Non-melanoma skin cancer risk factors

Non-melanoma skin cancer (NMSC) is associated with a number of risk factors.[1,2]

Non-Melanoma Skin Cancer Risk Factors

Increases risk ('sufficient' or 'convincing' evidence)

May increase risk ('limited' or 'probable' evidence)

Decreases risk ('sufficient' or 'convincing' evidence)

May decrease risk ('limited' or 'probable' evidence)

  • Solar radiation
  • Cyclosporine
  • Coal tar pitch and distillation
  • Mineral and shale oils
  • Soot
  • Arsenic and inorganic arsenic compounds[a]
  • X radiation, gamma radiation (BCC)
  • Azathioprine (SCC)
  • Methoxsalen plus UVA
  • Ultraviolet-emitting tanning devices (SCC)
  • HIV type I
  • Creosotes
  • Nitrogen mustard
  • Petroleum refining
  • Selenium supplements

 

  • Retinol supplements (SCC)
International Agency for Research on Cancer (IARC) and World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) classifications.
 
BCC – basal cell carcinoma, SCC – squamous cell carcinoma.
 
a Arsenic in drinking water classified by WCRF/AICR as a probable cause.

See also

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References

  1. Cogliano VJ, Baan R, Straif K, et al. Preventable exposures associated with human cancers. J Natl Cancer Inst 2011;103:1827-39.
  2. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR; 2007.
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International Agency for Research on Cancer (IARC) classifies the role of this risk factor in cancer development.[1]

An estimated 50-70% of squamous cell carcinoma (SCC) and 50-90% of basal cell carcinoma (BCC) in fair skinned people are caused by radiation.[2]

Sunburn

Basal cell carcinoma (BCC) risk is around twice as high in people who burn and never tan when exposed to the sun, compared with those who tan and never burn, a meta-analysis showed.[3] BCC risk is 69% higher in people who tan and rarely burn, and 55% higher in people who often burn then tan, compared with those who tan and never burn.[3]

Squamous cell carcinoma (SCC) risk is not associated with a history of sunburn, a cohort study showed.[4]

Sunbathing

26% of men and 33% of women in Britain actively try to get a tan, data from 1999 showed; rates were even higher in younger people.[5] Holidays abroad by UK residents have become increasingly popular in recent decades.[6] Climate changes may increase the strength of solar radiation and lead to more time spent in direct sunlight (due to warmer weather), with possible consequences for skin cancer incidence rates.[7] The impact of sunscreen use on skin cancer risk remains unclear, due largely to methodological limitations and other behaviours which may accompany (and perhaps counteract) sunscreen use.[8-15]

Sunbathing, tanning or burning should not be necessary to make sufficient vitamin D to obtain health benefits.

Chronic sun exposure

BCC risk is 43% higher in people who work outdoors, compared with those who do not, a meta-analysis showed.[16] SCC risk is 77% higher in outdoor workers compared with indoor workers, a meta-analysis showed.[17] These associations are stronger in countries nearer the equator.[16,17]

