Focus

With the onset of summer, people are spending more and more time in the sun. But with the UV index soaring, exposure to sunlight has a dark side - the risk of skin cancer. By Cynthia Busuttil

The deadly burn

A self-proclaimed former sun worshiper, Rose* has had to change her lifestyle quite drastically in the past few years, since she was diagnosed with malignant melanoma.

When Rose first came to Malta from England in 1960, sun protection was not at the forefront of her mind. In fact, believing - as she still does - that brown is beautiful, she used to mix oil with vinegar and lie for hours in the sun to get a nice suntan. She never used sunscreen.

"Imagine what that must do to the skin, especially to people with fair skin and freckles, like myself," she said recounting her sunburnt days.

"In those days we did not know anything about sun protection. It is only in the last one or two decades that people have become aware of its importance."

Alex* too used to spend a lot of time in the sun, putting on some oil while sunbathing "just like everybody else". He realised he had a problem after reading a magazine article which showed pictures of different types of skin problems.

"There was the picture of a bright black irregular spot - the worst type of melanoma. I realised I had such a spot on my upper chest."

Alex lost no time in making an appointment with the dermatologist, who looked at the patch and asked him to return the next day to have it removed.

Rose, on the other hand, never noticed that something was wrong and was diagnosed with melanoma just by chance.

"I went to the dermatologist for something completely different and when he asked if there was anything else bothering me I mentioned a brown patch on my back. I told him I was sure it was nothing since it was not raised, did not have any red parts and did not itch or bleed.

"But when he looked at it he told me it needed to be investigated and that he would remove part of it to test it. Since I was going abroad on business the following week, I resisted the idea. But he insisted that the patch should be seen to immediately."

When Rose found the result in the post she had the shock of her life. "I opened this letter, which said I had malignant melanoma, and almost died on the spot. I could not sleep and spent hours on the internet researching melanoma."

What she found alarmed her further. But a call to her dermatologist reassured her, because the melanoma was in situ, which meant it was localised and had not gone beyond the skin.

"The patch was removed and since then I have had regular check-ups and scans, which showed that I am doing well. But my lifestyle has changed completely. Realising that it can happen to you really jolts you to your senses. Now I am really careful to stay out of the sun as much as possible. If I am playing golf I cover up with long sleeves and trousers. I even cover up when I'm by the pool and wear a sunscreen with an SPF of 60+ every day."

Alex is also being more careful. He tries to stay out of the sun as much as possible and warns his children not to expose themselves to the sun.

"When I see people swathing oil all over them and spending hours in the sun, I think they are being stupid. There have been enough warnings about the danger of sun exposure now. Even if I had not been diagnosed with melanoma, I would still have changed my lifestyle where sun exposure is involved," he said.

Rose's attitude changed even with regard to the people around her. Her young grandchildren now have UV protective clothing to wear when they swim. It has also made her more sensitive and when she sees someone with a spot, she makes sure they are aware of it. "If melanoma is caught early, like in my case, the chances of survival are much higher."

Today she feels sorry for people who spend time in the sun with no protection, especially for young children who get burnt very easily. "Melanoma is a frightening thing because the damage can become evident in 10 to 15 years' time."

* Names have been changed

The effects on children

Although the incidence of melanoma skin cancer in children is low, there are reports from various parts of the world suggesting it can still occur. The chairman of the Dermatology Department at Sir Paul Boffa Hospital, Lawrence Scerri, said the number of reports of melanoma at a young age are on the increase.

Dr Scerri stressed that substantial irreversible sun damage still takes place in childhood when the skin is much more vulnerable to the harmful effects of ultraviolet radiation. This emphasises the importance of adequate sun protection being exercised during childhood.

"Scientific research has clearly shown time and time again that ultraviolet exposure in childhood and adolescence predisposes to a significantly higher risk of melanoma later on in life.

"The other undisputed risk factor for melanoma is a history of sunburn especially in children, adolescents and young adults. The risk is certainly higher for those individuals with fair skin which burns easily," he said.

Dr Scerri explained that many people do not realise how easy it is for someone with fair skin to get sunburnt. "A fair-skinned individual can burn after as little as 15 minutes of unprotected exposure to midday or early afternoon sun in spring or summer," he said.

Infants under six months old should be kept out of the sun altogether since no sunscreen is effective enough to protect their delicate skin. Dr Scerri said that in older children a sunscreen with a minimum sun protection factor (SPF) of 30+ is strongly recommended.

Sunscreen must be applied 20 to 30 minutes before going outdoors and should be re-applied every two hours as long as one is outdoors between 11 a.m. and 4 p.m. especially if one is repeatedly jumping in and out of the sea or pool. In this case, a water-resistant formula should be used.

"There is a danger that sunscreens might confer a false sense of security and fool people into thinking they can stay in the sun for longer periods just because they have applied sunscreen. One should bear in mind that although nowadays we have better and more sophisticated sunscreens, there is still no such thing as a total sun block which filters out all the harmful rays of the sun," he said.

