All Types Of Skin Cancer

good afternoon, or goodmorning or good evening, depending on where you'relistening from. i'm dr. john iskander, on behalfof cdc i'd like to welcome you to april's public health grandrounds. continuing education credits forpublic health grand rounds are available for physicians,nurses, pharmacists, health educators and other healthprofessionals. please see more at the grandrounds website. grand rounds is also availableon all of your favorite web and

social media sites.we have a featured video on youtube called "beyond thedata" which is posted shortly after the session.this month's segments features my interview with deputy surgeongeneral boris lushniak. we're live tweeting, ususe #cdcgrandrounds for all your tweeting needs.for those of you interested in related topics, many of thepeople involved in putting this session were also involved inwriting up an article recently published in the mmwr on thefuture of cancer screening.

please look for that online.today's speakers include not only the current deputy andformer acting surgeon general but an actual surgeon.i think that's a first. it's our pleasure and privilegeto work closely with our speakers to bring you thesesessions each month. i commonly introduce ourspeakers as public health heroes.in recognition of the coming may summer action movie season,you'll see that we have actually some superheroes in today'ssession as well.

we've partnered with the cdcpublic health library and information center to featurescientific articles relevant to the session, the full listis at cdc.gov/scienceclips.here is a preview of upcoming grand round sessions, pleasejoin us live or on the web at your convenience.it's now my pleasure to introduce admiral robin ikeda,deputy director for noncommunicable diseases, injuryand environmental health. thank you and good afternoon.we're delighted you could join

us this afternoon.skin cancer is one of the most commonly diagnosed cancers inthe united states, yet most cases are preventable.while rates of other cancers are decreasing, the rates of skincancer are increasing, creating a serious public health concernthat we cannot ignore. melanoma is one of the mostcommon cancers among u.s. adolescents and young adults.although those with lighter skin are more at risk, anyone can getskin cancer, and it can be serious, disfiguring and evendeadly.

ultraviolet or uv radiationis the most preventable cause of skin cancer.the most common types are strongly associated withexposure to uv radiation. tan skin is a sign of damagedskin, not health. when people tan or get sunburned, they increase the risk of getting skin cancer.there is no evidence that indoor tanning is safer than tanningoutdoors, or provides any protection from further sunexposure. indoor tan something riskybehavior, yet one out of every

three young white high schoolgirls reported indoor tanning in 2012.the surgeon general's call to action with a prevent skincancer was released last july and creates a plan for multiplesectors to take an active role in preventing skin cancer.as you heard, we're honored today to have the u.s. deputysurgeon general boris lushniak. schools and early learningcenters, colleges and universities, employers andemployee, health care systems, insurers and clinicians can alltake an active role in

protecting communities andindividuals from uv exposure. today you'll hear case studiesand examples of these policies and personal actions in thesession. today we'll hear aboutinnovative efforts at the federal, state and local levelthat are raising awareness about the increasing tide of skincancers. these efforts include bringingpartners together across federal agencies and in communities toaddress risk factors for skin cancer, intervene using proveneffective tools and accelerate

their progress over time.two of our speakers today come from heavily sun exposedstates -- arizona and texas, that recognize the need to takeaction against skin cancer at the population level.to reduce skin cancers in the population, people must get theinformation they need to make informed choices about sunprotection, policies must support these efforts, and youthmust be protected from the harms of indoor tanning.achieving these goals will not be a small task.it will require dedication,

ingenuity, skill, and aconcerted efforts of many partners in prevention acrossmany different sectors. many of these partners arealready involved but greater cooperationand support are needed to increase their reach of theseefforts. we must act with urgency to stopthe ever-increasing incidence of skin cancers in the unitedstates. thank you.[ applause ] thank you, admiral ikeda.our first speaker is meg watson.

skin cancer begins in thecells of the skin. there are three most commontypes of skin cancer, and in order of incidence those arebasal cell carcinomas, squamous cell carcinomas and melanomas.basal cell carcinomas alone are thought to be the most commontype of cancer. melanomas originate in thecells that make melanin, and it's the most deadly of thethree common types of skin cancer.skin cancer is associated with a significant public healthburden.

