June 17, 2024 • 39 mins
Are you at risk of developing a melanoma?
Dr George Moncrieff explains how “one episode of severe sunburn doubles your lifetime risk of melanoma. And using a sunbed ever, just using it once, increases your risk by 20%. And...in young people, in people under 35, that risk is actually increased by 59%.”
Listen to this episode where Dr Moncrieff and Dr Roger Henderson delve into risk factors in more detail, as well as...
- Explaining who is genetically at risk of developing a melanoma
- Discussing how common melanomas are now compared to some years ago
- Debating whether doctors are using the right approach to spotting and diagnosing melanomas.
Thank you to our kind sponsor AproDerm, who provide a range of emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
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We hope you find this podcast interesting and helpful. Please leave us a review or email info@aproderm.com with any feedback on this episode or suggestions on skin-related topics that you would like to hear about in future podcasts.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:10):
Hello and welcome to this Skin Deeppodcast where we look at skin-related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was the Chair
(00:31):
of the Dermatology Council for England.
Now today, George and I are going tobe discussing malignant melanomas.
And we're going to look at theircause, some figures as to how common
they are now compared to some yearsago, and whether we're actually
approaching them the right way.
(00:53):
Now, I know you've got some prettystrong views here on this topic,
George, so I think this is going tobe an absolute cracker of a podcast.
But let me start by asking, a perhapsan obvious question, as to why spotting
a malignant melanoma by doctors hasrather become like the shark in Jaws.
Everyone's afraid of it, everyone'stalking about it, and everyone's
keeping a constant lookout for it.
(01:15):
Indeed, they are.
Yeah, it certainly puncheswell above its weight, I think.
That's not to say melanomaisn't a terrible diagnosis.
I think part of the problem is thatdoctors recognise that they're not
forgiven, if they miss a melanoma.
And that's borne out by the factthat we're ten times more likely
to be sued for missing a melanomathan missing any other cancer.
(01:39):
Society, the courts, journalists, everyoneis ruthless if a doctor misses it.
They expect us to get this one right.
So, that's the first point.
The second concern is that theyare getting more common and it's
increasing in incidence fasterthan any other cancer I know.
(02:00):
So the incidence of melanoma isdoubling every 10 years and has done
so now for the past 40 or 50 years.
If you look back at 1998, the figures werejust five cases of melanoma per 100,000.
That's now over 20 per 100,000.
So it's increasing quite fast.
(02:20):
Admittedly, I think some of that increasecould be down to changes in the way in
which we make a diagnosis of melanoma.
In the past, I think people lookedunder a microscope and dismissed
something, whereas now, with specialimmunochemistry testing and other things
that histopathologists can do, they canrecognise that something is a melanoma.
So it's labelled a melanoma, where inthe past it might have been called a
(02:44):
dysplastic naevus, which
just means a mole that'snot looking very healthy.
The vast majority though, ofthis increase of melanomas, are
what we call melanoma in situ.
Now, dermatologists agree withme that a melanoma in situ
is almost a benign lesion.
(03:07):
We, think that left totheir own devices, they will
become invasive melanomas.
But there's definitely a body of opiniondeveloping, that there are very early
melanomas, which are very flat, whichare almost benign, and that the patient
(03:31):
might die with them and not from them.
And all this increase that we'veseen over the last 40 years has been
predominantly of these very early, insitu, almost, benign is almost the wrong
word to use, but very low risk melanomas.
And so, I used to say, don'tcall them malignant melanomas,
(03:53):
because they're all malignant.
But I've now gone back tocalling them malignant melanomas.
And in my mind, I'm also thinkingquietly, that there could be more benign
melanomas, these very flat, whirlyones, which, I'm just a bit worried
I might have imposed a diagnosis ofmelanoma on some of my patients, when
in fact they had a lesion that was nevergoing to cause them any harm at all.
(04:15):
Unfortunately, we will never know theanswer to this, because no one's going
to be brave enough to leave them.
I've certainly seen early melanomasthat the patient says, this one hasn't
been changing for at least four or five,six years and I look at it and I say,
well, it's clearly a melanoma and it is,when it's excised, and you just wonder.
(04:36):
But the current lifetime risk ofsomebody getting a melanoma is about
one in 36, in men, a bit less commonin women, almost one in 47 women, so
almost 3% in men and almost 2% in women.
Okay.
And I'm with you, you know, you'vegot to be very careful about malignant
melanomas and benign melanomas,but I tend to reserve malignant
(05:00):
melanomas for when we know they are.
So it's obviously increasing, quite fast.
But what about the ages ofpeople that we see it in?
My back of an envelope calculationcompared to say 20, 25 years ago, is
I'm probably seeing fractionally moreyounger people with it, but the bulk
still remains the older population.
(05:22):
Yeah, it's exactly that.
Yes, it gets common, morecommon, as you get older.
And its peak age of incidenceis in the 85 to 89 year olds.
And I suspect it would continueto increase per capita beyond
that, but just there are lesspeople alive after the age of 90.
So the peak age for seeing a melanomais in the 85 to 89 year old group.
(05:46):
But as you say, it's also a cancerof young people, and it's increasing
fastest in individuals under 55.
That's the cohort in which the incidenceis increasing fastest currently.
But about 4% of all melanomas occur invery young adults, 15 to 34 year olds.
(06:07):
Devastating stage in your life tobe given a diagnosis of a melanoma.
And so, it's not an uncommoncondition but it causes this huge
anxiety that we talked about earlier.
And as a consequence, half of allreferrals by a GP to the cancer
bureau, the two-week wait bureaus,are referrals of a lesion on the skin.
(06:30):
And I think this is the real problem.
We are overloading secondary carewith these huge numbers of patients
that we are concerned about because ofwhat their lesions are looking like.
Half of all referrals to dermatologyare for suspected skin cancer.
But this is a very interesting point.
Only 6% of our referrals to theskin cancer two-week bureau turn
(06:56):
out to be either a melanoma or theother cancer that matters, which
is a squamous cell carcinoma.
94% are benign, nothing to worry about.
So the purpose of that two-week bureauis to manage these potentially nasty
cancers rapidly, but only 6% turnout to be anything to worry about.
(07:19):
And more worrying to me than that, is somefigures that I got from the president of
the British Association of Dermatologists,when I was working at the Dermatology
Council for England, and he said he'ddone a Freedom of Information Act report
through all the trusts in the country,asking the dermatologists he knew, how
(07:40):
many of the referrals from GPs that wehad referred as suspected melanoma, or
other cancers, were obviously benign?
They could take one look at thisand they say nothing to worry about.
And the figure that came back was84%, are not just benign, but in
their view, were obviously benign.
(08:02):
So there's a big issue about whatGPs are sending to secondary care
and overloading secondary care.
And I think that we'll come on tothat in our next podcast when I'll
be talking about that in more detail.
I think so.
If we've got such a huge number of benignor harmless skin lesions, I'm struggling
to think about any other cancer,potential cancer diagnosis, referred
(08:24):
into a two-week pathway, when you'vegot such a low pickup at the end of it.
But we're obviously speaking intimes of massive waiting lists.
And we're obviously going to be furtheroverloading it, compromising the ability
of dermatologists to provide a service.
