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Red alert!

Skin cancer rates among young people have risen significantly over the last 20 years. But there are ways to enjoy the summer sun and reduce your risk of developing this potentially fatal disease, says one of Manitoba's leading cancer experts

Red alert!
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Skin cancer by the numbers

What is skin cancer?

Protect your skin

UV index

BY SUSIE STRACHAN
Winnipeg Health Region
Wave, Summer 2009

Karlie Ross was not terribly concerned about the harmful effects of the sun's rays when she was a teenager.

Back then, skin cancer seemed like the kind of disease that struck middle-aged folks who spent all their time in sunny hot spots like Palm Springs or the beaches of Mexico, or golfers striding the links, with skin browned to leather.

"When I was a kid, my parents put sunscreen on me, but when I was a teen and my parents weren't around, I wasn't nearly as conscientious," she says. "One year, I was visiting down in Los Angeles, and it was super hot and I got a bad burn on my shoulders, which blistered and peeled. It took about a year for one spot to heal."

Times have changed for Ross. Now in her late twenties and working as a nurse, Ross is far more conscious of the connection between the sun's rays and skin cancer.

That's not to say Ross spends her summer days cloistered in darkness. "I like to sit out in the sun, and I play Ultimate (Frisbee) in the summer. We also go to the cabin, just north of Gimli. We get out playing on the water, and go for walks with my dog Rascal," says Ross.

The difference is that she now takes the proper precautions to reduce the risk of developing skin cancer while enjoying the summer sun. "I wear a moisturizer on my face with SPF 30 every day, and I try to put at least 15 SPF sunscreen on my body if I'm going to be outside for longer than an hour." She's also taken to wearing hats. "There are so many fashionable hats to wear these days," she adds.

All of this is music to the ears of Dr. Dhali Dhaliwal, President of Cancer- Care Manitoba. Although skin cancer rates have stabilized in recent years, the number of cases has tripled over the last few decades. And while skin cancer is most prevalent among those 50 years of age and older, there has been a spike in the number of cases involving people in their twenties.

About 5,000 new cases of melanoma and about 75,000 cases of non melanoma skin cancer will be diagnosed this year in Canada, according to the latest Canadian Cancer Statistics survey. The survey estimates that 940 Canadians will die from melanoma this year, while about 270 will die from non-melanoma skin cancers.

Raising awareness about the dangers of skin cancer may seem like a tough sell in a winter climate like Winnipeg's; most people look forward to summer and embrace the sun. That's okay, says Dhaliwal, as long as people are smart about it. "We all like to work and play outside on a sunny day. The warm rays of the sun feel good, but too much sun can be harmful, so it's necessary to take precautions," he says.

The first step to preventing skin cancer is to understand how it occurs.

The sun emits three types of ultraviolet light - UVA, UVB and UVC. Research suggests that UVA rays penetrate deeply into the skin and contribute to premature wrinkling. UVB rays, meanwhile, affect the external layers of the skin and are thought to be the main cause of sunburn, and skin cancer. UVC rays are generally filtered out by the ozone layer. Exposure to the sun's UV rays causes damage to your skin's DNA. The result is the release of a chemical called melanin, a brown colouring more commonly known as a suntan. In other words, a suntan is not a "healthy glow," but rather your skin's response to being damaged by the sun.

Over time, suntans and sunburns can promote the growth of abnormal cells in the skin, which manifest as one of three forms of skin cancer: basal cell carcinoma, which makes up about 90 per cent of all skin cancers in North America; squamous cell carcinoma; and melanoma, a less common but more deadly form of skin cancer.

The first sign of melanoma often shows up in the shape of a mole, often beyond six mm. It may also be:

  • asymmetrical, where the shape of one side is different than the other;
  • have ragged or imprecise borders;
  • show colour variation within the mole;
  • be itchy, tender and prone to bleeding.

Melanoma can quickly spread to other parts of the body, so early detection is important. A self-check of your moles is recommended, done once a year on your birthday with the help of a partner to look at the back of your body.

Basal cell cancers, meanwhile, usually appear on sun-exposed areas of the skin, and often look like a reddish bump with a pearly border, or a pimple-like growth that bleeds, crusts over and then reappears, or a red scaling patch. Squamous cell cancers appear as thickened, red, scaly bumps or warts, and may grow quickly over the course of a few weeks. People who work or play outdoors are at greater risk of developing this disease.

While most skin cancers emerge in people over the age of 50, Dhaliwal says younger people are starting to develop one of the three major forms of skin cancer, particularly basal cell carcinoma. "Since the 1970s, there has virtually been a straight line upwards in the incidence of skin cancer among young people," he says. "There is a threefold increase, particularly among young men, who are more active outdoors. But young women had the biggest increase overall, to the point where melanoma is the third most common cancer in women aged 29 to 39."

The reasons for this surge are many and varied. Attitudes towards tanning have certainly changed over the years. In the Victorian Era, lily-white skin was praised in poetry, and upper-class young women carried parasols to ward off the sun's rays. But in the 1920s, fashion designer Coco Chanel got sunburned on the French Riviera, and her fans started to adopt darker skin tones. The bikini made its appearance in the 1940s, and Malibu Barbie had little kids playing with her tiny sunglasses and teeny bottle of suntan lotion in the 1970s.