estimates for medical extendtours show nearly 5 million skin cancers are treated in the u.s.each year. about 65,000 malignant melanomaswere diagnosed in 2011 and about 9,000 deaths due to the diseasein that year. there are also about 3,000deaths due to non-melanoma skin cancers each year, includingsome deaths from squamous melanomas and other skin cancer.they do not collect information on the more common so incidencewill be presented here. this slide shows invasivemelanoma incidence data from

the national cancer institutesprogram. incidents from melanoma isincreasing since at least the 1970s.incidence rates are higher overall for males, but have beenincreasing consistently for both sexes.we've seen overall incidence roughly triple over the last twogenerations with an average annual percentage increase ofabout 3% each year. this slide shows aggregated dataon invasive melanoma incidence over a five-yearperiod from cdc's national

program of cancer registries andnci's s.e.e.r. program which covers the united states.it starts at about age 50, however rates among adolescentsand young adults are higher among females than males.melanoma is the second most common cancer among women intheir 20s, likely related to intentional tanning eitheroutdoors or indoors. you'll hear much more about thisproblem and how it's being addressed by subsequentspeakers. and skin cancer is costly.treatment for skin cancer costs

$8.1 billion each year in theunited states, and annual costs more than doubled between theperiods 2002 to 2006, and 2007 to 2011.genetics has a strong effect on skin cancer risk.having light hair and eyes, fair skin, skin that burns, orfreckles or certain types or a large number of moles increasesthe risk of skin cancer as does having a family or a previouspersonal history of skin cancer. although those with lighter skinare at higher risk, people with darker skin may often bediagnosed later, making it more

difficult to treat.this slide again shows data from nci and cdc combined and showsmelanoma rates by race and hispanic ethnicity.non-his panning whites have 25 times compared to blacks and sixtimes the rate of hispanics. rates are higher among males inall ethnicities except for blacks for which statistics arenot significant. these differences are primarilyrelated to differences in skin type.melanin gives skin its color and protective against uv radiationso darker skin has more

protection.it's important to remember there's wide variability in skintypes and sun sensitivity within racial and ethnic groups.despite the importance of skin type and non-modifiable riskfactors, public health efforts focus on uv radiation exposurebecause it's the most preventable cause of skincancer. between 65% and 90% of skincancers are thought to be caused at least in part by uvradiation. uv from sunlight is the mostcommon source of exposure but

some people are exposed toartificial sources of uv from cosmetic indoor tanning, medicaltreatment or less commonly occupational exposures.uv damages the skin cell's dna. the lag time between exposure touv and development of cancer is thought to be about 10 to 20years but in some cases this time period appears to be muchshorter. and uv varies by wavelength.uva penetrates more deeply than uvb and both can cause cancer.the term broad spectrum protection means products suchas sunscreen protect against

both types of uv rays.tans and sunburns are reactions to damage from uv.although tanning provides a small amount of protectionagainst future burns, it also indicates that damage hasoccurred. sunburns indicate cell deathoccurred. national surveys and researchstudies, sunburns are used as indicators of uv exposurebecause they take into account individual sensitivity to uvrather than just exposure time. rates of sunburn remain highwith about 37% of americans

reporting getting burned everyyear. and among those who reportburning, many get burned frequently defined here as fouror more times in the past year. uv damage adds up over time.sunburns and overexposure in childhood and in adulthood canincrease risk. it's not surprising that, withhigh sunburn rates there's room for improvement andsun protection. although 70% of adults reportalways protecting themselves from the sun, when outdoors formore than an hour on a sunny day

a closer look at methods ofprotection tells a different story.use of each individual method of protection is quite a bit lowerparticularly using a wide brimmed hat or long sleevedshirt. protection differs by gender.with women primarily seeking shade or using sunscreen and menwearing long clothing to the ankles as their most commonmethod of protection. national survey asking highschool students about sunscreen found that only 10% of studentsreported wearing sunscreen when