But I know of many anecdotes wherecolleagues have been, almost pressured,
(08:44):
into referring, by patients who've lookedat Dr Google or whatever, even then, when
they were 99% certain their skin lesionwas benign, and this is the key point.
But I guess we come back to that, whatwe talked about right at the top of
the podcast, the fear of both missinga skin cancer or, in my view, probably
more of an issue, being sued if we do.
(09:06):
We're almost sued if we do andsometimes sued if we don't.
And I think this is where you've gotpretty strong views, on the advice
that as GPs, we are being given advicefrom the top, if you like, on this.
I do indeed.
Yes, that is a, clearly, a major issue.
And of course, as GPs, we, well certainlyin my day, we lived in the community.
(09:26):
The cinema I went to, I sat nextto my patients, the supermarkets, I
was in the queue behind my patients.
My wife taught my patientsat the local school.
So you live in that community and whenyou make a mistake, it's obviously a
disaster for the patient, but that wordgets around, and it's not just being sued.
(09:46):
You are, where you live, your home, wholelife is surrounded by your mistakes.
Agreed.
So you can't afford to get it wrong.
And so clearly, you know, doctorsare going to err on the side of being
cautious, not just for their patients,but also selfishly for themselves.
But I believe our whole approachto diagnosing melanoma is, I'd
(10:07):
actually say, dangerously flawed.
And I'll come on to that in a lotmore detail next time, where I'll
be discussing NICE's and the BritishAssociation of Dermatologists', frankly,
infatuation with what's called the ABCDEapproach to recognising a melanoma.
I think using that approach isresponsible for a lot of the problems
(10:30):
that we're having in primary carewith distinguishing these obviously
benign lesions from the potentiallymore serious melanomas and things.
ABCDE causes huge anxietywith false positives,
i.e. referring what turn out
to be obviously benign lesions that fail
that system for looking at lesions.
(10:52):
And it even accounts for someof the false negatives,
i.e. the patient has got a
melanoma, but it doesn't reach the criteria
for ABCDE to make you concerned.
So it fails both ways.
I think medicine is far moresophisticated than just reciting
the alphabet, and I think that weneed to be much more intelligent in
(11:13):
our way of looking at melanoma inthe community and recognising which
patients we need to be worried about.
Yes, I think I agree with that,and the medical students that I
teach, you know, do have ABCD sortof, imprinted on their foreheads.
And I suspect there are quite a fewpeople listening, wondering what the
George approach to melanomas is instead.
(11:34):
Now, my best guess with you is that youstart with the general perceptions around
melanomas and then work up from there,to look at the actual risk factors across
the whole area, and I'm thinking notjust the impact of ultraviolet light.
So that's where I'd be coming from.
Do I win a goldfish?
I think you win a clusterof goldfish actually.
(11:56):
Yes.
You've got it in one I think.
Yeah.
Well, I think my approach startsoff with, is this patient, who's
worried about something, or thepatients I've seen a lesion on, are
they a candidate for a melanoma?
Are they somebody who islikely to get a melanoma?
And when I talk to colleagues aboutthis, or even the public, more, I think
(12:19):
when I say to them, you know, "whatare the risks of getting a melanoma?"
They say, "well, it's sunlight.
Full stop.
It's going out in the sun, and howevermuch you get exposed to the sun,
that's what causes your melanoma",and that's as far as they think.
But in fact, let's look atthe actual risk factors.
(12:39):
Well, the first thing I think,to say is that age matters.
I've already mentioned that melanoma,is more common in the very elderly,
but turn it the other way around.
Children and young adolescents, peopleunder say, 14, 15, certainly risk
under the age of 11, is virtually nil.
There was a study fromBristol a couple of years ago.
(13:00):
They looked at all the referrals to theirtwo-week bureau of children, under 11.
There were 79 referralsover a two year period.
Doctors had referred the patients,these children, concerned that
the lesion could be melanoma.
They didn't have one melanomain their study, at all.
So children under 11, almost however uglythe lesion looks, you can be very relaxed.
(13:24):
It doesn't mean I wouldn't ask aspecialist to give a second opinion,
but I'm very relaxed indeed aboutchildren under the age of 11.
They don't really get melanomas.
Apart from perhaps the oneexception, well two exceptions,
one is the quite rare thing
called a spitzoid melanoma,
which looks different andI won't go into that here.
That's not, it's not that uncommon inchildren, but they don't tend to have
(13:45):
a terrible prognosis and under 11,they're usually not too serious anyway.
And the other is the child who's bornwith what's called a bathing trunk
naevus, where, for example, the half oftheir body has a huge pigmented patch,
often hairy, covering the whole of theirbuttocks and half their tummy and things.
Within that, there's a tinyrisk of getting a melanoma.
(14:07):
So first of all, children, don't worry.
The things that alert me and make meinstantly much more concerned is a
patient who's had a previous melanoma.
If somebody's had a melanoma beforeand they've now got a lesion that
they're concerned about, or ischanging in some way, I'm anxious.
Somebody who's had one melanomahas a 10% risk of having another.
(14:29):
So they need to be watched, carefully.
Similarly, if they've got a firstdegree relative, a brother, sister,
parent, who's had a melanoma inthe past, well, that doubles that
individual's risk of a melanoma as well.
So, those are two reallyimportant risk factors.
The next group of patientsI'm concerned about are the
patients with multiple moles.
(14:51):
We all see these patientsfrom time to time.
They've got loads of moles.
And I'm not talking about, what wecall these benign pigmented things
on the skin, which often most ofus get when we get older, sun spots
and seborrhoeic keratoses, theserather greasy, warty, crusty, sharply
demarcated lumps usually on our trunk.
(15:14):
But if you've got moles, actualmoles, which doctors call melanocytic,
because they've got cells that producemelanin, melanocytes, naevi, that
themselves, they're benign moles.
But if you've got more than 40, whichis not uncommon, that doubles your risk.
You've got the geneticmakeup for melanoma.
(15:34):
If you've got over a hundredmoles, you've got seven times
that risk, the normal risk.
And if five of them are looking a bit odd,irregular, in themselves they're perfectly
fine, we call those atypical moles.
But if you've got more than fiveatypical looking moles, then
you've got six times the risk.
(15:55):
So, patients with multiple moles,I'm concerned about, and I'm
concerned about them for two reasons.
One, they're more likely to get amelanoma, and two, when they get a
melanoma, it's a devil's own job to spotit, because initially, when it's small,
it looks just like their other moles.
And the only way in which you can reallyreliably say this is a melanoma and
(16:19):
not just one of the moles you've hadfor years is having serial photographs.
You've got a photograph of whatyour back looked like last year
and now there's a mole there thatwasn't there, then that's the one to
worry about.
While I'm on the
subject of moles, by the way, mostof our mole population appears from
(16:40):
about the age of 11 or so, 8, 9, 10,11 onwards, and we develop most of
our moles in our early adult years,up to in our teens and early 20s.
I don't like new moles appearingafter the age of 30, and I get
particularly anxious about anyonehaving a new mole over the age of 50.
(17:02):
But the risk of these acquired molesbecoming a melanoma is trivial.
It's about, if you've got a mole,the risk of that mole becoming a
melanoma is about 1 in 200,000.
