Bulliard, J-L.

Correia, O.

Duarte , A. F.

Gandini, S.

Nagore, E.

Njimi, H.

Peris, K.

Stratigos, A.

Suppa, M.

Serveur académique lausannois

Mariano	  Suppa,1	  Sara	  Gandini,2	  Hassane	  Njimi,1	  Jean-­‐Luc	  Bulliard,3	  Osvaldo	  Correia,4,5,6	  Ana	  Filipa	  Duarte,4,5,7	  KeIy	  Peris,8	  Alexander	  J	  StraNgos,9	  Eduardo	  Nagore,10	  Maria	  Isabel	  Longo,11	  Mathilda	  Bylaite-­‐Bucinskiene,12	  Raymond	  Karls,13	  H	  Helppikangas,14	  Euromelanoma	  Working	  Group*	  and	  Véronique	  del	  Marmol1	  AssociaNon	  of	  sunbed	  use	  with	  skin	  cancer	  risk	  factors	  in	  Europe:	  an	  invesNgaNon	  within	  the	  Euromelanoma	  skin	  cancer	  prevenNon	  campaign	  	  1Department of Dermatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium 2Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy 3Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland 4Centro de Dermatologia Epidermis, Instituto CUF, Porto, Portugal 5Portuguese Skin Cancer Association, Lisbon, Portugal 6Center for Health Technology and Services Research (CINTESIS) and Basic & Clinical Immunology Unit, Faculty of Medicine, University of Porto, Portugal 7Department of Community Medicine, MEDCIDS, Faculty of Medicine, University of Porto, Portugal 8Institute of Dermatology, Catholic University, Rome, Italy 9First Department of Dermatology, National and Kapodistrian University of Athens School of Medicine, Andreas Sygros Hospital, Athens, Greece 10Department of Dermatology, Instituto Valenciano de Oncología; and Universidad Católica de València San Vicente Ferrer, Valencia, Spain 11Department of Dermatology, University of Florida College of Medicine, Gainesville, FL, US 12Clinic of Infectious, Chest diseases, Dermatovenereology and Allergology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania 13Department of Infectiology and Dermatology, Riga Stradins University, Riga, Latvia 14Dermatology Department, Clinical Center, University of Sarajevo, Bosnia & Herzegovina Figure	  1.	  Example	  of	  skin	  cancer	  risk	  factors	  on	  the	  back	  of	  a	  55	  years	  old	  man,	  including	  high	  nevus	  count	  (>50),	  presence	  of	  atypical	  nevi	  and	  lenNgines,	  as	  well	  as	  suspected	  melanomas.	  *	  Euromelanoma	  Working	  Group	  Members	  –	  E	  Baltas:	  Department	  of	  Dermatology	  and	  Allergology,	  University	  of	  Szeged,	  Szeged,	  Hungary;	  O	  Bogomolets:	  Department	  of	  Dermatology,	  Ins<tute	  of	  Dermatology	  and	  Cosmetology,	  Kiev,	  Ukraine;	  A	  Girnita:	  Theme	  Cancer,	  Karolinska	  Ins<tute	  and	  Karolinska	  University	  Hospital,	  Stockholm,	  Sweden;	  J	  Hafner:	  Department	  of	  Dermatology,	  University	  Hospital	  of	  Zürich,	  Zürich,	  Switzerland;	  J	  Hercogová:	  Dermatovenereology	  Department,	  2nd	  Medical	  Faculty,	  Charles	  University,	  Bulovka	  Hospital,	  Prague,	  Czech	  Republic;	  P	  Konno:	  Dermatology	  Outpa<ent	  Clinic,	  Clinic	  of	   Internal	  Medicine,	  East	  Tallinn	  Central	  Hospital,	  Tallinn,	  Estonia;	  HF	  Lorentzen:	  Department	  of	  Dermatology,	  Aarhus	  University	  Hospital,	  Aarhus,	  Denmark;	  T	  Maselis:	  Private	  Prac<ce,	  Tienen,	  Belgium;	  L	  Medenica:	  Department	  of	  Dermatology	  and	  Venereology,	  School	  of	  Medicine,	  University	  of	  Belgrade,	  Belgrade,	  Serbia;	  L	  Mekokishvili:	  Faculty	  of	  Medicine,	  Caucasus	  Interna<onal	  University,Tbilisi,	  Georgia;	  M	  Murphy:	  Dermatology	  Department,	  South	  Inﬁrmary	  Victoria	  University	  Hospital,	  Cork,	  Ireland;	  B	  Nedelciuc:	  Department	  of	  Dermatovenerology,	  "Nicolae	  Testemitanu"	  State	  University	  of	  Medicine	  and	  Pharmacy,	  Chisinau,	  Republic	  of	  Moldova;	  AC	  Nicolescu:	  Department	  of	  