Sun Protection Industry Seminar —
Speaker 4 (Dr Philippe Autier)

"Solaria — How Safe or How Dangerous"

Good Morning. It’s a great honour for me to be here in Melbourne and to share some data with you and also to be here in the very well known SunSmart project and the heart of sun protection and studies on skin cancer. So again, I’m very pleased to be here with you today.

So I’ve been asked to speak about solaria — how safe or how dangerous they are. We will try to work like that if it’s impossible. So I will try to give an overview of the issues surrounding the use of solaria. The first thing to be said when we speak about solaria use is that it is fashion now, increased quite a lot over the past 20 years, essentially in the Northern Europe and North America. And it’s clear that when we look at the increase of that fashion it is that the main reason for solaria use, tan acquisition. In fact — and we are going to speak a lot about the European situation — and why? Just because it’s in Europe that it happens that we find the highest rate of exposure to these sunlamps and sunbeds. In fact in presenting you must realise in Sweden which is a country where there is about — I would say in Sweden the Winter here is in fact the Summer in Sweden. And in fact in Sweden about 80% of subjects between 15 to 40 years old have ever used a sunbed. So in fact the exposure rate of sunbeds in Sweden is extremely high and many people use it on practically a weekly basis since years now. So in fact we have a very high exposure rate in the Northern part of Europe. In fact when we look in more southern parts in Europe, like in France, you see that the proportion decreases to 30%. These are very recent figures particularly of last year. In North America reported users were about 15 to 30% of young women and about 10% of young men. Who are the main users? Typical average user of sunbeds are young female subjects of high socio-economic status. In Europe we have about three female users for one male. The average typical user in Europe is 30 years old. We would have expected probably some younger users but in fact it is people are using that mainly in their 30s. And it generally starts around 16-18 years old, depending on the legal age you may for the majority. What is a typical solaria course in general, what is offered to people and what is recommended? I mean by commercial advertising and by tanning parlour operators is about ten sessions of about fifteen minutes if you have double sided unit and a session of thirty minutes if you have single sided unit with a fluorescent lamp. So in fact you may have yearly exposure of around 2.5 to 5 hours depending on the type of machine that is used. And in Northern Europe recent data showed that about 25%, one quarter, of sunbed users in that age group (18 to 50 years) have accumulated more than thirty hours of sunbed use. So it’s clear that you have quite a large amount of sunbed use. The sunlamps have been used since World War II and have been quite different over the years. Up to the 60s in fact you had mainly the sunlamps that had a very high amount of UVB and as Peter Gies said before you could get a burn in one minute or less just because the output of UVB was extremely high. You had even a proportion of 30-40% of UVC with those mercury arc lamps and UVC never reaches earth’s surface. That radiation never reaches our surface. So in fact why there was a lot of concern with the sunbed users use is of course the fact that in the 80s it was recognised and since years now that the UV radiation was carcinogenic radiation and also that UVB was much more erythemogenic, much more capable of inducing erythema than was the UVA. And in fact because of the danger, well known danger associated with UVB tanning in the 80s there has been a considerable shift in the construction of the tanning machines and it has become what is so called UVA tanning. That is to say that in the 90s, late 80s and 90s, practically all tanning machines that have been marketed have greater ouput of UVA as compared to UVB. That is to say that in fact the spectrum of the sunbed machine has been shifted to UVA radiation and much less in the UVB radiation.

Now of course as you just heard with Bruce Armstrong’s presentation is that in fact we are — another problem — that since about ten years that UVA radiation is no longer considered as an innocent radiation. So in fact it has been so because of these concerns about UVA radiation it has been said that high exposures to sunbeds could be dangerous, at least certainly for melanoma.