outdoors on a sunny day for morethan an hour, that's 13% of females and only 7% of males.unfortunately this is not the only behavior that puts youth atrisk from skin cancer. indoor tanning exposes users tointense uv to tan the skin for cosmetic purposes.this intense uv increases the risk of skin cancer.one study estimated that about 400,000 cases of skin cancer inthe united states could be caused by indoor tanning eachyear, including over 6,000 melanomas.indoor tan something common

mopping some groups.tanning rates are highest among non-hispanic white women andpeak age 16 to 25. almost one in three of thesewomen report indoor tanning in the past year.the food and drug administration warns against indoor tanning bypeople younger than age 18 and 11 states currently prohibittanning by minors. recent estimates suggest about1.6 million high school students younger than age 18 are tanningin the u.s. each year. so what works to prevent skincancer?

reducing overexposure to uvreduces rates of skin cancer in the population but how do we getthere? because of the long lag time andlarge populations required to detect cancer outcomeseffectiveness is usually measured by reductions insunburn or indoor tanning and increases in sun protection.based on the outcomes the community guide recommendedseveral interventions. multi-component community wideinterventions are defined as at least two interventionsimplemented in at least two

different types of settings, sofor example, a school sun safety education program combined witha mass media campaign in a community.the most comprehensive examples of this type are from australia.education and policy interventions have beendemonstrated to be effective in schools from early childhood upto eighth grade, as well as outdoor recreational andoccupational settings. the u.s. preventative servicestask force has recommended provider counseling aboutminimizing exposure to uv

patients aged 10 to 24.the task force currently found insufficient evidence torecommend provider screening for the general population, in otherwords, clinical examination of the skin in the absence ofsymptoms for patients at average risk.the task force is currently re-reviewing the evidence oncancer screening. time and cost are key barriersto assessing cancer outcomes but there are some new studiesregarding skin cancer screening which are going to be includedin the updated review.

based on the existing evidence,acting surgeon general boris lushniak issued a call to actionto prevent skin cancer last year july 29st, 2014.cdc worked closely with the office of the surgeon general todevelop the document. based on the current evidence,the surgeon general outlined five broad overarching goals toprevent cases of skin cancer. the first goal aims to increaseopportunities for sun protection while outdoors in settings likerecreational areas and schools. the second goal addressescommunications about skin cancer

prevention and the need toidentify and disseminate effective prevention messages.the third goal relates to policies across all levels fromfederal to state and local and it includes organizationalpolicies, as well as legislative.for example, school policies can help support skin cancerprevention in a number of ways. the fourth goal relates toreducing harms from indoor tanning and the fifth goalrelates to strengthening research and increasing ourunderstanding of how best to

prevent skin cancers in thefuture. thank you, and the next speakerwill be sharon mckenna from the arizona department of health.>> thank you, meg. it's exciting to be here todayto share with you my personal experience implementing sunsafety. i became a sun safety advocatein 2002 after my first melanoma diagnosis.clinical trial nurse urged me to contact the state health department. i told her after my diagnosis, iwas stunned to learn that

childhood exposure toultraviolet radiation has a huge impact on whether a person willdevelop skin cancer. i took her advice.i met with the health department and shortly after i was giventhe job opportunity of a lifetime to create and implementa sun safety program. it was a grassroots door-to-dooreffort starting with my then kindergartener school.i called and asked for ten minutes to speak about sunsafety during a staff meeting. i phoned school after schoolrequesting the same thing, and

those ten-minute talks led to anhour-long presentation, and today i can give about 300school presentations across our state.i get paid to obsess about my affliction.after 31 biopsies, lesions, and diagnoses of all three forms ofskin cancer, i am one among millions of skin cancer patientswho likely had no idea that skin cancer is the most common yetmost preventable of all cancers. arizona, where i'm from, if acountry would rank number two in the world in skin cancerincidence and we have over 300

