members:

Dr D. Whitaker (President), Dr C. Albrecht (CANSA), Dr E. Bam, Mr G. Dempster, Mrs S. Janse van Rensburg(CANSA), Prof. F. Jordaan, Dr G. Levy, Dr J. Malan, Dr G. McAdam, Dr J. Moche, Dr C. Nel, Dr B. Ritchie, Dr P. Scott, Prof. W. Sinclair, Dr C. Thatcher, Mz E. Tzetis, Dr D. Vorobiof

  1. Melanoma – Definition/Diagnosis/Incidence
  2. Sun wise behavior
  3. Sunscreen debate
  4. Vitamin D issue
  5. Sun bed issue
  6. Skin screening
  7. Melanoma management – Every patient needs follow up according to guidelines.
  8. Future trends – Reverse the incidence, funding, registry.
Defining Melanoma

Melanoma is a type of skin cancer which derives from the pigment-producing cells (melanocytes) in the skin. It can, unlike other forms of skin cancer (basal cell carcinoma and squamous cell carcinoma) spread rapidly through the lymph or blood system to other major organs (bone, brain, liver etc). If detected early, it carries an excellent prognosis. If not diagnosed, it can be a rapidly progressing fatal disease.

South Africa has one of the highest incidences, if not the highest, of malignant melanoma in the world (similar to that of Australia). To date, we do not have accurate statistics, but the estimated 2009 figure for the Cape is 69 new cases per year per population of 100 000 Caucasians, compared to 65 per 100 000 for Australia. This translates to one in 1429 people developing a malignant melanoma. From 1990 to 1995, this figure was 22.2 per 100 000 for females and 27.5 per 100 000 for males. In the period 2000 – 2003, this rose to 33.5 per 100 000 for females and 36.9 per 100 000 for males. Clearly, something needs to be done to address the risk factors and to try and reverse this trend.

Sun-wise Behaviour

Melanomas develop in people who have a genetic predisposition coupled with excessive, unprotected sun exposure. So far, more than 20 gene mutations have been identified which play a role in the transformation from a normal cell to a melanoma cell. Some forms of melanoma have been linked to overexposure to UV radiation, particularly sun binges and blistering sunburns in childhood. It is therefore imperative to implement sun-wise behaviour such as:

  • Avoid direct, unprotected sun exposure seeking shade wherever possible.
  • Cover up with sun protective clothing, i.e. hat, long sleeve shirt, and trousers.
  • Use a high factor sunscreen on unprotected skin, i.e. face, arms, hands etc.

Sunscreen Debate

There seems to be a lot of controversy about the use of sunscreen in general and selecting the right sunscreen in particular. The current SPF system only addresses UVB protection and is poorly understood by the general public. The SPF relates to a time factor, namely the time any individual can spend in the sun without burning. This depends on the skin type but also the so-called ‘safe sun time’ (SST), which is area specific. The SST depends on the UV concentration measured, i.e. 10 minutes in Cape Town between November and March. So the SPF of 10 increases the SST to 10 minutes x 10 SPF = 100 minutes. Bear in mind that a sun exposure of 10 hours or more is not unusual in summer.

As UVA protection has not been standardised yet, it is even more confusing for the consumer. While the experts are still debating a unified message, we can formulate the following advice regarding sunscreen use.

A good sunscreen should:

  • Have UVA and UVB protection
  • Be tested by an accredited organisation (such as CANSA) for safety and efficacy.

The higher the SPF (and UVA protection) the better, because if one uses too little, the efficacy drops dramatically. Any sunscreen should be reapplied frequently – there is no such thing as daylong protection. There is also no such thing as one correct sunscreen; it is more important for the sunscreen to fit the activity of the individual. For example, a surfer requires a different sunscreen to a runner, whilst children and men often prefer sprays while women tend to prefer creams.

Vitamin D Issue

There has been considerable publicity around the fact that people think they produce insufficient amounts of Vitamin D if they are using sunscreens on a regular basis. This has been disproven, particularly in a sunny country like South Africa. The main source of Vitamin D comes from food. There are no reported cases of children and teenagers with Vitamin D deficiency, and these young people need strict sun protection. An area of 10cm squared (the size of the back of your hand) exposed to the sun for 10 minutes produces sufficient amounts of Vitamin D. No sunscreen will ever give you complete and absolute protection from UV radiation.

Sun Bed Issue

In the past, the UVA radiation emitted by sun beds was thought to cause ageing of the skin but to be relatively harmless. Genetic and molecular studies have now proven the causative relationship between UVA and development of malignant melanoma. Sun beds do not deliver a ‘safe tan’ and all machines should carry a serious health warning similar to that found on cigarettes, i.e. ‘The use of this machine can cause skin cancer’.

Skin Screening:

A positive prognosis of malignant melanoma depends on early diagnosis and management. A surgically removed early melanoma (i.e. melanoma in situ) carries an excellent prognosis, while a melanoma detected late can carry a high mortality rate. Although regular skin checks by a dermatologist are desirable, these are often restricted to follow-up of risk patients (i.e. patients with more than 50 moles, more than five atypical moles and patients with their own or family history of malignant melanoma). However, the public should be educated to do self-checks on a regular basis following the ABCD rule:

  • A stands for Asymmetry
  • B for Border; irregular
  • C for Colour; more than one colour
  • D for Diameter; greater than 5mm or any lesion which grows
  • E for Elevation

Any sensation (itch, pain, bleeding) is also cause for concern. If any suspicious lesion is noted, a doctor should be consulted. Even today 80% of all melanomas are first detected by the patients rather than doctors.

Melanoma Management:

Once a patient is diagnosed, it is vital that they are followed-up on a regular basis. This should be done by a dermatologist, with or without an oncologist, according to the guidelines. The risk of developing a second primary melanoma is 10%. Multi-disciplinary follow-up in late stage disease or thick melanoma should be encouraged.

Future Trends

It is unlikely that our environment is going to change and produce less harmful UV radiation, so it is imperative to aim for a behavioural change by adapting to our ozone-depleted atmosphere. People need to be educated about sun-wise behaviour and must be strongly encouraged to avoid sunburn. Educational programmes must run continuously targeting schools, sports associations, parents and teenagers. Lectures, videos, magazines, radio and TV ads and programmes should be used to spread the message. Risk groups should be identified and monitored on a regular basis. The initiation of a melanoma registry would provide useful and vital information regarding the recognition and management of this serious disease.

Summary

The messages which need to be conveyed are:
  • Never burn your skin, cover up and protect.
  • Always use sun protective clothing and the highest factor sunscreen (SPF 30 or higher). DON’T use sun beds.
  • DON’T worry about Vitamin D deficiency or bad chemicals in the sunscreens. (Remember a chemical may cause cancer, the sun will cause cancer)
  • Check your skin on a regular basis.
See a doctor or Dermatologist if you are at risk or have a mole you think is not all right.

In 2010, Vichy is proud to be able to develop its educational mission by forming a unique partnership with the South African Melanoma Advisory Board.