References

  1. International Agency for Research on Cancer. List of Classifications by cancer sites with sufficient or limited evidence in humans, Volumes 1 to 119. Accessed September 2017.
  2. Lucas RM, McMichael AJ, Armstrong BK, et al. Estimating the global disease burden due to ultraviolet radiation exposure. International Journal of Epidemiology 2008;37:654-67
  3. Khalesi M, Whiteman DC, Tran B, et al. A meta-analysis of pigmentary characteristics, sun sensitivity, freckling and melanocytic nevi and risk of basal cell carcinoma of the skin. Cancer Epidemiol. 2013 Oct;37(5):534-43.
  4. Veierød MB, Couto E, Lund E, et al. Host characteristics, sun exposure, indoor tanning and risk of squamous cell carcinoma of the skin. Int J Cancer. 2013 Dec 6.
  5. Office for National Statistics. ONS Omnibus Survey, Knowledge of the Solar UV Index. 2000.
  6. Office for National Statistics. Travel Trends. Available from: http://www.ons.gov.uk/ons/rel/ott/travel-trends/index.html. Accessed May 2014.
  7. Diffey B. Climate change, ozone depletion and the impact on ultraviolet exposure of human skin. Phys Med Biol 2004 Jan 7;49(1):R1-11.
  8. Chesnut C, Kim J. Is there truly no benefit with sunscreen use and Basal cell carcinoma? A critical review of the literature and the application of new sunscreen labeling rules to real-world sunscreen practices. J Skin Cancer 2012;2012:480985.
  9. Diffey BL. Sunscreens as a preventative measure in melanoma: an evidence-based approach or the precautionary principle?. Br J Dermatol 2009;161:25-7.
  10. Weinstock MA. Do sunscreens increase or decrease melanoma risk: an epidemiologic evaluation. J Investig Dermatol Symp Proc 1999;4:97-100.
  11. Autier P, Boniol M, Dore JF. Sunscreen use and increased duration of intentional sun exposure: still a burning issue. Int J Cancer 2007;121:1-5.
  12. Dennis LK, Beane Freeman LE, VanBeek MJ. Sunscreen use and the risk for melanoma: A quantitative review. Annals of Internal Medicine 2003;139:966-78.
  13. International Agency for Research on Cancer. IARC Handbook on Cancer Prevention Vol.5: Sunscreens. 2001.
  14. Sánchez G, Nova J, Rodriguez-Hernandez AE, et al. Sun protection for preventing basal cell and squamous cell skin cancers. Cochrane Database Syst Rev. 2016.
  15. Xie F, Xie T, Song Q, et al. Analysis of association between sunscreens use and risk of malignant melanoma. Int J Clin Exp Med. 2015 Feb 15;8(2):2378-84.
  16. Bauer A, Diepgen TL, Schmitt J. Is occupational solar ultraviolet irradiation a relevant risk factor for basal cell carcinoma? A systematic review and meta-analysis of the epidemiological literature. Br J Dermatol 2011;165:612-25.
  17. Schmitt J, Seidler A, Diepgen TL, Bauer A. Occupational ultraviolet light exposure increases the risk for the development of cutaneous squamous cell carcinoma: a systematic review and meta-analysis. Br J Dermatol 2011;164:291-307.
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International Agency for Research on Cancer (IARC) classifies the role of this risk factor in cancer development.[1]

SCC risk is at least 67% higher in people who have ever used a sunbed (at any age), compared with sunbed never-users, meta-analyses have shown.[2,3] Basal cell carcinoma (BCC) risk is up to 29% higher in people who have ever used a sunbed (at any age), compared with sunbed never-users, a meta-analysis showed.[2,3] BCC risk is 40% higher in people who first used a sunbed before age 25, a meta-analysis showed.[3] Melanoma skin cancer and BCC risk are increased in people who have ever used a sunbed even if they have not been burned while doing so, case-control studies have shown.[4-6] Early-onset melanoma and BCC risk may be increased by sunbed use, cohort studies have shown.[7]

2% of adults in Britain trying to get a tan do so using a sunbed/tanning machine only, data from 1999 showed.[8] 5-6% of young people use or have used sunbeds, data from 2008 and 2009 showed.[9,10] Higher sunbed use rates in young females than young males may explain their higher melanoma incidence rates.[11,12] Sunbed use by under-18s is banned in Scotland, England and Wales, and Northern Ireland.

Sunbed use may be particularly dangerous for children; for people with skin phototypes I or II, many moles (naevi), a history of frequent childhood sunburn, pre-malignant/malignant skin lesions, or sun-damaged skin; and for people wearing cosmetics or taking medications which may enhance their UV-sensitivity.[13,14] In addition to increased skin cancer risk, sunbed users may also be at increased risk of eye damage, photodermatosis, photosensivity and premature skin ageing.[13]