sunny days.our warm climate allows us to wear t-shirts and shorts in thewinter resulting in year-round exposure than in colder climates. we were able to bring attentionto sun safety which enabled our agency to make it a toppriority. every time i go out, everyoutreach activity performed, every e-mail i send, everypotential partner i approach is asked to share a sup safetymessage, embrace it, and adopt it.as meg mentioned, state cancer

registries collect melanomadata. arizona's invasive melanoma rateis somewhat higher than the national rate but we in thefield thought our rates were a little bit lower than weexpected so a melanoma task force was formed to compare thenumber of cases received by our registry with the number ofcases logged with an individual dermatology practices bypreparing cases recorded to cases treated, we found anunreported rate of 70%. now we are collecting the datafrom the state's 531

dermatologists.we've revised the melanoma reporting form.we created a monthly newsletter focused on helping providersimprove reporting requirements, and once that data is cleaned,we can map and rank arizona in terms of highest to lowestmelanoma rates and while we can't yet pinpoint what causesone neighborhood in our state to have triple the melanoma ratesof another we can reach people in all 127 census blockneighborhoods simply by reporting our findings to themedia, so that everyone can

learn how to protect themselves.we are proud that arizona is the first state to pass a sun safetyeducation mandate. over 700,000 students in 1,100 kthrough eight schools learn how to protect their skin andprevent skin cancer. private and non-traditionalschools can also use the program voluntarily and we've formedpartnerships with over 250 organizations.success in this state recently led to programs expansion tochild care sites. under our empower program over2,400 child care providers are

required to meet our sun safetystandard with detailed protocols for applying sunscreen andproviding outdoor shaded play areas.this program reaches 20,000 children ages birth through 12and the great thing is, this is consistent with the communityguides, community preventative services guide and the surgeongeneral's call to action to prevent skin cancer.we are expanding through the sectors.so our initial goals were to protect kids and reduce uvexposure.

we adapted the free epa sun lifeprogram with easy-to-use curriculum activities that havebackgrounds in science, math and social studies, that average 20minutes and are categorized by grade level.we modified the curriculum to meet our state standards, wrotetip sheets and created a physical education module toshow kids how to be active outside and sun safe.we're turning sun safety messages into daily and lifelonghabits. sunburn and suntans can causeskin cancer so use a broad

spectrum sunscreen and lip balmwith an spf, sun protection factor of 15 or higher, protectyour eyes with sunglasses, wear a hat with a wide brim, seekshade, and under a tree, awnings or indoor especially during peakmidday sun. in arizona some offices havebuckets of umbrellas so you can use them walking outdoors orfrom building to building to a meeting.we ask new schools be built to optimized shadows and shade castespecially during midday lunch recess and some tvmeteorologists announce the uv

index which tells us how muchprotection is needed to prevent sunburn and suntan on any givenday, and of course, avoid sun lamps and tanning booths.artificial sources of uv are just as dangerous as the sun'snatural radiation. simply, keep your skin the colorit was born in. we're helping schools expandtheir commitment the to sup safety with strong policies.we provide a sun safety policy template to our 2,800 k through12 schools so they don't have to create something from scratch.our policy, not only allows but

encourage sun safety practicesbecause in some schools wearing hats and using sunscreen is notallowed. remember the easier you makeimplementation for the people you're asking to do it, thesooner it will occur. we reiterate the communityguide's recommendations primary safety school education is veryeffective in increasing sun protection among kids.in fact our arizona study of 281 k through eight school educatorsduring a seven-year period found a 63% increase in studentability to provide examples of

the harmful effects of the sunon skin, and that ability to provide examples is up 25% sincewe first asked the question in 2007.and 85% of our respondents cited arizona as their primary sourceof sun safety education. as mentioned we offer a policytemplate and this is just a brief excerpt, just the firstparagraph of a two-page fill in the blank policy that schoolscan use, adopt or expand on if they wish.and we always recommend in creating a sun safety policythat you use the trusted

educator and child care sourcesthat limit, that promote limiting sun safety policiesamong children. so phase two, proliferate.the more successful you become, the more partners you'llattract, the more people you can reach.in 2003, the phoenix zoo allowed us to provide animal themed tipsheets to patrons that evolved into sun safety murals onbathroom walls and thousands of students this summer are able toget sunscreen and wide brimmed hats as part of their sun safetyuniform.