Indeed we have to be careful when we speak about UVA tanning which is quite a very frequent word used even in scientific publications. In all units you always have certain amounts of UVB radiation. And you need in fact that amount of UVB radiation if you want to get a deep tan. It’s practical impossible to have a long lasting deep tan without some UVB radiation. This is of course if we want to use a sunbed for getting a tan it’s better to use a sunbed where there is some UVB radiation. What is the evidence finally, what is the evidence from say the scientific evidence that eventually the exposure, the use of the sunbed could be dangerous and I will focus on melanoma since practically all studies, emerging studies done so far have been done on melanoma. In fact, practically all the scientific evidence we have comes essentially from a ** for two reasons, that first of all we don’t have to date satisfactory animal model for human melanoma. These make it quite difficult then to establish a causation from these sunbeds. There are many anecdotal clinical reports associated with sunbed use and extremely good reviews have been done there in journals. In fact when we look at the literature about sunbed melanoma association we have generally many studies. "Have you ever been exposed to a sunlamp or sunbed?’ In fact that type of question is not very informative. Why? That type of information is not very informative just because the exposure to sunlamps and sunbeds is an extremely recent type of fashion. And if you take a large number of people - people with melanoma -and you compare with people with no melanoma — so called case control approach that has many uses in trying to look at the issue here and when we look at the people who have been ever exposed to a sunbed we may find as these example a little bit higher number of people who have melanoma and then we can calculate a risk — slightly more elevated but it’s not that elevated. But in fact we have really to look at the fact that there are people who have started their sunbed exposure much earlier than others. And then we have absolutely to look at the difference between those people who started probably 20 years ago and make a difference between those who started 20 or 30 years ago — these type of exposure — as compared to those who probably started last week or one or two months ago. Because it’s clear that, and * you can understand it’s well known in cancers that probably the most recent exposure have not yet been effective in causing the melanoma if there is a real association. So it’s clear that we have absolutely to look at making a difference between the most ancient and the most recent exposure. So at this moment there have been six studies done over the world, essentially in North America, Northern Europe on the issue of melanoma and exposure to sunbeds. And some have been done ***** the years during which the case of control were interviewed. So in fact the exposure was related to the years before the study years. In fact the first study that was done by Swerdlow* and * in the UK in fact it was related to sunbed exposure in the very early beginning of the UVA tanning fashion. At the other end of the scale we have the most recent study that has been published by the group of Westerdahl in Lund* University in Sweden and this relates to much more recent exposures. This last study * attract attention * in an area where you have a very high exposure rate to sunbed first of all, and also that the exposure rates start at quite long ago, certainly the end of the 70s, beginning of the 80s as soon as the modern type of machine were available. In fact when we look at the first, what I jut said when we tried to have an idea of the importance of the amount of exposure to sunbeds and melanoma risk and we tried to have for instance an idea of is there any relationship between the amount of exposure to sunbed and the risk of melanoma? We are taking one here as the baseline, one being no risk in fact and you have here the cumulative, those of sunbed exposure. You can see that the scale is very arbitrary just because from one study to another the parameters that have been used to measure the cumulative sunbed exposure have been extremely viable. Some studies are speaking in numbers of sessions, others are speaking in number of hours so in fact it’s very, very difficult to put together all these data and in fact I just choose here to put just the increase in scale and nothing more, related to melanoma risk. And when we look now at the amount of sunbed use and the melanoma risk you can see that there is one study here, that was the first study done in Scotland, relatively small study where you see they found quite a high risk for high sunbed exposure. And that study was done in 1984, triggered a lot of interest and say ‘well probably there is a considerable problem.’ And as you remember you were shown in another slide that study is in fact related to exposures to place essentially during the 70s and the beginning of the 80s, so at the very beginning of the fashion. Whereas if we take the last study in Sweden done in Lund* where you have an extremely high sunbed use rate. In fact you have an increase, looks like there is an increase * high number of sessions, it fails to continue to increase so there is — in fact when we look at all these data there is some inconsistency on those relationship between sunbed use and melanoma risk. And this of course is a little bit * because I would say we would have expected to have this type of curve for the most ancient type of studies * most recent type of studies. And it’s probably the reverse that we see at this moment. For instance here at the green line referring to a study done in Connecticut in the USA, practically nothing that emerged from there. Also from a statistical point of view practically of the point you see there were non-significant. In fact one of the most important findings we had in the study we conducted in Europe, in Belgium and France and in Germany and this was the only study to do it, was to look at the association between melanoma and the sunburn or skin reddening that was due to sunbed use. So in fact there is a certain number of people, probably around 20-30% depending on the skin phototype, skin sensitivity that complain about skin reddening and sunburn after having used sunbeds. And in fact in our study it came out that people who had used a certain amount, ten hours or more of the sunbed and who had complained of some skin burn because of sunbed use, had a much higher risk of melanoma — 7.3. We must be careful that, this relates to a quite small number of subjects finally and you see their confidence in **** you can see it’s quite large from 1.7 to 32. It means in fact that the error measurement that we can have on the risk here is quite large. So it looks like there is something to do with the sunburn that is due to sunbed use although a bit like the sunburn, sun exposure association, the classical one but probably that this figure is a little bit higher than the reality. So the four studies have looked at the most ancient exposure versus the most recent exposure and in fact again there was absolutely not very consistent data showing the most ancient exposure to sunbeds * significantly higher risk of melanoma at this moment.