Wow.
And to be honest, that's no differentreally, from the neighbouring normal skin.
(17:22):
So cutting out a mole to prevent itone day becoming a melanoma, you might
as well just take all the skin off.
It's pointless.
Slightly different with
congenital naevi.
If you've got a congenital naevus,
i.e. that's a naevus that's been there
from birth, the risk of those one day
turning into a melanoma is very small.
(17:45):
It's about 1 in 200, and that'slikely to happen in later adult life.
In fact, the overall risk of acongenital naevus one day becoming a
melanoma is more like 0.8% which isfractionally more, but that includes
the rare but very large so called giantcongenital naevi which can cover the
(18:11):
whole buttocks and are really huge.
But those are closely followed upin hospital, those are uncommon, but
the risk of melanoma within those issignificantly more and so that raises
the overall risk of a congenital naevusone day becoming a melanoma, but when
you discount those, the actual riskof a small to medium sized mini naevus
(18:31):
that's been there from birth or a fewmonths after birth is only 1 in 200.
Most of those don't do anything.
They either disappear or they turninto what's called intradermal naevi.
But there's a small risk.
So those are the major risk factors.
Past history, familyhistory, multiple moles.
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(21:09):
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Obviously, skin type matters, and I'llbe discussing that in a bit more detail.
But if you've got ginger hair or, thatalone, just having ginger hair, doubles
your lifetime risk of a melanoma.
In fact, more than doubles it.
(21:29):
It's between 1.5 and 3.6times increased risk.
So, that's certainly a risk factor.
Turn it the other way around, havingvery dark skin, Caribbean sort of skin,
really, sort of, dark brown, the risk ofa melanoma on the skin, what we call a
cutaneous melanoma, is vanishingly small.
Melanomas on the foot, on thefingerprint skin, so the soles and
(21:53):
the palms, and around the nails,at the same rate with white skin.
Mucosal cancers, melanomas, I mean,so you can get it in the nasopharynx,
that's behind the nose, or inside thenose, in the nostrils, or in the throat.
I've even seen a melanoma in the stomach.
So you can get melanomas elsewhere,and they're just as uncommon in
(22:14):
dark skin as they are in light skin.
But all these things, gingerhair, skin type, genetic factors,
I'm sorry multiple moles, familyhistory, so these are all genetics,
and you can't change any of those.
That's your genetic makeup thatgives you a predetermined risk of
developing a melanoma, one day.
(22:35):
Yeah, and I said, listening to thatmade me come back to the point we've
often mentioned in our podcast, whichis, take the history, even before you
sort of put your eyes on someone'sskin, actually take the history, because
the patient is likely to tell you anawful lot of what you're going to need.
(22:55):
So, you know, you ask about thefamily history, you ask about whether
they've had skin problems in thepast and that sets you on the road.
Now ultraviolet light, as youmentioned earlier, you know, everyone
thinks about ultraviolet light.
The other thing we, but before weeven talk about that, the other thing
that I sometimes have to remind myselfto, to remember, if I'm thinking
(23:19):
about someone with melanomas, isimmune suppression in patients,
the impact of immune suppression,and again, taking the history.
Is there anything which is going toimpact on the immune system, which
in turn is going to fire up thepossibility of melanomas occuring.
Yep, that's such an important point.
(23:40):
Yep, it's estimated that in ouradult life, each of us is producing
one new melanoma cell every day.
But our immune system is spottingthat quickly and removing it.
So it's not a problem.
But if you suppress that immune responsefor whatever reason, if you're on long
term steroids, perhaps for asthma oranother medical condition, or if you're
(24:06):
on drugs that knock your immune systembecause your immune system is messing
up, azathioprine is an example, thenyour body's ability to clear that
melanoma cell early is diminished.
Patients with HIV or lymphomas andthings like that, they are, their
immune system is dysfunctional.
And the organ transplant populationare looked at very carefully.
(24:31):
They have two and a half timesincreased risk of getting a melanoma.
They have a much more increasedrisk of getting other cancers of
the skin, squamous cell carcinoma.
So, my patients who've had organtransplantation, where their immune
system has to be calmed down fairlyaggressively, to prevent them rejecting
their transplant, they're usuallyunder secondary care in hospital,
(24:53):
having their skin checked, at leastannually, and they're given a lot
of advice on reducing modifiablerisk factors like ultraviolet light.
So yeah, I think immune suppression isvery important and I do feel that as
GPs, if you've got somebody whose immunesystem is not working as well as it
should be, for whatever reason, they'revery old, that's perhaps why melanoma
(25:16):
gets more common as we get older, ourimmune system becomes less aggressive.
Or they're on drugs that knock it, orthey've got another condition that affects
their immune system, then they should begiven good advice about sun protection
and probably, in my patients certainly,I would check their skin annually.
Yeah, you mentionedultraviolet light there.
So let's look at that now.
(25:38):
I think you and I definitely agree aboutrisks of sunbed use and especially now,
in teens and young people who are imageobsessed and again, without wanting
to hark back to the old days beforesocial media, again, in my practice,
undoubtedly, one of the huge changes I'veseen is the impact of social media on
(25:59):
some health behaviour in younger people.
And I think ultraviolet light,sunbed use, tanning, is perhaps
the biggest example I can think ofthat's changed in the last 20 years.
And I did some work on this recently, andI came across a statistic that actually
made my jaw drop so much, I didn'tbelieve it, and I went away and checked
(26:20):
it again before I actually believed it andrealised that the statistics were sound.
And that statistic was that there weremore skin cancer cases caused as a
direct result of sunbed usage than oflung cancer cases caused by smoking.
I still can't quite believe I'msaying that, but it appears to be
(26:40):
generally the case and sunburn, andobviously, as we all know, the sign
of a so called healthy tan is actuallya sign of significant skin damage.
Sunburn, and the use of of sunbeds,is a real power up here when
we're specifically talking aboutultraviolet light, aren't they?
(27:02):
Well, it's very complicated, but I thinkthat's a staggering statistic, isn't it?
And I'm not surprised, but itis pretty amazing, isn't it?
Yeah, I'm proud to say that I was a,sort of, low grade member of, I wasn't
a proper full member, of the All-PartyParliamentary Group for Skin Disease,
but I attended their meetings aboutsix, seven years ago, when the APPGS
(27:26):
managed to get a law passed makingit illegal for anybody under the
age of 18 to go and use the sunbed.
So I think, in the UK, so I thinkthat was a very important thing to do.
Yeah, ultraviolet light, it isterribly important because it is
the one modifiable risk factor.
You can't really do much about the immunesuppression, which is usually important.
(27:49):
You can't do much about your genetics.
And a history of sunburn.
It seems to be episodes of, intermittentepisodes of, intense sunlight, ultraviolet
light, that causes the risk for melanoma,whereas it's the low grade background,
cumulative sun exposure that causesthe keratotic cancers, things like
(28:13):
squamous cell carcinoma, which areusually much lower grade, much less
worrying, but they're still cancers.
So it's low grade background sunlight,just has a cumulative risk increasing
for the non melanoma skin cancers.
Whereas melanoma seems to besomething to do with episodes
of intense burning sunlight.