skin cancer has become a topfive priority in programs i never dreamed possible, simplybecause i asked, came to the table, armed with somecompelling facts, and promised that we would support theirefforts. new empower schools program isbeing piloted for k through 12 schools who received usdanational lunch services and this might be an opportunity for yourstates to someday incorporate sun safety.supply people and partners with subject matter.we tweet, blog, provide updates

on trends and policies much fromthe brilliant collaborators we work with here at cdc and aroundthe world. we've learned a lot of lessons.i believe no only means not right now.keep plugging away. measure the processes andoutcomes of your skin cancers.i initially thought that contacting schoolsuperintendents would open the doors to sun safety education,but quickly found that approaching individual schoolsyielded much better results, and

one sun safety assembly couldlead to a statewide version of school district training.use the tools you already have at your disposal and identifythe data your state collected. for example cancer registrydata, behavioral risk factor survey surveillance data thatsometimes reveals adult sun behaviors.policies can be effective at even the smallest level.start with one intervention, one high risk group you have thegreatest chance of reaching and partner widely outside publichealth sectors to reach people

who don't yet know that sun andsun lamps can cause skin cancer. i remind students at the end ofevery assembly, you are my first generation of sun safe kids.now you know how to protect your skin and prevent skin cancer.tell everybody what you've learned and be a role model.tomorrow, i hope you'll e-mail the grand rounds links to yourfriends, family, school nurse, and anyone you think couldbenefit from it, with one short sentence that says "i think thisinformation would be wonderful to include in the upcomingnewsletter or blog."

i thank you for sharing the sunsafety message and letting me talk today. our next speaker isdr. jeff gershenwald. [ applause ] good afternoon.i'm jeff gershenwald. i'm a surgical oncologist andmedical director of the melanoma and skin cancer center at theuniversity of texas and cancer center in houston, texas.in addition to an active clinical practice focused onmelanoma i also lead and

participate in research onmelanoma. i'd like to introduce you to arelatively new team science research program at md andersoncalled the melanoma moonshoot. m.d. anderson cancer centersmoonshot program aims to accelerate the pace ofconverting scientific discoveries into clinicallyimpactful advances that reduce cancer deaths.i have the privilege of co-leading with mike davies, amelanoma medical oncologist and physician scientist.we work with a large research

team that represents manydisciplines. melanoma was chose as one ofm.d. anderson's moonshot programs because we have a verylarge clinical and research program and a clear vision withdetailed goals and implementation plans.programs and leadership were considered to have significantpotential to leverage advances and scientific knowledge towardsmaximal impact and making a difference for our patients andthose who are not yet patients. more specifically, we know thatwhen detected early, melanoma is

treatable and often curable butoutcomes can vary widely across patients.for patients with advanced disease there's been poorlong-term survival. nonetheless, recent advanceshave transformed our understanding of melanomamolecular biology and immunology and these scientific advanceshave opened the door to targeted and immunotherapies alike.there's clear and compelling epidemiologic evidence that uvradiation both from the sun and from indoor tanning devicescontributes to melanoma risk.

the role of uv is also supportedby recent research on genetic mutations in melanoma, researchadvances include work with the melanoma cancer genome atlasprogram which i've had the privilege of coleading over thelast five years. recent studies from the programoverall have shown that melanoma has the highest mutation rateany of cancer analyzed thus far to date.this cancer plot shows how often mutations occur.the plot shows about 40 tumor types arranged with increasingfrequency according to the

overall frequency of somatic ortumor-based mutations. melanoma is at the extremeright. in the plot, each dot representsthe frequency of mutations in an individual melanoma tumor.taken together we can see that melanoma has the highestfrequency of mutations across this enter panel.please note the large mostly yellow box below melanoma.it is color coded to display the type of mutation.in this graph yellow indicates most of the yellow are c to t,transition plan, classic by

associated with a uv signature.this provides further evidence for the role of uv radiation inmelanoma. the goals of the melanoma moonshot are to reduce the incidence and increase the proportion ofpatients diagnosed with early stage potentially curablemelanoma to personalized manage the strategies in clinicallylocalized melanoma and to improve long-term diseasecontrol and survival in advanced melanoma through personalizedtreatment approaches. there are two initial flagshipprojects.

