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An Interview With

Petr F Hausner, M.D., Ph.D.
Chief of Hematology and Oncology, Baltimore VA Medical Center
August 13, 2014

 

Hausner


Prevention and Early Detection of Skin Cancer

 

For more information about Dr Hausner

 

Melanoma Research Foundation

 

 

Spencer: Skin cancer is the most common form of cancer. Over the last 40 years melanoma rates have increased an estimated 800 percent among young women and 400 percent among young men. What are some of the measures we need to take to reverse this trend?

Dr. Hausner:

I think first is to understand why we develop melanoma and its pathophysiology. Melanoma is usually caused by light or sunlight that hits the unprotected skin. And how is it unprotected? It’s unprotected by the absence of pigment.

In evolution, people were outdoors all the time and the skin was never without pigment, unless the individual had a skin type that just didn’t tan. So people had tan from being outdoors and that tan protected the skin from too much sunlight.

The other thing that has in the past protected the skin was dirt. People were just dirty, in particular kids. I don't think that they liked to wash themselves in cold water. I don’t see how people living in Europe and in the Arctic were washing themselves in the winter. So I think people living in the north got pretty dirty and had a nice protective layer.

These days people are washing themselves and spending most of the time indoors. They go once a year in the winter to a subtropical country, expose the marble, pale skin to the tropical sun, and the result is that the UVA, UVB reaches the melanocytes that are deep in the skin and stimulates them. At the same time the sunlight causes mutations of the DNA and local immunosuppression. Without immunosuppression there would be intractable skin inflammation caused by the sunlight, and you know the blistering sunburn.

So there are three factors - immunosuppression, DNA damage from the sunlight, and the stimulation of melanocytes to proliferate. They come together and the result is that the patient develops melanoma-precursor lesions called dysplastic nevi, which might turn into melanoma.

I’ve seen melanomas on the buttocks. That’s something I’ve never seen before because people usually don’t expose their buttocks to the sunlight, but now in tanning booths, they do. Again, it’s the unprotected skin, the skin that doesn’t have the suntan, because the suntan is the physiologic protection from sunlight.

Migration of people plays another big factor. The skin of Africans is very resistant to the sun. The skin of Europeans or Caucasians in the northern hemisphere is light, and the reason for that is that they need to convert vitamin D. So it’s the protection against melanoma and skin cancer on one side that you get from dark skin, but you lose the ability to convert vitamin D.

Skin color is a geographic adaptation, but then humanity started to move around and that adaptation does not work. If somebody from Ireland moves to Australia they will have an increased risk of melanoma. Australia has the highest incidence of melanomas on the whole planet. Suddenly the movement of humans has negated the geographic adaptation because people just live in latitudes that the skin is not made for.

Also, there is cultural influence. Caucasians, because they have so little sunlight, understood that they had to expose themselves to sunlight. Physicians, encouraged people to expose themselves to sunlight in the northern hemispheres. At the end of the last century, physicians figured out that you need that sunlight so that kids don’t develop the rickets due to lack of vitamin D. So, civilization started to love sunlight and going out and playing in the sunlight.

But if you take Africans, they know that you have to protect yourself from that intensive sunlight. They will not go out at noon because they know it’s bad. That’s a different civilization, a different tradition. So those traditions were broken and now with the migration, we are keeping the northern traditions, not adopting the southern traditions like covering your head, not going out around noon, and keeping siesta.

Some people with very light skin have a phototype of zero. They never tan. So they basically cannot go into the sun and they have to arrange their activities to avoid the midday sun. The beach can be especially dangerous. At the beach you get the reflected light from the water and the reflected light from the sand. So there is no real shade at the beach.

I think there are a few things that would go an extremely long way in doing a lot of good at protecting people. At some point I even considered putting some posters at the beaches, explaining how the sun works on your skin, and the safety of the sun in the morning and evening, with most damage around noon. Businesses would like it because it would drive people at noon from the beaches into the town and into the shops and eateries.

There is a need for regulations to protect the beach guards. Like the smoking ban started more or less with protecting waiters in restaurants. So now you can say we have to close the beach at noon because the beach guards need a break and they are in danger of being out there in the sun. I think that would be a way to start introducing legislation that would protect the public, and I think it’s similar to the smoking ban legislation. It’s just necessary, and legislation can start with the beach guards.

Spencer:

You had mentioned UVB, and there is I think a lot of confusion over sunscreens. The SPF rating system tells us how effective the product is against UVB rays, but there doesn’t seem to be a rating system for UVB. I’m wondering if you think this will be coming in the future?

Dr. Hausner:

I think it might be, but the important thing is to distinguish sunscreens that are reflective from sunscreens that are absorptive, because the reflective sunscreens, they reflect most light. The absorptive ones, they still permit the transmission of a most wavelengths of the sunlight. So with a reflective sunscreen you can protect yourself from UVA and UVB, but people don’t like them because they leave a whitish tan on the skin, but they are cheaper. Choosing the right sunscreen is important.

If you look at the Arabs walking in the deserts, the way they are dressed for the summer is so different from the way that we dress for summer, but you have to just accept the fact that they know better than we do. They live with sun and they are able to survive the sun, but we are not.

I think that cleanliness is something that plays a major role. Just to be clean, our tendency to wash the children and keep them clean reduces protection from sunlight. If we want to protect our kids from the sun, it may not be the right thing to do.