(28:34):
So, children under 11 their melanocytes,which are the cells that produce
melanin, are migrating to the skin,and they migrate from the spinal cord
area, and they take about 10 yearsto get there, which is why our mole
population appears in our adolescence.
That's when the moles are gettingthere, they're arriving in the skin.
(28:57):
But the ability of the skin to protectitself is therefore compromised, and
so children under 11 are particularlyvulnerable to ultraviolet light, and I
think they should be kept out of the sunas much as possible, and given vitamin D.
They should be covered up, usequality sunblock, and kept out
of any worrying intense sunlight.
(29:19):
One episode of severe sunburn doublesyour lifetime risk of melanoma.
And using a sunbed ever, just usingit once, increases your risk by 20%.
Wow.
And if you do that in young people,in people under 35, that risk
is actually increased by 59%.
(29:41):
So, these are huge increased risksso, and actually sunbeds also increase
the risk of these other cancers, likesquamous cell carcinoma, it increases
the risk even more by two thirds, to 67%.
So, sunbeds, from my point of view,are definitely a no, and I will
come onto those in more detaillater, but essentially they are,
(30:05):
it's hard to regulate the amount ofultraviolet light they're producing.
They're producing a lot of UVA, andalthough UVA doesn't burn, UVA wave
ultraviolet light penetrates quite deepand increases the risk quite considerably.
I think the, taking all that apartthough, avoid sunbeds, avoid intense
(30:27):
sunburn or intense ultraviolet light,episodes of sunburning, enough to
cause your skin to peel or blister.
Those are a disaster.
Apart from that though, I have to say,I am on my own in this, and this is
not the view of dermatologists, butI think that non burning, sensible,
(30:48):
ultraviolet light exposure, in adulthood,is not a huge risk factor for melanoma.
Yes, it's the one thing we can modify.
But it's not the major risk factor.
The major ones are theones I've talked about.
Family history, past history,multiple moles, immune suppression.
(31:10):
So it's a complicated message, but...
when you make a tan, these melanocytesproduce little packets of melanin,
called melanosomes, and those are takenup by all the cells in the epidermis,
the top layer of the skin, and thenthat melanin is released as globules
(31:35):
in the cytoplasm of those cells.
Now this is the clever thing.
What then happens is that they aggregateon the outer surface of the nucleus of
the cell, like an umbrella, protectingthe nucleus from the ultraviolet
light getting through, so that theDNA of that cell is not damaged.
(31:56):
But they leave the cytoplasm clear,so that's where you produce the
vitamin D and the other things thatsunlight does which are good for you.
So, I argue that if you've got, if you'vebuilt up a gentle tan, and I don't mean
a tan that ends up with lots of frecklesand sun damaged spots, age spots, sun
(32:16):
spots, solar lentigos, whatever you wantto call them, but you've developed a
nice even tan, what you've managed todo is you've managed to put an umbrella
on the outer surface of all the nucleiof your epidermis, and are protecting
your epidermal cells from ultravioletlight, and you're then getting all
the benefits of sunlight as well.
(32:36):
Now that's a highly controversialview, but I think in adulthood,
carefully and sensibly building up atan over a period of time, might be
a very reasonable thing to be doing.
I will come back to that.
But yeah, I accept, most melanomasdo occur on sun exposed skin.
(33:00):
Interestingly, it's on the backin men and on the legs in women.
Maybe the thought there is that inwomen, it's because they often wear
a skirt and the light is reflectingoff the ground and hitting their legs.
But one thing we do know that isif all people with white skin, used
total sunblock, 24/7, we would onlystop about a third of melanomas.
(33:26):
Two thirds of melanoma would still occur.
So yeah, sunlight, unquestionably matters.
And yes, sunlight is somethingwe can do something about.
And yes, getting an invasivemelanoma is horrible, but
it's, it's not the whole story.
And to put that into context, therewas a recent study in the Journal of
(33:49):
the American Academy of Medicine andthey compared Puget Sound in Washington
with Orange County in California.
Two populations that have completelydifferent ultraviolet light exposure.
And they matched these two populationsfor all the possible variables that
they could come up with, and theylooked at the number of melanomas
(34:12):
occurring in those two populations.
They were almost identical.
72 cases per hundred thousand in PugetSound in Washington state, and 73 cases
in California, a state where they'regonna be even more alert to the risk and
the possibility of getting a melanoma,and so more likely to go to their doctor.
And the conclusion they came to isthat we do need to consider whether
(34:36):
the time has come to be a littlebit more circumspect about our
messaging over ultraviolet light.
I think there's almost too muchanxiety generated by stressing
ultraviolet light, in adults.
I think in children, ultravioletlight protection is important.
What I say is, I think childrenshould be kept in the dark.
(34:59):
Perhaps in more ways than one.
But I think in adults, I thinkwe simply need to avoid sunbeds.
Avoid severe sunburn, and I think, usesunblock sensibly to enable us to build
up a sensible tan, and that's what I do.
(35:20):
When you talk to Australiandermatologists, they'll often talk
about the Australian truckers' armmelanoma, and this is a good example
of the high intensity, blisteringand burning, because Australian truck
drivers driving along in the heat, theywill stick their left arm on, out of
(35:44):
the window as they're driving along,and nine times out of ten, that's where
they power up their melanoma, if they'regoing to get one, and that actually
chimes exactly with what you're saying.
There's nothing about graduallow level acclimatisation to
sensible levels of UV light.
This is just constant day in, dayout, that arm is being hammered by
(36:05):
high intensity ultraviolet light andthat's what tends to power them up.
Just a final point, George, am Iright in thinking that low altitude
populations, compared to populationsliving at higher altitudes, are
at a higher risk of melanoma?
I seem to remember reading that somewhere.
Yep, you're absolutely right.
It's very interesting, isn't it?
(36:26):
UVA, which doesn't burn, goes straightthrough glass, straight through cloud, and
it penetrates our atmosphere very well.
So, at low altitude, you'regetting quite a lot of UVA.
UVB doesn't go through glass,it doesn't go through cloud.
UVB is a hundred timesmore burning than UVA.
(36:49):
So, we know you don't burn, for example,indoors, you don't burn on a cloudy day.
And at the extremes of the day, when thesun's low and you've got to go through
more atmosphere, UVB is also filtered out.
So you don't get UVB at all.
But UVA does penetrate downinto very low altitudes.
And so populations at these lowaltitudes, they're not going to burn.
(37:12):
They're not going to tan very well either.
UVA doesn't produce much tanning.
It causes release of those packetsof melanin I've talked about, but
it doesn't stimulate the productionof more packets of melanin.
So you don't get a good,permanent tan from UVA.
So, interestingly, yes, UVA is penetratingthe atmosphere, it's penetrating their
skin deeper, and it does seem to beassociated with a higher risk of melanoma.
(37:36):
And that might go some way to explainingthe worry with sunbeds, because
sunbeds have this high intensity UVA.
Yes, exactly.
And it's, maybe that is what's therisk, along with the intermittent
episodes of intense UVB burningwith blistering and peeling.
But it's a complicated story, isn't it?
(37:56):
It is, it really is.
But I hope that for everyone listening,that they found this complicated story
interesting, helpful, and allowing you tohave more confidence in understanding a
little bit more about melanomas and therisks involved with them across the board.