Today, tanning has inexplicably become associated with leisure time, and a bronzed body is something some people aspire to, damage to the skin notwithstanding. A recent national survey suggested that about 49 per cent of females and 28 per cent of males between the ages of 16 and 24 sought a tan from the sun within a 12-month period. Moreover, 27 per cent of females in that age group - more than one in four - reported using tanning equipment to get a tan over a 12-month period, according to the survey.

These numbers trouble Dhaliwal. "Tanning among teens has increased dramatically, especially in females under 25, which is a worrisome trend, as they are at a vulnerable age," he notes. Most experts agree that tanning salons have played a role in rising skin cancer rates. Like the sun, tanning lights and sunlamps emit ultraviolet rays that cause sunburn and aging skin, and increase the risk of skin cancer. While people consider tanning booths to provide their skin with a measure of protection against sunlight, a 1994 Swedish study found that women between the ages of 18 and 30 who visit tanning salons 10 or more times a year have a seven times greater incidence of melanoma than women who don't. Meanwhile, a 2002 study from Dartmouth Medical School found that tanning salon users have a 2.5 times greater risk of squamous cell cancer, and 1.5 times the risk of basal cell cancer, according to the Skin Cancer Foundation in the USA.

"Years ago, you never saw a tanning lamp or bed. Today they are everywhere and people use them with greater frequency, thinking they are safe," says Dhaliwal. "The World Health Organization says that people under the age of 18 should not use these devices. Minors under the age of 16 in Canada require parental consent. I've heard of teens passing one parental permission note around, so they can all get a tan. This contributes to their risky behaviour."

While skin cancer is a problem, the good news is that the cure rate among patients is around 90 per cent, as long as the condition is diagnosed and treated promptly. Treatments range from freezing with liquid nitrogen, surgical removal, radiation therapy or immune system modulating creams, depending on the type of skin cancer. Melanoma is the most deadly form of skin cancer, but the other two major varieties can lead to scarring and disfigurement.

"One of the treatments is Mohs micrographic surgery, in which the scarring is smaller because less normal skin is removed; the skin cancer is cut out in layers," says Dhaliwal. "A scar from a non-Mohs skin cancer excision usually ranges from one to two inches. On a person's back, an inch scar is not so bad but an inch-long scar on the nose is much more noticeable!"

The best way to cure skin cancer is to reduce your risk of developing it in the first place. Younger people need to understand that the tanning and burning done today is what causes the skin cancer of tomorrow, says Dhaliwal. "There is a 10-year time lag between burns from the sun in childhood and the appearance of skin cancer," he says.

There are a number of steps a person can take to reduce their risk. For example, it is important to know your skin type. People with fair skin with lots of freckles and natural red hair are the most prone to burning in the sun. You should also reduce your sun exposure between 11 a.m. and 4 p.m. by seeking or creating shade, slipping on light, loose-fitting clothing, and wearing a broadbrimmed hat and anti-UV sunglasses. And if you have to go out during the middle of the day, Dhaliwal emphasizes the importance of not only using sunscreen, but using it properly. "Sunscreen (with SPF 15) should be applied at least 30 minutes before going outside, and allowed to be absorbed into the skin," says Dhaliwal. "Re-apply it one hour after being in the sun. People often only put on one-third the amount they require. You need at least one ounce to be protected, or else it's too little, too late."

Dhaliwal says awareness about skin cancer is growing. For example, his organization puts up sun awareness displays in places such as grocery stores, and hands out SunSense bracelet kits to children at events like the Teddy Bears' Picnic. The SunSense bracelets come with clear beads that turn darker in the presence of UV light. The kit also comes with child friendly graphics helping kids learn how to become sun-safe. The agency is also promoting sun awareness to family physicians, who are the first to detect skin cancer in patients. "We know of people who take (digital) photos of their moles, to keep track of any changes, and who take these files in to show to their doctors," he says.

But Dhaliwal says more can be done. He suggests that Canada could learn from other countries. "We need to follow the example of Australia, which has quite a large population of very fair-skinned people. Over the past 20 years, there has been a dramatic decrease in skin cancers, due to a publicity campaign and almost mandatory behaviour to protect your skin from the sun. In places in Australia, parents can be fined for not covering their children properly."

Fortunately, there are signs that the awareness campaigns are paying off.

Allison Thomas, a Grade 8 student at Charleswood Junior High School, has picked up the message about wearing sunscreens to avoid skin cancers, from reading magazines aimed at young women. She notes the people shown in the magazines don't have dark tans.

"Mom used to be the one putting sunscreen on us, and I remember that daycare did the same thing. I use some with SPF 30 as a moisturizer, on my face and arms and legs," says Thomas. "Sure, many of my friends don't wear sunscreen, but most of them don't try to get a tan."

Thomas knows that burns from too much sun aren't fun, and that sunlight causes wrinkled skin. Her elementary teachers talked about using sunscreen to prevent burns, and she's been shown nasty photos of skin cancers.

"I'd rather use a self-tanning lotion, because I don't want to be too pale, especially in the middle of winter, when your skin is pasty and unnaturally pale," she says, adding she's not interested in tanning beds or lying out in the sun to get a dark tan. "But I don't want to stay inside. I like being outside in the summer."

Susie Strachan is a Winnipeg writer.

Wave

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Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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