SUN STRUCK

Basking in the rays can do more than burn you. Here's how to enjoy yourself and keep safe, if not necessarily cool, this summer

U.S. News & World Report

June 24, 1996

The sun has betrayed its worshipers. It is almost solely responsible for nearly 1 million cases of skin cancer that U.S. doctors are expected to diagnose this year. Most of those cancers will be the generally non-life-threatening, though often disfiguring, forms of basal cell carcinoma (800,000 cases) and squamous cell carcinoma (100,000 cases). But malignant melanoma, the most deadly form of skin cancer, will strike 38,300 people, about half of them under the age of 50; 7,300 will die. One in 87 Americans will get malignant melanoma at some point, up 1,800 percent since the 1930s. And the fastest-growing group of those sacrificing themselves to the sun god are young women. Melanoma is the most frequent cancer in women ages 25 to 29 and runs second only to breast cancer in women 30 to 34.

Researchers are working on cures and skin cancer vaccines, with a breakthrough announced in major journals just last week (Page 68). For the present, many of those burned by a cancer scare, like Cindy Katri, 34, have rejected the sun's hot seduction. Katri's diagnosis with malignant melanoma four years ago jolted her into seeking the shady side of the street forevermore. "I'm as white as a sheet. People who don't know I've had skin cancer say, `Oh, you need a tan,' " says Katri, at which point her voice turns icy as she responds: "No, I don't."

But not everyone feels that way. Nearly 60 percent of under-25 adults admit to working on a tan, flinging themselves in the path of UVA and UVB rays for the sole purpose of toasting their skin, according to a 1995 survey by the American Academy of Dermatology.

A million to 2 million people have a serious tanning habit, paying good money to cook in tanning salons as many as 100 times a year, according to the academy. Such salons, which remain popular despite moves to regulate them in 26 states, bathe patrons in ultraviolet A, which tans rather than burns, and plays less of a role in skin cancer than UVB rays do. But most researchers believe that UVA rays multiply the effects of UVB or accelerate the growth of existing cancer cells. Moreover, UVA exposure prematurely wrinkles and withers the skin, leading to a prunish look. The American Medical Association has urged the Food and Drug Administration to ban the nonmedical use of tanning equipment. The FDA is monitoring studies exploring the link between UVA and skin cancer. For now, tanning salons must post warning signs about UVA risks.

Risk takers. Perhaps most astonishing, the dermatologists' survey shows that only about 1 sunbather in 3 bothers with UVB-thwarting sunscreen lotion. The sun's rays are most potent between 10 a.m. and 3 p.m., prime recess and play time for children. In early morning and late afternoon, the sun's intensity is one quarter of its noon power. "We tell people that if they're going to jog or play tennis, do it in the morning or late afternoon," said David Buller, director of the Arizona Cancer Center's behavioral science section.

Buller has good reason to keep the hazards of sunning on his mind. Arizona's latitude, about 10 degrees closer to the equator than, say, Maine, puts it in a position to receive a stronger dose of UV, and Tucson averages 310 days of sunshine a year. Sun Belt states have the country's highest skin cancer rates. "We see people here in their 40s and 50s whose skin looks 70 or 80," says Norman Levine, chief of dermatology at the University of Arizona and author of Skin Healthy (Taylor, 1995, $12.95).

It doesn't help that the ozone layer has thinned by 6 percent to 7 percent in the mid-latitudes of the Northern Hemisphere, which includes the United States, since 1979. That lets 6 percent to 14 percent more UVB rays through the Earth's protective atmosphere.

How can the glorious warmth of the sun be unhealthful? How can something that feels so good be so bad? Edward De Fabo, a research professor of dermatology at George Washington University Medical Center in Washington, D.C., and chair of the International Arctic Science Committee investigating the consequences of ozone depletion on human health, says scientists have known for decades that radiation causes skin cancer. Now they know it also compromises the immune system. He and his research partner and wife, Frances Noonan, helped unravel the way that the sun inhibits the ability of the immune system to fight cancer cells.