In fact we have to deal with many meteorological issues when we try to study the link between epidemiology. We try to study with epidemiology the links between the use of the sunbed and melanoma. In fact fortunately we have to work mainly with these kind of *case control design * well known by many people at least because it’s such a **** certainly in the research in melanoma but these case control * are prone to several biases as we say. For example one important bias are the rumination bias when you ask somebody who has a melanoma, ‘did you expose to sunlamps and sunbed’ he is probably going to recall it better than somebody who doesn’t have a melanoma. And this is what we call rumination bias. You also have interviewer bias, people, the interviewer who knows the case **** So in fact we have some problem with the design itself. The other problem we have is that sunbed use is quite correlated with intentional sun exposure, sunbathing essentially. People who use sunbeds are typically people who like the sunbed on the beach. So in fact it’s extremely important, difficult sometimes to really make the difference between what would be the risk due to sunbed use and what would be the risk due to more well known risk due to the intentional sun exposure. In fact, because we are dealing with — you have seen the figures — with risk of about 2, something like that, not being sure that we don’t have biases in the study and also not being sure that we can control carefully for usual sun exposure, makes it quite hazardous to get firm conclusion for the data * so far. Also the studies done so far they didn’t look at the type of machine use. Only the Americans did try to do it but it was still quite limited and there was little appraisal of risk sunbed use according to the values*. So in fact, yes, just a word on psoriasis patients. Psoriasis is treated with what is called * which is a mixture of UVA irradiation with *. Not going to go more into it but in fact it has been discovered that these patients also have very high rates of sunbed use. And in fact it looks like finally when we take all the evidence from * data is that in fact the incidence rate of melanoma among psoriasis patients seems to be quite low in fact. There is only one study published by the group of ten which is a well known group and they have a * cohort of people treated for *. They found a higher number of melanoma than expected in patients treated with * but in fact it’s not difficult from the study to know whether the UV therapy that was the cause of the melanoma and not the 5-MOP which is a known carcinogen and also other carinogens like * that these people receive as part of their treatment. So in fact when we try to combine the evidence we could say that in June 2001 there is no conclusive epidemiological evidence of an association between sunlamp and bed use and melanoma occurrence. And so of course, why? Apart from the methods I just presented to you which is first quite considerable, the first would be the latency period. In fact the fashion of sunbed use is quite recent and why not, it could be possible that at this moment we are not yet capable to * the association existing sunbed use and melanoma. As Bruce said it’s quite important and sun exposure during childhood is important for melanoma occurring later in life but then you can have ten, twenty, thirty years before initial exposure and the cancer. And probably at this moment in this year we are not yet in a position to assess the full impact of sunbed exposure and probably in countries like Sweden and Germany probably that the full impact of sunbed use will only be apparent in those studies in two, five or six years. The other alternative is to say finally the sunlamps and sunbeds they contain much less UV radiation than the midday sun. In terms of UV radiation we could say that probably it’s the UV radiation that is mainly implicated in the genesis of melanoma and therefore if you use a UVA tanning device probably you have a lower risk of getting a melanoma and that’s why also it would be so difficult to assess the small increase in risk that could be associated with sunbed use just because in fact the amount of UV radiation you receive there is much lower than what you receive when you lay down on the beach.

This is very recent data, it’s not published yet, it’s in the publication pipeline. It’s a large study, very well done in the Stockholm area in Sweden among typically collaborative studies were done with these groups and * from 18 to 50 years old. It is that age range that is the most greater sunbed users in Sweden and one thing they have looked at, they have asked the people whether they had had a sunburn in the past twelve months, exactly in the past twelve months, sunburn or skin reddening and they asked whether they had sunburn due to sunbathing or eventually also due to sunbed use and making the difference. And what we can see from this picture here is that in red here you have the sunburn, skin reddening due to sunbed use as compared as compared to outdoor tanning and seaside. And you see that in fact the number of sunburn, skin reddening that was reported as being attributable to sunbed use is about one out of ten only. In fact you have the same for females. So these recent data would suggest that in fact if we believe in the association between sunburn and melanoma as being very relevant observation for the position of melanoma then we would say that with this data from Sweden where you have the highest sunbed use in the world probably it’s only one unit out of ten that would be due to sunbed as compared to the usual intentional sun exposure. It’s about recommendation so in fact there are many countries where at this moment we have recommendations. So regulations that exist in many countries, in Europe at this moment. One program is that there is wide variation from country to country for *. In the European Commission there is no such thing as a Standard for sunbed use. Each country has the choice depends upon the regulation they may adopt. One thing we would like to insist on is the fact that when you implement regulations for sunbed use it is good in the sense that you may avoid some hazards. However one thing also is that probably it provides a false sense of security. Everywhere where these recommendations have been implemented, in fact the use of sunbeds has always increased after it just because it appeals to the sense that it could be very secure to use the sunbed. That’s an effect of these regulations. Although they are important we must be aware that these regulations are probably some cosmetic change to the real issue. The real issue being the exposure to UV radiation and these regulations make little about that. I will finish it here. Thank you very much.

Mark —

Can I ask you on the Westerdahl, Swedish study. You stressed the fact that the experience of sunbed use was higher in that study than others — is it possible that on your combined graph the top category of Westerdahl is greater exposure than the top categories of the others? In other words could we be getting something equivalent to a constant exposure pattern that we see with sun exposure and that could explain why you’ve got a curvilinear relationship.

Inaudible response (no mic).