Dermatology	  –	  CDT	  Roma,	  Bucharest,	  Romania;	  J	  Oláh:	  Department	  of	  Dermatology	  and	  Allergology,	  University	  of	  Szeged,	  Szeged,	  Hungary;	  N	  Onsun:	  Department	  of	  Dermatology,	  School	  of	  Medicine,	  Bezmialem	  Vakif	  University,	  Istanbul,	  Turkey;	  A	  Pallouras:	  Department	  of	  Dermatology,	  Cyprus	  Society	  of	  Dermatology	  and	  Venereology,	  Larnaca,	  Cyprus;	  W	  Placek:	  Department	  of	  Dermatology,	  Sexually	  TransmiWed	  Diseases	  and	  Clinical	  Immunology,	  University	  of	  Warmia	  and	  Mazury,	  Olsztyn,	  Poland;	  N	  Potekaev:	  Moscow	  Scien<ﬁc	  and	  Prac<cal	  Center	  of	  Dermatovenereology	  and	  Cosmetology,	  Moscow,	  Russia;	  M	  Reusch:	  Dermatological	  Prac<ce	  Tibarg,	  Hamburg,	  Germany;	  I	  Roscher:	  Department	  of	  Dermatology,	  Oslo	  University	  Hospital,	  Oslo,	  Norway;	  T	  Planinšek	  Ručigaj:	  Dermatovenereological	  Clinic,	  University	  Medical	  Centre	  Ljubljana,	  Ljubljana,	  Slovenia;	  L	  Scerri:	  Department	  of	  Dermatology	  &	  Venereology,	  Sir	  Paul	  Boﬀa	  Hospital,	  Floriana,	  Malta;	  M	  Šitum:	  University	  Department	  of	  Dermatovenereology,	  University	  Hospital	  “Sestre	  milosrdnice”,	  Zagreb,	  Croa<a;	  Z	  Zaﬁrovik:	  University	  Clinic	  of	  Dermatology,	  Medical	  Faculty,	  University	  “St.	  Cyril	  and	  Methodius”,	  Skopje,	  Former	  Yugoslav	  Republic	  of	  Macedonia	  (FYROM).	  Belgium(Bosnia(Herzegovina(Czech(Republic(Estonia(Georgia(Greece(Hungary(Ireland1(Italy(Macedonia((FYROM)(Norway(Poland(Portugal(Slovenia(Sweden(Switzerland(Summary(RelaHve(Risk(1.05((1.01M1.10)(  0.6( 0.8( 2.0( 3.0( 4.0(1.0(((((((((Nevus(count(>50(RelaHve(risk((95%(CI)(Belgium(Bosnia(Herzegovina(Czech(Republic(Estonia(Georgia(Greece(Hungary(Ireland(Italy(Macedonia((FYROM)(Norway(Poland(Portugal(Slovenia(Sweden(Switzerland(Summary(RelaGve(Risk(1.04((1.00M1.09)(    0.6( 0.8( 2.0( 3.0( 4.0(1.0(((((((0.3(((Atypical(nevi(≥1(RelaGve(risk((95%(CI)(Belgium(Bosnia(Herzegovina(Czech(Republic(Estonia(Georgia(Greece(Hungary(Ireland(Italy(Macedonia((FYROM)(Norway(Poland(Portugal(Slovenia(Sweden(Switzerland(Summary(RelaGve(Risk(1.16((1.05N1.29)(  0.6( 0.8( 2.0( 3.0( 4.0(1.0(((((((((LenGgines(RelaGve(risk((95%(CI)(Belgium(Bosnia(Herzegovina(Czech(Republic(Estonia(Georgia1(Greece(Hungary(Ireland2(Italy(Macedonia((FYROM)(Norway(Poland(Portugal(Slovenia(Sweden(Switzerland(Summary(RelaIve(Risk(1.13((1.00N1.27)(((((0.1((A.(Suspected(Melanoma(RelaIve(risk((95%(CI)(0.3( 0.8( 2.0( 3.0( 4.0( 8.0( 20.0(1.0((((((((((!!IntroducNon.	   Sunbed	   use	   has	   been	   signiﬁcantly	   associated	   with	   increased	   risk	   of	  melanoma	   and	   non-­‐melanoma	   skin	   cancer	   (NMSC),	   but	   its	   rela<onship	   with	  melanoma’s	  risk	  factors	  such	  as	  high	  nevus	  count,	  atypical	  nevi	  and	  len<gines	  (Figure	  1)	  is	   poorly	   studied.	   Euromelanoma	   is	   a	   skin	   cancer	   preven<on	   campaign	   conducted	   all	  over	  Europe.	  It	  oﬀers	  a	  once-­‐a-­‐year	  screening	  during	  which	  par<cipants’	  data,	  including	  sunbed	  use	  and	  phenotype,	  are	  collected	  via	  ques<onnaires.	  	  ObjecNves.	   To	   inves<gate	   the	   associa<on	   of	   sunbed	   use	   with	   nevus	   count,	   atypical	  nevi,	  len<gines	  and	  suspicion	  of	  skin	  cancer.	  	  Material	   and	   methods.	   To	   ensure	   reliability	   of	   the	   data,	   we	   deﬁned	   inclusion	   and	  exclusion	   criteria	   for	   countries’	   eligibility	   for	   the	   risk	   analysis.	   Mul<variate	   logis<c	  regression	   models	   (including	   age,	   gender,	   educa<on,	   skin	   type,	   family	   history	   of	  melanoma,	  personal	  history	  of	  skin	  cancer,	  any	  sun	  exposure,	  and	  any	  sunscreen	  use)	  were	  used	   to	  calculate	  summary	  odds	   ra<os	   (SORs)	  of	  each	  clinical	  endpoint	   for	  ever	  sunbed	  use.	  	  