Solar radiation is doubly taxing, both causing tumors and promoting existing ones. When the sun burns the skin, perhaps triggering the mutation of a healthy cell into a cancer cell, the body's immune defenses identify the burned tissue as foreign and poise to mount an attack. But the UV rays also transform urocanic acid, found on the surface of the skin as a byproduct when the outermost layer of skin is formed. Until the 1983 discovery by De Fabo and Noonan of the chemical's role in the immune system, it had no known function.

The urocanic acid molecules twist and bend under the sun's rays. In their altered state, they switch off the immune system's attack on the skin. That is not necessarily bad; it keeps the immune system from attacking the body's own skin and gives the burn time to heal itself. But if a malignant cell is hidden among other skin cells, the switched-off immune response gives it free rein to grow and multiply.

If you come from a fair-skinned line who passed on a propensity to burn rather than tan, your chances increase that UV rays will spark a malignancy. As a professor of history and humanities at Hawaii Pacific University, Daniel Binkley, 54, couldn't believe his good fortune at being able to build a life in sunny paradise. "I wanted to be as brown as everyone else," he said. But his Irish ancestors did not possess appropriate genes. Binkley's sun-induced brownness was confined to a mole on his right arm that was diagnosed as malignant melanoma about 20 years ago. It was treated successfully, and he no longer seeks a tan.

Looking for moles. Binkley was fortunate. At the time he heard the words "malignant melanoma" in the late 1970s, the likelihood that it was a death sentence was far higher than it is now. In the early 1960s, 60 percent of melanoma patients survived five years; today the rate is about 90 percent. "That's entirely due to early diagnosis," said Arthur Sober, head of the melanoma clinic at Massachusetts General Hospital in Boston. The key is that more people seem to be recognizing unusual moles and having them removed early (box, Page 65).

Basal cell and squamous cell carcinomas, while much less deadly than melanoma, can be a recurring annoyance, showing up most commonly on face, ears, neck, arms, hands and legs as warty bumps or scaly patches. Surgery to pluck them out can also be disfiguring if they've grown deep into skin, and can require extensive reconstructive surgery. Even an open car window can take its toll, as evidenced by contrasting statistics from two sides of the Atlantic Ocean. In Americans, skin cancer is more common on the left side of the face, since the driver's window is on that side; in England, it's the right side. (Closed windows and windshields absorb most of the harmful rays.)

Strategy for life. Damage done cannot be undone. Sunburns and suntans accumulate, ultimately resulting in premature wrinkles. For children who have suffered a sunburn before age 20, the consequences are more serious--a higher lifetime risk of skin cancer. The dermatologists' survey found that 30 percent of parents with children under 13 reported that their children had suffered at least one sunburn. Babies should be kept out of direct sunlight for the first six months of life, when their skin is thinner than that of older children. Sunscreens are not approved for babies younger than six months--not because of demonstrable danger, but because the lotions have not been tested on such young children. Lawrence Schachner, director of the division of pediatric dermatology at the University of Miami School of Medicine, says all other children should be protected with a water-resistant sunscreen, which will hold up against sweating as well as swimming, of SPF 15 or higher.

Beyond such universal advice, personal preference can help map out a protective but realistic regimen. Of the two basic types of effective sunscreens, the most popular kind relies on chemicals to absorb UV rays. The other sunscreens, called physical blockers and sometimes marketed as chemical free, use titanium dioxide or zinc oxide--the white-nosed, lifeguard look. SPF ratings apply to both types of sunscreens, but a rating lower than 15 may allow for some tanning among individuals who tan but don't burn. If your skin type says SPF 4 will give you an hour in the sun, after an hour your time is up. Don't make the mistake of thinking that putting on another layer will get you more time in the sun. If you want more time in the sun, use a higher SPF. Most dermatologists prefer to insist on SPF 15 or higher, however, believing that no tan is a safe tan.