Roger and I hope you'll join us againnext time, where we'll be discussing
(38:17):
some of the potentially tricky areasabout how to diagnose a melanoma.
Some of which you mightnot have considered.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
We couldn't have done it without them.
So, until the next time,it's goodbye from George.
Goodbye.
And, as always, it's goodbye from me.
(38:38):
Goodbye.
Hello and welcome to this Skin Deeppodcast where we look at skin-related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was the Chair
(00:31):
of the Dermatology Council for England.
Now today, George and I are going tobe discussing malignant melanomas.
And we're going to look at theircause, some figures as to how common
they are now compared to some yearsago, and whether we're actually
approaching them the right way.
(00:53):
Now, I know you've got some prettystrong views here on this topic,
George, so I think this is going tobe an absolute cracker of a podcast.
But let me start by asking, a perhapsan obvious question, as to why spotting
a malignant melanoma by doctors hasrather become like the shark in Jaws.
Everyone's afraid of it, everyone'stalking about it, and everyone's
keeping a constant lookout for it.
(01:15):
Indeed, they are.
Yeah, it certainly puncheswell above its weight, I think.
That's not to say melanomaisn't a terrible diagnosis.
I think part of the problem is thatdoctors recognise that they're not
forgiven, if they miss a melanoma.
And that's borne out by the factthat we're ten times more likely
to be sued for missing a melanomathan missing any other cancer.
(01:39):
Society, the courts, journalists, everyoneis ruthless if a doctor misses it.
They expect us to get this one right.
So, that's the first point.
The second concern is that theyare getting more common and it's
increasing in incidence fasterthan any other cancer I know.
(02:00):
So the incidence of melanoma isdoubling every 10 years and has done
so now for the past 40 or 50 years.
If you look back at 1998, the figures werejust five cases of melanoma per 100,000.
That's now over 20 per 100,000.
So it's increasing quite fast.
(02:20):
Admittedly, I think some of that increasecould be down to changes in the way in
which we make a diagnosis of melanoma.
In the past, I think people lookedunder a microscope and dismissed
something, whereas now, with specialimmunochemistry testing and other things
that histopathologists can do, they canrecognise that something is a melanoma.
So it's labelled a melanoma, where inthe past it might have been called a
(02:44):
dysplastic naevus, which
just means a mole that'snot looking very healthy.
The vast majority though, ofthis increase of melanomas, are
what we call melanoma in situ.
Now, dermatologists agree withme that a melanoma in situ
is almost a benign lesion.
(03:07):
We, think that left totheir own devices, they will
become invasive melanomas.
But there's definitely a body of opiniondeveloping, that there are very early
melanomas, which are very flat, whichare almost benign, and that the patient
(03:31):
might die with them and not from them.
And all this increase that we'veseen over the last 40 years has been
predominantly of these very early, insitu, almost, benign is almost the wrong
word to use, but very low risk melanomas.
And so, I used to say, don'tcall them malignant melanomas,
(03:53):
because they're all malignant.
But I've now gone back tocalling them malignant melanomas.
And in my mind, I'm also thinkingquietly, that there could be more benign
melanomas, these very flat, whirlyones, which, I'm just a bit worried
I might have imposed a diagnosis ofmelanoma on some of my patients, when
in fact they had a lesion that was nevergoing to cause them any harm at all.
(04:15):
Unfortunately, we will never know theanswer to this, because no one's going
to be brave enough to leave them.
I've certainly seen early melanomasthat the patient says, this one hasn't
been changing for at least four or five,six years and I look at it and I say,
well, it's clearly a melanoma and it is,when it's excised, and you just wonder.
(04:36):
But the current lifetime risk ofsomebody getting a melanoma is about
one in 36, in men, a bit less commonin women, almost one in 47 women, so
almost 3% in men and almost 2% in women.
Okay.
And I'm with you, you know, you'vegot to be very careful about malignant
melanomas and benign melanomas,but I tend to reserve malignant
(05:00):
melanomas for when we know they are.
So it's obviously increasing, quite fast.
But what about the ages ofpeople that we see it in?
My back of an envelope calculationcompared to say 20, 25 years ago, is
I'm probably seeing fractionally moreyounger people with it, but the bulk
still remains the older population.
(05:22):
Yeah, it's exactly that.
Yes, it gets common, morecommon, as you get older.
And its peak age of incidenceis in the 85 to 89 year olds.
And I suspect it would continueto increase per capita beyond
that, but just there are lesspeople alive after the age of 90.
So the peak age for seeing a melanomais in the 85 to 89 year old group.
(05:46):
But as you say, it's also a cancerof young people, and it's increasing
fastest in individuals under 55.
That's the cohort in which the incidenceis increasing fastest currently.
But about 4% of all melanomas occur invery young adults, 15 to 34 year olds.
(06:07):
Devastating stage in your life tobe given a diagnosis of a melanoma.
And so, it's not an uncommoncondition but it causes this huge
anxiety that we talked about earlier.
And as a consequence, half of allreferrals by a GP to the cancer
bureau, the two-week wait bureaus,are referrals of a lesion on the skin.
(06:30):
And I think this is the real problem.
We are overloading secondary carewith these huge numbers of patients
that we are concerned about because ofwhat their lesions are looking like.
Half of all referrals to dermatologyare for suspected skin cancer.
But this is a very interesting point.
Only 6% of our referrals to theskin cancer two-week bureau turn
(06:56):
out to be either a melanoma or theother cancer that matters, which
is a squamous cell carcinoma.
94% are benign, nothing to worry about.
So the purpose of that two-week bureauis to manage these potentially nasty
cancers rapidly, but only 6% turnout to be anything to worry about.
(07:19):
And more worrying to me than that, is somefigures that I got from the president of
the British Association of Dermatologists,when I was working at the Dermatology
Council for England, and he said he'ddone a Freedom of Information Act report
through all the trusts in the country,asking the dermatologists he knew, how
(07:40):
many of the referrals from GPs that wehad referred as suspected melanoma, or
other cancers, were obviously benign?
They could take one look at thisand they say nothing to worry about.
And the figure that came back was84%, are not just benign, but in
their view, were obviously benign.
(08:02):
So there's a big issue about whatGPs are sending to secondary care
and overloading secondary care.
And I think that we'll come on tothat in our next podcast when I'll
be talking about that in more detail.
I think so.
If we've got such a huge number of benignor harmless skin lesions, I'm struggling
to think about any other cancer,potential cancer diagnosis, referred
(08:24):
into a two-week pathway, when you'vegot such a low pickup at the end of it.
But we're obviously speaking intimes of massive waiting lists.
And we're obviously going to be furtheroverloading it, compromising the ability
of dermatologists to provide a service.
But I know of many anecdotes wherecolleagues have been, almost pressured,
(08:44):
into referring, by patients who've lookedat Dr Google or whatever, even then, when
they were 99% certain their skin lesionwas benign, and this is the key point.
But I guess we come back to that, whatwe talked about right at the top of
the podcast, the fear of both missinga skin cancer or, in my view, probably
more of an issue, being sued if we do.
(09:06):
We're almost sued if we do andsometimes sued if we don't.