There is a nice website, the Environmental Protection website that gives you at any time, at any place, the amount of time you can safely spend on that day in the sun. It’s surprising how short those times are. So in the summer it would tell you, “You can be safely at the beach unprotected from sun for about four minutes.”

EPA's Sunwise website

EnviroFlash: Environmental Notifications

Sunsmart website

It is important to understand the anatomy of the skin and how those melanocytes work and how they protect. They are making pigment, the melanin, in melanosomes. They interact with the basal cells, i.e. the cells that are proliferating at the base of the epithelium of the skin. The melanocytes have long branches and arms, and they reach out to all the other cells of the basal layer and they feed them with melanosomes, and the other cells put them on top of their nucleus as a roof. So then all the other cells are protected and that’s the suntan.

Spencer:

So many people go to tanning salons and you mentioned that. Do you have any advice? I assume people probably are going to continue to go, but should you avoid them completely?

Dr. Hausner:

I think the official recommendation is to avoid them completely. I would say there might be one exception. Let’s say you are planning a vacation in January for some tropical island. And you have a skin that tans with sun because you have a phototype of two or higher, such as phototype 2, 3, 4. Thus you know that you tan with sun. You can go to a tanning salon and very slowly and gradually prepare yourself for the vacation, so that you don’t go on the vacation pale as a marble statue, but you go on the vacation with a reasonable and safely acquired tan.

The vacation is going to be safer, and if you acquire that tan very slowly and gradually in a tanning booth, then I think you did the right thing. But you have to make sure that you have the right phototype, that you are not a person who just burns with sun and never tans. There would be no advantage to people who just never tan.

Most of melanoma patients that I see, they are of that phototype. They just never tan, so their melanocytes can never protect them. Then there is absolutely no use of the sun tanning and it’s extremely dangerous for them. Thus, the first step is to understand your own phototype.

The patients that are phototype 5 are very dark, black skin. They don’t get melanomas on their skin at all. If you examine a black person, you would see that the skin has the smooth quality of baby skin, completely unchanged by sunlight. They can do whatever they want. They may get melanomas on the soles of their feet and palms or their hands, because that’s where they have very little pigment. African Americans often have mucosal melanomas, which we don’t have the slightest idea how to prevent.

Spencer:

Should we all do self-exams?  I understand it can be very difficult to tell a skin cancer from something innocent.

Dr. Hausner:

I think one should pay attention to one’s own skin and look for changes, anything that’s new or changing. There are many lesions on the skin that are completely innocent and you don’t have to worry about. Some small moles or acquired nevi are completely benign, but then there are the dangerous squamous cell cancers, basal cell cancers, melanomas, dysplastic nevi, actinic keratoses and things like that. All of them, if they are dangerous they are changing with time, mostly growing. So if you see any change, then pay attention.

Take a picture of the lesion with your cell phone to have a date and with a tape measure next to the lesion. Then, maybe a month later take another picture and compare them. If you see that the lesion is changing, see a dermatologist immediately.

Spencer:

I’m switching gears a little bit, but lung cancer is the second most common cancer in the U.S., accounting for about 30 percent of all cancer deaths. I’m wondering if we’re doing enough to reverse the trend.

Dr. Hausner:

Lung cancer is mostly a smoking-related disease in Caucasians, not necessarily in other parts of the world like in Asia, where about 35 percent of the lung cancer is not related to smoking. It may be related to cooking on open fires or things like that. But in western culture, the best measure we can take is to stop smoking, banning smoking everywhere and not introducing young people to smoking.

The truth is that the earlier one starts to smoke the worse it is. Children in school may try experimenting with smoking. That’s absolutely terrible because kids are growing organisms and the harm is much greater than in an adult.

There are about 6,000 or 8,000 different carcinogens that are present in the gas phase and the particular phase of the smoke that cause the lung cancer. Unfortunately, smoking is an addiction to nicotine, and the nicotine itself can be a driving force for one type of lung cancer and that is the small cell lung cancer. Switching to e-cigarettes after you have smoked regular cigarettes can increase the risk of small cell lung cancer. I think people who have never smoked who are determined to start, if they would be starting with e-cigarettes, that might be preferable to regular tobacco, but switching to e-cigarettes is not something that I can support.

Spencer:

Supported by aggressive industry campaigns, the popularity of asbestos continues and is rising in China, India, Russia and Brazil and many developing nations. Is there anything that can be done and can you tell me a little about the relationship of asbestos to mesothelioma?

Dr. Hausner:

I think asbestos is another risk factor for lung cancer and it’s a major risk factor for mesothelioma. It’s so unfortunate. It takes about 25-30 years from the point that somebody was exposed to asbestos to get mesothelioma. Therefore people are not seeing that imminent risk. Nothing is happening. They have exposed themselves to asbestos and nothing happens. It is only 30 years later that they may be dying of mesothelioma.

It’s a major risk factor. Asbestos was used in different industries. In steel making in the United States there was a lot of asbestos, and in the military with submarines. There was asbestos in brakes, and workers who were repairing car brakes were at significant risk. Then obviously the building industry was at risk. I think at some point asbestos was even part of filters in cigarettes. If you smoked a cigarette with a filter you inhaled asbestos fibers as well.

I hope that regulations are going to take place and that asbestos is going to be completely eliminated. I think that one country that has a big asbestos industry is Australia. There are many patients there with mesothelioma and they do a lot of screening. They really address the asbestos issue very seriously, and I think they should be an example for other countries that don’t take it as seriously, such as Russia.

Spencer:

Thank you for your time today.  I hope we can meet again.