Sunburns and Risk of Cutaneous Melanoma: Does Age Matter? A Comprehensive Meta-Analysis
Introduction
Ultraviolet radiation (UVR) is considered the foremost environmental cause of cutaneous melanoma (CM). Most dermatologists and melanoma researchers agree that sunburns are an important risk factor for CM. In particular, sunburns occurring during childhood are often cited as posing the greatest risk for CM. Armstrong (1) in a 1988 review outlined strong evidence for a hypothesis put forward by Elwood and Hislop (2) that CM risk was associated with intermittent sun exposure. These early reviews found less clear evidence for cumulative sun exposure. Armstrong theorized that at low frequencies of sun exposure, a tan is not maintained (1). Tanned skin may be a mechanism to shield melanocytes from UVR, similar to the protection seen in naturally darker skin. With intermittent exposure to the sun, the skin is more vulnerable to the effects of UVR and exposure may result in sunburn. Thus, we are examining sunburns as a marker for intermittent sun exposure.
Quantification of the magnitude of risk by life-period may help dispute that only childhood sunburns matter. Although there have been previous meta-analyses of sunburns and CM risk, none have examined the dose-response effects. We believe that pooling “ever” sunburned separately from dose-response analyses and using all categories from original studies in the dose-response analyses is more appropriate and offers more information about the association between sunburns and CM. The purpose of this meta-analytic review was to quantify the overall magnitude of association between CM and increasing number of sunburns for different life-periods of exposure.
Section snippets
Literature Search
Analytic studies that measured sunburns in relation to CM were eligible for this meta-analysis. We repeatedly searched the PubMed database through December 2007 for articles with key words related to melanoma and sun exposure including sun, sunlight, tanbed, sunbed, artificial UV, and sunburn, along with references in relevant articles. Titles and abstracts from over 1,300 articles were screened to exclude case reports, commentaries or editorials, animal studies, therapies, biological aspects
Results
We pooled 51 studies in one or more analyses 3, 4, 17, 18, 19, 20, 21, 22, 23, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79. Among these, 16 were population-based studies. Often, recruitment included all cases (41% of studies) and randomly selected controls (53% of studies). Exclusion or inclusion of in-situ cases was often unreported
Discussion
This review and meta-analysis is the first to pool data on the number of sunburns in relation to CM. Other analyses have considered sunburn to be a dichotomous exposure of either ever/never or lowest versus highest category of sunburns. Our pooled analyses of dose-response data on number of sunburns provide evidence for causality (81). Even with misclassification known to exist in ordered categories, an estimation of numbers of sunburns will give a better characterization of the true
Conclusions
This meta-analysis pooled ORs from 51 studies on CM and “ever” experiencing a sunburn. Our analyses further examined linear dose-response data among 26 studies, which had not previously been reported. These results suggest increasing number of sunburns increase the risk of CM regardless of when they are received. The large ORs seen per decade for adult and lifetime exposure suggest that it is the number of sunburns that increases melanoma risk not when they are received. More consistency may be
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This research was supported in part by the National Cancer Institute (grant number: CA88834-01) and by the American Cancer Society (grant number: RSGPB CPPB-0400801).