References

  1. International Agency for Research on Cancer. List of Classifications by cancer sites with sufficient or limited evidence in humans, Volumes 1 to 119. Accessed September 2017.
  2. Boniol M, Autier P, Boyle P, et al. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ 2012;345:e4757 doi: 10.1136/bmj.e4757.
  3. Wehner MR, Shive ML, Chren MM, et al. Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis. BMJ 2012;345:e5909. doi: 10.1136/bmj.e5909.
  4. Ferrucci LM, Cartmel B, Molinaro AM, et al. Indoor tanning and risk of early-onset basal cell carcinoma. J Am Acad Dermatol. 2011.
  5. Lazovich D, Vogel RI, Berwick M, et al. Indoor Tanning and Risk of Melanoma: A Case-Control Study in a Highly Exposed Population. Cancer Epidemiol Biomarkers Prev 2010;19:1557-68.
  6. Vogel RI, Ahmed RL, Nelson HH, et al. Exposure to indoor tanning without burning and melanoma risk by sunburn history. J Natl Cancer Inst 2014 Jul;106(7).
  7. Cust AE, Armstrong BK, Goumas C, et al. Sunbed use during adolescence and early adulthood is associated with increased risk of early-onset melanoma. Int J Cancer 2011;128:2425-35.
  8. Office for National Statistics. ONS Omnibus Survey, Knowledge of the Solar UV Index. 2000.
  9. Thomson CS, Woolnough S, Wickenden M, et al. Sunbed use in children aged 11-17 in England: face to face quota sampling surveys in the National Prevalence Study and Six Cities Study. BMJ 2010;340.
  10. Boyle R, O’Hagan AH, Donnelly D, et al. Trends in reported sun bed use, sunburn, and sun care knowledge and attitudes in a U.K. region: results of a survey of the Northern Ireland population. Br J Dermatol 2010;163:1269-75.
  11. Cokkinides V, Weinstock M, Lazovich D, et al. Indoor tanning use among adolescents in the US, 1998 to 2004. Cancer 2009;115:190-8.
  12. Coelho SG, Hearing VJ. PUVA tanning is involved in the increased incidence of skin cancers in fair-skinned young women. Pigment Cell Melanoma Res 2010;23:57-63.
  13. International Commission on Non-Ionizing Radiation Protection. Health issues of ultraviolet tanning appliances used for cosmetic purposes. Health Phys 2003;84:119-27.
  14. World Health Organization. Artificial tanning sunbeds: risk and guidance. 2003.
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Hair colour

Basal cell carcinoma (BCC) risk is around twice as high in people with red hair, compared with dark-haired people, a meta-analysis showed.[1] BCC risk is 69% higher in people with red/blonde hair, 38% higher in blondes, and 27% higher in people with light brown hair, compared with dark-haired people.[1]

Squamous cell carcinoma (SCC) risk is higher in people with red and light blonde hair, compared with people with black hair, case-cohort study has shown.[2]

Eye colour

BCC risk is 68% higher in people with blue/blue-grey eyes, compared with dark-eyed people, a meta-analysis showed.[1] BCC risk is 61% higher in people with green/green-grey-hazel eyes, and 58% higher in people with blue-grey/green-hazel eyes, compared with dark-eyed people.[1]

SCC risk is not associated with eye colour, a cohort study showed.[3]

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Basal cell carcinoma (BCC) risk is 70% higher in people with skin phototype I/II compared with people with skin phototype III/IV, a meta-analysis showed.[1]

Skin Phototypes

Skin Phototype

Typical Features

Tanning Ability

Type I

Tends to have freckles, red or fair hair, and blue or green eyes.

Often burns, rarely tans.

Type II

Tends to have light hair, and blue or brown eyes.

Usually burns, sometimes tans.

Type III

Tends to have brown hair and eyes.

Sometimes burns, usually tans.

Type IV

Tends to have dark brown eyes and hair.

Rarely burns, often tans.

Type V

Naturally black-brown skin. Often has dark brown eyes and hair.

 

Type VI

Naturally black-brown skin. Usually has black-brown eyes and hair.

 

Based on: Fitzpatrick T. Soleil et peau. J Med Esthet 1975;2:33-4.
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Moles

Basal cell carcinoma (BCC) risk is 60% higher in people with moles, compared with people without moles, a meta-analysis showed.[1]

Most moles are genetically determined, appearing during childhood or adolescence.[2-4] Sun exposure can increase the number of moles, with chronic sun exposure more influential than number of sunburn episodes.[2]

Freckles

BCC risk is 57% higher in people with freckles as a child, compared with people without freckles as a child, a meta-analysis showed.[1] BCC risk is not associated with the presence of freckles in adulthood.[1]