And I think this is where you've gotpretty strong views, on the advice
that as GPs, we are being given advicefrom the top, if you like, on this.
I do indeed.
Yes, that is a, clearly, a major issue.
And of course, as GPs, we, well certainlyin my day, we lived in the community.
(09:26):
The cinema I went to, I sat nextto my patients, the supermarkets, I
was in the queue behind my patients.
My wife taught my patientsat the local school.
So you live in that community and whenyou make a mistake, it's obviously a
disaster for the patient, but that wordgets around, and it's not just being sued.
(09:46):
You are, where you live, your home, wholelife is surrounded by your mistakes.
Agreed.
So you can't afford to get it wrong.
And so clearly, you know, doctorsare going to err on the side of being
cautious, not just for their patients,but also selfishly for themselves.
But I believe our whole approachto diagnosing melanoma is, I'd
(10:07):
actually say, dangerously flawed.
And I'll come on to that in a lotmore detail next time, where I'll
be discussing NICE's and the BritishAssociation of Dermatologists', frankly,
infatuation with what's called the ABCDEapproach to recognising a melanoma.
I think using that approach isresponsible for a lot of the problems
(10:30):
that we're having in primary carewith distinguishing these obviously
benign lesions from the potentiallymore serious melanomas and things.
ABCDE causes huge anxietywith false positives,
i.e. referring what turn out
to be obviously benign lesions that fail
that system for looking at lesions.
(10:52):
And it even accounts for someof the false negatives,
i.e. the patient has got a
melanoma, but it doesn't reach the criteria
for ABCDE to make you concerned.
So it fails both ways.
I think medicine is far moresophisticated than just reciting
the alphabet, and I think that weneed to be much more intelligent in
(11:13):
our way of looking at melanoma inthe community and recognising which
patients we need to be worried about.
Yes, I think I agree with that,and the medical students that I
teach, you know, do have ABCD sortof, imprinted on their foreheads.
And I suspect there are quite a fewpeople listening, wondering what the
George approach to melanomas is instead.
(11:34):
Now, my best guess with you is that youstart with the general perceptions around
melanomas and then work up from there,to look at the actual risk factors across
the whole area, and I'm thinking notjust the impact of ultraviolet light.
So that's where I'd be coming from.
Do I win a goldfish?
I think you win a clusterof goldfish actually.
(11:56):
Yes.
You've got it in one I think.
Yeah.
Well, I think my approach startsoff with, is this patient, who's
worried about something, or thepatients I've seen a lesion on, are
they a candidate for a melanoma?
Are they somebody who islikely to get a melanoma?
And when I talk to colleagues aboutthis, or even the public, more, I think
(12:19):
when I say to them, you know, "whatare the risks of getting a melanoma?"
They say, "well, it's sunlight.
Full stop.
It's going out in the sun, and howevermuch you get exposed to the sun,
that's what causes your melanoma",and that's as far as they think.
But in fact, let's look atthe actual risk factors.
(12:39):
Well, the first thing I think,to say is that age matters.
I've already mentioned that melanoma,is more common in the very elderly,
but turn it the other way around.
Children and young adolescents, peopleunder say, 14, 15, certainly risk
under the age of 11, is virtually nil.
There was a study fromBristol a couple of years ago.
(13:00):
They looked at all the referrals to theirtwo-week bureau of children, under 11.
There were 79 referralsover a two year period.
Doctors had referred the patients,these children, concerned that
the lesion could be melanoma.
They didn't have one melanomain their study, at all.
So children under 11, almost however uglythe lesion looks, you can be very relaxed.
(13:24):
It doesn't mean I wouldn't ask aspecialist to give a second opinion,
but I'm very relaxed indeed aboutchildren under the age of 11.
They don't really get melanomas.
Apart from perhaps the oneexception, well two exceptions,
one is the quite rare thing
called a spitzoid melanoma,
which looks different andI won't go into that here.
That's not, it's not that uncommon inchildren, but they don't tend to have
(13:45):
a terrible prognosis and under 11,they're usually not too serious anyway.
And the other is the child who's bornwith what's called a bathing trunk
naevus, where, for example, the half oftheir body has a huge pigmented patch,
often hairy, covering the whole of theirbuttocks and half their tummy and things.
Within that, there's a tinyrisk of getting a melanoma.
(14:07):
So first of all, children, don't worry.
The things that alert me and make meinstantly much more concerned is a
patient who's had a previous melanoma.
If somebody's had a melanoma beforeand they've now got a lesion that
they're concerned about, or ischanging in some way, I'm anxious.
Somebody who's had one melanomahas a 10% risk of having another.
(14:29):
So they need to be watched, carefully.
Similarly, if they've got a firstdegree relative, a brother, sister,
parent, who's had a melanoma inthe past, well, that doubles that
individual's risk of a melanoma as well.
So, those are two reallyimportant risk factors.
The next group of patientsI'm concerned about are the
patients with multiple moles.
(14:51):
We all see these patientsfrom time to time.
They've got loads of moles.
And I'm not talking about, what wecall these benign pigmented things
on the skin, which often most ofus get when we get older, sun spots
and seborrhoeic keratoses, theserather greasy, warty, crusty, sharply
demarcated lumps usually on our trunk.
(15:14):
But if you've got moles, actualmoles, which doctors call melanocytic,
because they've got cells that producemelanin, melanocytes, naevi, that
themselves, they're benign moles.
But if you've got more than 40, whichis not uncommon, that doubles your risk.
You've got the geneticmakeup for melanoma.
(15:34):
If you've got over a hundredmoles, you've got seven times
that risk, the normal risk.
And if five of them are looking a bit odd,irregular, in themselves they're perfectly
fine, we call those atypical moles.
But if you've got more than fiveatypical looking moles, then
you've got six times the risk.
(15:55):
So, patients with multiple moles,I'm concerned about, and I'm
concerned about them for two reasons.
One, they're more likely to get amelanoma, and two, when they get a
melanoma, it's a devil's own job to spotit, because initially, when it's small,
it looks just like their other moles.
And the only way in which you can reallyreliably say this is a melanoma and
(16:19):
not just one of the moles you've hadfor years is having serial photographs.
You've got a photograph of whatyour back looked like last year
and now there's a mole there thatwasn't there, then that's the one to
worry about.
While I'm on the
subject of moles, by the way, mostof our mole population appears from
(16:40):
about the age of 11 or so, 8, 9, 10,11 onwards, and we develop most of
our moles in our early adult years,up to in our teens and early 20s.
I don't like new moles appearingafter the age of 30, and I get
particularly anxious about anyonehaving a new mole over the age of 50.
(17:02):
But the risk of these acquired molesbecoming a melanoma is trivial.
It's about, if you've got a mole,the risk of that mole becoming a
melanoma is about 1 in 200,000.
Wow.
And to be honest, that's no differentreally, from the neighbouring normal skin.
(17:22):
So cutting out a mole to prevent itone day becoming a melanoma, you might
as well just take all the skin off.
It's pointless.
Slightly different with
congenital naevi.
If you've got a congenital naevus,
i.e. that's a naevus that's been there
from birth, the risk of those one day
turning into a melanoma is very small.