Asked whether there is enough awareness in Malta about the detrimental effects of the sun, Dr Scerri said local surveys conducted among schoolchildren and adults in recent years have shown that the level of awareness about the harmful effects of the sun and skin cancer is encouragingly high.

"This is not surprising given the aggressiveness of education campaigns dealing with this matter in the past 10 years," he said, adding that such campaigning is in line with current scientific knowledge and has been equally aggressive in most countries harbouring predominantly white-skinned populations which, in turn, have been similarly afflicted by a rising incidence of melanoma skin cancer.

However, Dr Scerri said, we are unfortunately still a long way away from putting this level of knowledge into practice.

"In particular, the education authorities still have not responded positively to health warnings. Although the third term of the scholastic year stretches from early April until the end of June, during which the UV index routinely reaches seven to 10, outdoor school recreational activities after 11 a.m. are still common practice, in spite of a growing body of concerned parents repeatedly lodging complaints with the competent authorities year after year.

"It is high time for school recreational breaks to move to safer hours. Another positive measure would be that of setting up more shade-generating structures in the playing grounds, such as tents and planting more trees," he said.

Dr Scerri commended the Tree 4U afforestation campaign, which aims to plant more trees around the island. He said it would not be such a bad idea to extend this to school grounds.

"Similar efforts to protect our younger citizens from lethal solar radiation should be made by coordinators of summer sport activities, summer camps and summer schools."

He said that as part of a meaningful, concerted effort, influential sources such as media advertising and fashion gurus, which have a profound impact on adolescent attitudes and behaviour, would do well to tone down their everlasting promotion of the "gorgeous tan".

"The gorgeous tan will not be so gorgeous when blotchy wrinkled skin sets in after as little as 10 years of sun worship," he said.

Early detection can save lives

Catching melanoma early can be life saving because once melanoma spreads, there is no turning back.

Although most moles are not cancerous, it is vital to keep an eye on existing moles. Leading dermatologist Joe Pace, who is also the secretary general of the European Academy of Dermatology and Venereology, said the first indications of melanoma are a change in the colour or consistency of an existing mole, or if it starts itching or bleeding without trauma. It is imperative to watch out for a new pigmented lesion.

Moreover, Dr Pace said, people with multiple moles need to see a dermatologist regularly, approximately once a year, although he stressed that this depended on the individual situation.

"It is of great help to have a professionally taken photograph both in low and high resolution for comparison in later years," he said.

Asked about the treatment of melanoma, Dr Pace said that in early cases, simple excision with a small margin of normal skin, depending on the depth of the tumour, may be curative. He said chemotherapy and radiotherapy, with the possible exception of Interferon for late cases, do not help.

If part of the skin is removed, reconstructive surgery is offered but Dr Pace stressed that today experts do not remove large areas of adjacent skin as this has been proved not to add longevity to the patient.

On a positive note, the survival rate of melanoma after five years is over 90 per cent for superficial lesions which are caught early.

Melanoma - facts and figures

Melanoma is the most dangerous form of skin cancer due to its propensity to spread and cause death.

Statistics from the Maltese National Cancer Registry show that between 1993 and 2003 there were 264 new cases of melanoma in Malta, with an overall mortality rate of 19.3 per cent.

Melanoma skin cancer is caused by exposure to sunlight. It can develop anywhere on the body, although it is most common on the back in men and on the legs in women. It may appear as a quick-growing, irregular, dark-coloured lump or patch, or may develop in a pre-existing mole which changes in size, colour or shape.

Although melanoma and other skin cancers are normally associated with sun exposure near the sea, the sun does not just burn at the beach, of course.

Dr Lawrence Scerri underlined the importance of staying out of the sun during the peak hours - wherever one happens to be.

"One of the most important components of the so-called 'sun protection package' is keeping out of the sun during the peak hours - between 11 a.m. and 4 p.m. - when the sun's ultraviolet rays are the strongest," he said.

If this is not possible, people should adopt protective measures: using sunscreen - at least factor 30+ for children and adolescents and factor 20+ for adults - and wearing a wide-rimmed hat and clothes which give reasonable coverage. "A short-sleeved top is certainly much better than a sleeveless one."

Dr Scerri said the ultraviolet (UV) index is a reliable scale which nowadays forms part of the weather forecast and tells us the intensity of UV radiation around midday. The index comes on a scale of zero to 11+, with the higher the reading, the stronger the intensity of radiation.

"A reading of seven to nine should alert people to take sun protection seriously, whereas a reading of 10 or higher signifies a state of red alert meaning that one should make a great effort to stay indoors between 11 a.m. and 4 p.m., rather than just rely on sunscreen," he said.

Dr Scerri said it was amazing how many people were still taken by surprise year after year and get sunburnt despite repeated warnings from the health authorities.