References

  1. Khalesi M, Whiteman DC, Tran B, et al. A meta-analysis of pigmentary characteristics, sun sensitivity, freckling and melanocytic nevi and risk of basal cell carcinoma of the skin. Cancer Epidemiol. 2013 Oct;37(5):534-43.
  2. Bauer J, Garbe C. Acquired Melanocytic Nevi as Risk Factor for Melanoma Development. A Comprehensive Review of Epidemiological Data. Pigment Cell Res 2003;16:297-306.
  3. Dulon M, Weichenthal M, Blettner M, et al. Sun exposure and number of nevi in 5- to 6-year-old European children. Journal of Clinical Epidemiology 2002;55:1075-81.
  4. Wachsmuth RC, Gaut RM, Barrett JH, et al. Heritability and gene-environment interactions for melanocytic nevus density examined in a U.K. adolescent twin study. J Invest Dermatol. 2001;117:348-52.
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Squamous cell carcinoma (SCC) risk is increased in people with a family history of the same disease, a cohort study has shown.[1] Basal cell carcinoma (BCC) risk is increased in people with a family history of melanoma skin cancer, a cohort study has shown.[2]

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Psoriasis

Squamous cell carcinoma (SCC) risk is around five times as high in people with psoriasis, compared with the general population, a meta-analysis showed.[1] Basal cell carcinoma (BCC) risk is around twice as high in people with psoriasis, compared with the general population, a meta-analysis showed.[1

Inflammatory bowel disease (IBD)

Non-melanoma skin cancer (NMSC) risk among people with IBD may be higher in those treated with thiopurines versus those not, but evidence is unclear, a meta-analysis showed.[2]

References

  1. Pouplard C, Brenaut E, Horreau C, et al. Risk of cancer in psoriasis: a systematic review and meta-analysis of epidemiological studies. J Eur Acad Dermatol Venereol. 2013 Aug;27 Suppl 3:36-46.
  2. Ariyaratnam J, Subramanian V. Association between thiopurine use and nonmelanoma skin cancers in patients with inflammatory bowel disease: a meta-analysis. Am J Gastroenterol 2014;109(2):163-9.
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International Agency for Research on Cancer (IARC) classifies the role of this risk factor in cancer development.[1]

NMSC risk is more than twice as high in people with HIV, compared with those without, a meta-analysis showed.[2] The association may be stronger in men than women.[2]

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Basal cell carcinoma (BCC) risk is 12% lower, and squamous cell carcinoma (SCC) risk is 11% lower, per 5-unit BMI increment, a meta-analysis showed.[1] Again, this may reflect self-limited sun exposure in people with higher BMI;[1-3] the association with SCC may be limited to women.[2]

Early onset melanoma skin cancer risk is more than doubled in people weighing 4.5-6kg at birth, compared with those weighing 3-3.5kg at birth, a cohort study showed.[4]

References

  1. Zhou D, Wu J, Luo G. Body mass index and risk of non-melanoma skin cancer: cumulative evidence from prospective studies. Sci Rep. 2016 Nov 29;6:37691. doi: 10.1038/srep37691.
  2. Gerstenblith MR, Rajaraman P, Khaykin E, et al. Basal cell carcinoma and anthropometric factors in the U.S. radiologic technologists cohort study. Int J Cancer 2012;131:E149-E55.
  3. Pothiawala S, Qureshi A, Li Y, et al. Obesity and the incidence of skin cancer in US Caucasians. Cancer Causes and Control 2012;23:717-26.
  4. Yang TO, Reeves GK, Green J, et al. Birth weight and adult cancer incidence: large prospective study and meta-analysis.. Ann Oncol 2014;25(9):1836-43.
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International Agency for Research on Cancer (IARC) classifies the role of this risk factor in cancer development.[1]

Melanoma skin cancer or NMSC risk is 14% higher in people who receive at least one computed tomography (CT) scan of the brain before age 20, with no significant effect of CT scans to other anatomical sites, a cohort study showed.[2]

Basal cell carcinoma (BCC) risk is higher in atomic bomb survivors compared with the general population, a cohort study showed, with a greater risk increase in those exposed at a younger age.[3]

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International Agency for Research on Cancer (IARC) classifies the role of this risk factor in cancer development.[1] An estimated 7% (males) and 1% (females) of non-melanoma skin cancers (NMSCs) in Britain are due to occupational exposures (including solar radiation).[2]

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