An average adult-size dose sufficient to cover all exposed skin is about 1 ounce. Clothing provides some protection, so cover up what the heat will allow. "Cotton clothing is pretty good protection and it's lightweight, so wear longer sleeves, longer shorts and higher socks," says Schachner. "And get out of the hip-hop mode of wearing the baseball cap backwards. Worn the right way, a billed cap will protect 70 percent of the face." A wide-brimmed hat is even better.

For anyone facing an unusual risk because of a family or personal history of skin cancer, skin that easily burns or a weakened immune system, new lines of clothing block out almost all UV rays. A line cleared by the FDA called Solumbra, which includes articles from leggings and safari shirts to toddler coveralls, has an SPF of 30 or more. (Call 800-882-7860 for a catalog.) Some dermatologists, like Levine, think of such clothing as extreme and unrealistic for most people and say that normal summer-weight clothing with a tight weave provides adequate protection.

Black- and brown-skinned people who don't sunburn have far less risk of skin cancer than do fair-skinned people who sunburn easily, but they still benefit from SPF 15, says Perry Robins, president of the Skin Cancer Foundation. Even the darkest-skinned people can get skin cancer--often on the lighter skin of their palms or soles or on previously traumatized parts of their bodies, such as a vaccination scar or an area that has been burned or scalded.

Far sighted. All eyes, regardless of skin color genes, are equally vulnerable to sun damage. Sunlight stimulates cataracts, a clouding of the lens that results in 1 million surgeries annually to substitute an artificial lens for a damaged one. A 1988 study in the New England Journal of Medicine asked 838 Chesapeake Bay fishermen ages 30 to 94 about their eye-protection habits since the age of 16. Those who wore no eye protection had three times as many cataracts as those who routinely wore sunglasses or a brimmed hat.

The fishermen conscious of their eyes likely were wearing sunglasses less sophisticated than those now available, although all sunglasses offer some protection. To be fully protective, a pair of sunglasses should block at least 99 percent of all UV light or provide UV absorption up to 400 nanometers, which covers the range of harmful UV. Some sunglasses claim to block infrared rays, but research to date has found no reason to worry about infrared. Polarized lenses cut glare but do not stop UV. Mirror-coated lenses cut down on light, but unless they're also labeled as outlined above, don't assume they fully protect you. For those who have had cataract surgery or who have macular degeneration, wraparound glasses are recommended.

The ultimate safe prescription, it might seem, is no sun at all. But the human craving for sunlight is basic, and not even the most strident dermatologist advocates cave dwelling as a lifestyle. There's no doubt that the sun lifts our moods, and those who live in northern latitudes suffer disproportionately from seasonal affective disorder, a rhythmic depression that gears up as the days grow shorter and lifts as the summer solstice nears. SAD sufferers can be treated by exposure to high levels of artificial light--special fluorescent bulbs in light boxes designed for intensity.

Chemical engineer Herb Kern, now 79, was instrumental in steering researchers toward evidence that the sun's energy could affect one's state of mind. For most of his life, Kern had felt his energy drain away during the fall and winter, to return in the spring and summer. Ever the scientist, he kept a 14-year diary of his seasonal mood changes. In the early 1980s, the diary caught the attention of Norman Rosenthal, chief of environmental psychiatry and director of seasonality studies at the National Institute of Mental Health; 1984 saw the first published paper on the disorder. Some scientists believe the light stimulates production of serotonin, a brain chemical known to affect mood. Kern now treats his illness with a light box during the part of the winter he spends in his New Jersey home. The light from the box is about 20 times brighter than normal room illumination, though still only one-tenth the brightness of a sunny day at the beach.

But it's the real sun that Kern finds most healing. Now retired, he heads for a second home in Florida from January to May. As much as his psyche craves sunlight, his mind also respects the power of its rays. He splashes on sunscreen, dons wraparound sunglasses, puts on lightweight, long-sleeved and long-legged clothing, tops it with a brimmed hat, and heads out for an early morning or late afternoon dose of golden happiness.

BY SUSAN BRINK WITH CORINNA WU

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