(17:45):
It's about 1 in 200, and that'slikely to happen in later adult life.
In fact, the overall risk of acongenital naevus one day becoming a
melanoma is more like 0.8% which isfractionally more, but that includes
the rare but very large so called giantcongenital naevi which can cover the
(18:11):
whole buttocks and are really huge.
But those are closely followed upin hospital, those are uncommon, but
the risk of melanoma within those issignificantly more and so that raises
the overall risk of a congenital naevusone day becoming a melanoma, but when
you discount those, the actual riskof a small to medium sized mini naevus
(18:31):
that's been there from birth or a fewmonths after birth is only 1 in 200.
Most of those don't do anything.
They either disappear or they turninto what's called intradermal naevi.
But there's a small risk.
So those are the major risk factors.
Past history, familyhistory, multiple moles.
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provide you with the best care possible.
Obviously, skin type matters, and I'llbe discussing that in a bit more detail.
But if you've got ginger hair or, thatalone, just having ginger hair, doubles
your lifetime risk of a melanoma.
In fact, more than doubles it.
(21:29):
It's between 1.5 and 3.6times increased risk.
So, that's certainly a risk factor.
Turn it the other way around, havingvery dark skin, Caribbean sort of skin,
really, sort of, dark brown, the risk ofa melanoma on the skin, what we call a
cutaneous melanoma, is vanishingly small.
Melanomas on the foot, on thefingerprint skin, so the soles and
(21:53):
the palms, and around the nails,at the same rate with white skin.
Mucosal cancers, melanomas, I mean,so you can get it in the nasopharynx,
that's behind the nose, or inside thenose, in the nostrils, or in the throat.
I've even seen a melanoma in the stomach.
So you can get melanomas elsewhere,and they're just as uncommon in
(22:14):
dark skin as they are in light skin.
But all these things, gingerhair, skin type, genetic factors,
I'm sorry multiple moles, familyhistory, so these are all genetics,
and you can't change any of those.
That's your genetic makeup thatgives you a predetermined risk of
developing a melanoma, one day.
(22:35):
Yeah, and I said, listening to thatmade me come back to the point we've
often mentioned in our podcast, whichis, take the history, even before you
sort of put your eyes on someone'sskin, actually take the history, because
the patient is likely to tell you anawful lot of what you're going to need.
(22:55):
So, you know, you ask about thefamily history, you ask about whether
they've had skin problems in thepast and that sets you on the road.
Now ultraviolet light, as youmentioned earlier, you know, everyone
thinks about ultraviolet light.
The other thing we, but before weeven talk about that, the other thing
that I sometimes have to remind myselfto, to remember, if I'm thinking
(23:19):
about someone with melanomas, isimmune suppression in patients,
the impact of immune suppression,and again, taking the history.
Is there anything which is going toimpact on the immune system, which
in turn is going to fire up thepossibility of melanomas occuring.
Yep, that's such an important point.
(23:40):
Yep, it's estimated that in ouradult life, each of us is producing
one new melanoma cell every day.
But our immune system is spottingthat quickly and removing it.
So it's not a problem.
But if you suppress that immune responsefor whatever reason, if you're on long
term steroids, perhaps for asthma oranother medical condition, or if you're
(24:06):
on drugs that knock your immune systembecause your immune system is messing
up, azathioprine is an example, thenyour body's ability to clear that
melanoma cell early is diminished.
Patients with HIV or lymphomas andthings like that, they are, their
immune system is dysfunctional.
And the organ transplant populationare looked at very carefully.
(24:31):
They have two and a half timesincreased risk of getting a melanoma.
They have a much more increasedrisk of getting other cancers of
the skin, squamous cell carcinoma.
So, my patients who've had organtransplantation, where their immune
system has to be calmed down fairlyaggressively, to prevent them rejecting
their transplant, they're usuallyunder secondary care in hospital,
(24:53):
having their skin checked, at leastannually, and they're given a lot
of advice on reducing modifiablerisk factors like ultraviolet light.
So yeah, I think immune suppression isvery important and I do feel that as
GPs, if you've got somebody whose immunesystem is not working as well as it
should be, for whatever reason, they'revery old, that's perhaps why melanoma
(25:16):
gets more common as we get older, ourimmune system becomes less aggressive.
Or they're on drugs that knock it, orthey've got another condition that affects
their immune system, then they should begiven good advice about sun protection
and probably, in my patients certainly,I would check their skin annually.
Yeah, you mentionedultraviolet light there.
So let's look at that now.
(25:38):
I think you and I definitely agree aboutrisks of sunbed use and especially now,
in teens and young people who are imageobsessed and again, without wanting
to hark back to the old days beforesocial media, again, in my practice,
undoubtedly, one of the huge changes I'veseen is the impact of social media on
(25:59):
some health behaviour in younger people.
And I think ultraviolet light,sunbed use, tanning, is perhaps
the biggest example I can think ofthat's changed in the last 20 years.
And I did some work on this recently, andI came across a statistic that actually
made my jaw drop so much, I didn'tbelieve it, and I went away and checked
(26:20):
it again before I actually believed it andrealised that the statistics were sound.
And that statistic was that there weremore skin cancer cases caused as a
direct result of sunbed usage than oflung cancer cases caused by smoking.
I still can't quite believe I'msaying that, but it appears to be
(26:40):
generally the case and sunburn, andobviously, as we all know, the sign
of a so called healthy tan is actuallya sign of significant skin damage.
Sunburn, and the use of of sunbeds,is a real power up here when
we're specifically talking aboutultraviolet light, aren't they?
(27:02):
Well, it's very complicated, but I thinkthat's a staggering statistic, isn't it?
And I'm not surprised, but itis pretty amazing, isn't it?
Yeah, I'm proud to say that I was a,sort of, low grade member of, I wasn't
a proper full member, of the All-PartyParliamentary Group for Skin Disease,
but I attended their meetings aboutsix, seven years ago, when the APPGS
(27:26):
managed to get a law passed makingit illegal for anybody under the
age of 18 to go and use the sunbed.
So I think, in the UK, so I thinkthat was a very important thing to do.
Yeah, ultraviolet light, it isterribly important because it is
the one modifiable risk factor.
You can't really do much about the immunesuppression, which is usually important.
(27:49):
You can't do much about your genetics.
And a history of sunburn.
It seems to be episodes of, intermittentepisodes of, intense sunlight, ultraviolet
light, that causes the risk for melanoma,whereas it's the low grade background,
cumulative sun exposure that causesthe keratotic cancers, things like
(28:13):
squamous cell carcinoma, which areusually much lower grade, much less
worrying, but they're still cancers.
So it's low grade background sunlight,just has a cumulative risk increasing
for the non melanoma skin cancers.
Whereas melanoma seems to besomething to do with episodes
of intense burning sunlight.
(28:34):
So, children under 11 their melanocytes,which are the cells that produce
melanin, are migrating to the skin,and they migrate from the spinal cord
area, and they take about 10 yearsto get there, which is why our mole
population appears in our adolescence.
That's when the moles are gettingthere, they're arriving in the skin.
(28:57):
But the ability of the skin to protectitself is therefore compromised, and
so children under 11 are particularlyvulnerable to ultraviolet light, and I
think they should be kept out of the sunas much as possible, and given vitamin D.