Results.	  Overall,	  227,888	   individuals	   from	  30	  countries	  completed	  the	  Euromelanoma	  ques<onnaire.	   Aier	   the	   data	   quality	   check,	   16	   countries	   were	   eligible	   for	   the	  mul<variate	  analysis,	  for	  a	  total	  of	  145,980	  par<cipants	  (64.8%	  females;	  median	  age	  43	  years;	  62.3%	  highly	  educated;	  28.5%	  skin	  type	  I-­‐II;	  11.0%	  ever	  sunbed	  use).	  Ever	  sunbed	  use	  was	  independently	  associated	  with	  suspicion	  of	  melanoma	  [SOR=1.13	  (1.00-­‐1.27)]	  (Figure	   2A),	   nevus	   count	   >50	   [SOR=1.05	   (1.01-­‐1.10)]	   (Figure	   2B),	   atypical	   nevi	  [SOR=1.04	   (1.00-­‐1.09)]	   (Figure	   2C),	   and	   len<gines	   [SOR=1.16	   (1.04-­‐1.29)]	   (Figure	   2D).	  Conversely	   no	   signiﬁcant	   associa<on	   was	   found	   between	   ever	   sunbed	   use	   and	  suspicion	  of	  NMSC	  [SOR=1.00	  (0.91-­‐1.10)].	  Conclusions.	  Indoor	  tanning	  is	  signiﬁcantly	  associated	  with	  well-­‐recognised	  risk	  factors	  for	  melanoma	  (including	  high	  nevus	  count,	  presence	  of	  atypical	  nevi	  and	  len<gines)	  as	  well	  as	  suspicion	  of	  melanoma	  within	  the	  Euromelanoma	  screenees.	  In	  order	  to	  reduce	  the	  prevalence	  of	  melanoma	  risk	  factors,	  avoidance/discon<nua<on	  of	  sunbed	  use	  should	  always	  be	  encouraged,	  especially	  but	  not	  exclusively	  for	  individuals	  with	  high-­‐risk	  phenotypes.	  Figure	   2.	   Forest	   plots	   of	   associaNon	   of	  suspected	   melanoma	   (A),	   high	   nevus	   count	  (>50	   nevi)	   (B),	   ≥1	   atypical	   nevus	   (C),	  lenNgines	  on	  back/chest	  (D)	  with	  ever	  use	  of	  sunbeds.	  	  All	   odds	   ra<os	   are	   adjusted	   for	   age,	   gender,	  educa<on,	   skin	   type,	   family	   history	   of	  melanoma,	   personal	   history	   of	   skin	   cancer,	  any	   sun	   exposure,	   and	   any	   sunscreen	   use.	  FYROM,	   Former	   Yugoslav	   Republic	   of	  Macedonia.	  	  Heterogeneity	   I2=11%	   (suspected	  melanoma),	  I2=0%	   (high	   nevus	   count),	   I2=0%	   (≥1	   atypical	  nevus),	  I2=68%	  (len<gines)	  for	  all	  countries.	  	  	  1In	   order	   to	   calculate	   the	   odds	   ra<o	   for	  Georgia,	   the	   model	   for	   this	   country	   was	   not	  adjusted	   for	   age,	   skin	   type	   and	   personal	  history	   of	   skin	   cancer,	   due	   to	   frequency	   of	  suspected	   melanoma	   being	   too	   low	   in	  exposed	  individuals.	  	  	  2A	   sensi<vity	   analysis	   for	   Ireland,	   the	   only	  country	   with	   a	   considerable	   amount	   of	  missing	   data	   on	   sunbed	   use	   (20.3%,	  Supplementary	  Table	  S2)	   found	  that	  the	  odds	  ra<o	  of	   suspected	  melanoma	  associated	  with	  the	   missing	   values	   was	   similar	   to	   the	   odds	  ra<o	  for	  exposed	  individuals	  [6.31	  (0.74-­‐53.71)	  and	  6.27	  (0.69-­‐57.27),	  respec<vely].	  	  	  3The	  odds	   ra<o	   for	   Ireland	  was	  not	   available,	  due	   to	   frequency	   of	   high	   nevus	   count	   being	  too	  low	  in	  exposed	  individuals.	  	  3 C	  A	  B	   D	  

Association of sunbed use with skin cancer risk factors in Europe : an investigation within the Euromelanoma skin cancer prevention campaign

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Association of sunbed use with skin cancer risk factors in Europe : an investigation within the Euromelanoma skin cancer prevention campaign

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