They should be covered up, usequality sunblock, and kept out
of any worrying intense sunlight.
(29:19):
One episode of severe sunburn doublesyour lifetime risk of melanoma.
And using a sunbed ever, just usingit once, increases your risk by 20%.
Wow.
And if you do that in young people,in people under 35, that risk
is actually increased by 59%.
(29:41):
So, these are huge increased risksso, and actually sunbeds also increase
the risk of these other cancers, likesquamous cell carcinoma, it increases
the risk even more by two thirds, to 67%.
So, sunbeds, from my point of view,are definitely a no, and I will
come onto those in more detaillater, but essentially they are,
(30:05):
it's hard to regulate the amount ofultraviolet light they're producing.
They're producing a lot of UVA, andalthough UVA doesn't burn, UVA wave
ultraviolet light penetrates quite deepand increases the risk quite considerably.
I think the, taking all that apartthough, avoid sunbeds, avoid intense
(30:27):
sunburn or intense ultraviolet light,episodes of sunburning, enough to
cause your skin to peel or blister.
Those are a disaster.
Apart from that though, I have to say,I am on my own in this, and this is
not the view of dermatologists, butI think that non burning, sensible,
(30:48):
ultraviolet light exposure, in adulthood,is not a huge risk factor for melanoma.
Yes, it's the one thing we can modify.
But it's not the major risk factor.
The major ones are theones I've talked about.
Family history, past history,multiple moles, immune suppression.
(31:10):
So it's a complicated message, but...
when you make a tan, these melanocytesproduce little packets of melanin,
called melanosomes, and those are takenup by all the cells in the epidermis,
the top layer of the skin, and thenthat melanin is released as globules
(31:35):
in the cytoplasm of those cells.
Now this is the clever thing.
What then happens is that they aggregateon the outer surface of the nucleus of
the cell, like an umbrella, protectingthe nucleus from the ultraviolet
light getting through, so that theDNA of that cell is not damaged.
(31:56):
But they leave the cytoplasm clear,so that's where you produce the
vitamin D and the other things thatsunlight does which are good for you.
So, I argue that if you've got, if you'vebuilt up a gentle tan, and I don't mean
a tan that ends up with lots of frecklesand sun damaged spots, age spots, sun
(32:16):
spots, solar lentigos, whatever you wantto call them, but you've developed a
nice even tan, what you've managed todo is you've managed to put an umbrella
on the outer surface of all the nucleiof your epidermis, and are protecting
your epidermal cells from ultravioletlight, and you're then getting all
the benefits of sunlight as well.
(32:36):
Now that's a highly controversialview, but I think in adulthood,
carefully and sensibly building up atan over a period of time, might be
a very reasonable thing to be doing.
I will come back to that.
But yeah, I accept, most melanomasdo occur on sun exposed skin.
(33:00):
Interestingly, it's on the backin men and on the legs in women.
Maybe the thought there is that inwomen, it's because they often wear
a skirt and the light is reflectingoff the ground and hitting their legs.
But one thing we do know that isif all people with white skin, used
total sunblock, 24/7, we would onlystop about a third of melanomas.
(33:26):
Two thirds of melanoma would still occur.
So yeah, sunlight, unquestionably matters.
And yes, sunlight is somethingwe can do something about.
And yes, getting an invasivemelanoma is horrible, but
it's, it's not the whole story.
And to put that into context, therewas a recent study in the Journal of
(33:49):
the American Academy of Medicine andthey compared Puget Sound in Washington
with Orange County in California.
Two populations that have completelydifferent ultraviolet light exposure.
And they matched these two populationsfor all the possible variables that
they could come up with, and theylooked at the number of melanomas
(34:12):
occurring in those two populations.
They were almost identical.
72 cases per hundred thousand in PugetSound in Washington state, and 73 cases
in California, a state where they'regonna be even more alert to the risk and
the possibility of getting a melanoma,and so more likely to go to their doctor.
And the conclusion they came to isthat we do need to consider whether
(34:36):
the time has come to be a littlebit more circumspect about our
messaging over ultraviolet light.
I think there's almost too muchanxiety generated by stressing
ultraviolet light, in adults.
I think in children, ultravioletlight protection is important.
What I say is, I think childrenshould be kept in the dark.
(34:59):
Perhaps in more ways than one.
But I think in adults, I thinkwe simply need to avoid sunbeds.
Avoid severe sunburn, and I think, usesunblock sensibly to enable us to build
up a sensible tan, and that's what I do.
(35:20):
When you talk to Australiandermatologists, they'll often talk
about the Australian truckers' armmelanoma, and this is a good example
of the high intensity, blisteringand burning, because Australian truck
drivers driving along in the heat, theywill stick their left arm on, out of
(35:44):
the window as they're driving along,and nine times out of ten, that's where
they power up their melanoma, if they'regoing to get one, and that actually
chimes exactly with what you're saying.
There's nothing about graduallow level acclimatisation to
sensible levels of UV light.
This is just constant day in, dayout, that arm is being hammered by
(36:05):
high intensity ultraviolet light andthat's what tends to power them up.
Just a final point, George, am Iright in thinking that low altitude
populations, compared to populationsliving at higher altitudes, are
at a higher risk of melanoma?
I seem to remember reading that somewhere.
Yep, you're absolutely right.
It's very interesting, isn't it?
(36:26):
UVA, which doesn't burn, goes straightthrough glass, straight through cloud, and
it penetrates our atmosphere very well.
So, at low altitude, you'regetting quite a lot of UVA.
UVB doesn't go through glass,it doesn't go through cloud.
UVB is a hundred timesmore burning than UVA.
(36:49):
So, we know you don't burn, for example,indoors, you don't burn on a cloudy day.
And at the extremes of the day, when thesun's low and you've got to go through
more atmosphere, UVB is also filtered out.
So you don't get UVB at all.
But UVA does penetrate downinto very low altitudes.
And so populations at these lowaltitudes, they're not going to burn.
(37:12):
They're not going to tan very well either.
UVA doesn't produce much tanning.
It causes release of those packetsof melanin I've talked about, but
it doesn't stimulate the productionof more packets of melanin.
So you don't get a good,permanent tan from UVA.
So, interestingly, yes, UVA is penetratingthe atmosphere, it's penetrating their
skin deeper, and it does seem to beassociated with a higher risk of melanoma.
(37:36):
And that might go some way to explainingthe worry with sunbeds, because
sunbeds have this high intensity UVA.
Yes, exactly.
And it's, maybe that is what's therisk, along with the intermittent
episodes of intense UVB burningwith blistering and peeling.
But it's a complicated story, isn't it?
(37:56):
It is, it really is.
But I hope that for everyone listening,that they found this complicated story
interesting, helpful, and allowing you tohave more confidence in understanding a
little bit more about melanomas and therisks involved with them across the board.
Roger and I hope you'll join us againnext time, where we'll be discussing
(38:17):
some of the potentially tricky areasabout how to diagnose a melanoma.
Some of which you mightnot have considered.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
We couldn't have done it without them.
So, until the next time,it's goodbye from George.
Goodbye.
And, as always, it's goodbye from me.
(38:38):
Goodbye.
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