the first involves primaryprevention of melanoma through uv radiation protection andyouth led by mary tripp, susan peterson and ellen gritz ofthe department of human sciences.the second integrated analyses and targeted of key cancer genesand better personalized care and increased long-term survival inmelanoma. i lead this latter project withmike davies. we'll focus on the melanomaprevention flagship, which focuses on working with youthand increasing their use of uv

protection, decreasing their sunexposure, and decreasing their tanning behavior.these objectives can achieve the long-term goal of reducing theincidence of melanoma and the project includes activities tosupport, facilitate and evaluate legislative activities andmaximize reach and impact of evidence-based interventions.the prevention flagship will initially focus on primaryprevention of melanoma across the age continuum.initial efforts are dissemination for pre-k withsimilar activities planned for

kindergarten through secondgrade. uv phototography protocol is being targeted to middle school students that we'll talk aboutin just a moment and soon embark on indoor tanning facilitylegislation, compliance and research efforts that as notedby meg targets behaviors common in high school.finally, i'll introduce a skin cancer prevention toolkitinitiative that's being developed for colleges anduniversities. the aim of the preschoolcurriculum is to teach children

about sun protection and promotesafe behaviors in an effort to reduce the child's chances ofdeveloping skin cancer later in life.sun protection is actually a superpower.the central idea is the superhero characters travelaround the world and each has a sun safe superpower to protecthim or herself against the harmful effects of the sun'srays. in the center here is ray, andhe's part of ray and the sunbeatables.ray is the leader, he's in the

center and has a superpower ofshade, and he also knows when it's safe to be outdoors.ray wears the magic watch that reminds him to be superprotected from 10:00 a.m. to 4:00 p.m. when the sun's raysare most harmful. left to right, chloe, serena,stefan and hannah have superpowers of protectiveclothing, sunscreen, protective sunglasses and protective hats.our strategy includes the recently announced collaborationwith the catch global foundation an acronym for coordinatedapproach to child health.

catch includes programs forearly childhood educational and afterschool components.the original catch study was the largest school-based healthpromotion study ever conducted in the united states.catch has a history of 25 years of research and real worldimplementation, and currently reaches approximately 50% oftexas school districts. we're also expanding ourcurriculum for k through second grade.consistent with the surgeon general's call to action goalsthe curriculum emphasizes

providing individuals with theinformation they need to make informed healthy choices aboutultraviolet radiation exposure. we have aligned these activitiesto the state's standards as well as the common core and nationalstandards. as a component of the melanomamoon shot m.d. anderson informs legislators in texas about thelink between indoor tanning and skin cancer.in 2013 texas legislators passed sb-329 which prohibits indoortanning bed use for persons under 18 years of age.texas was the fourth state in

the united states to enact sucha law. and this was really a tremendouseffort collaborative across the platform at md anderson,government relations team, multiple medical societies,foundations and several of our patients.by 2014, there were 11 states that had passed under 18 tanningbed prohibitions, and were actively involved now inproviding technical assistance and education across otherstates that are considering similar legislation.md anderson has continued to use

its experience to help insupport similar efforts in nine other states to date from coastto coast, including arizona, where sharon comes from.understanding how the legislation is implemented andhow well tanning facilities comply with the ban is acritical next step. we'll begin a new study todetermine the proportion of texas tanning facilities thatcomply with sb-329 soon. we'll be examining complianceamong 1,100 facilities licensed by the texas department of statehealth services.

there have been some recentchanges in the regulation of indoor tanning devices in theunited states that also provide some important opportunities forprevention. the fda recently changed theclassification of indoor tanning devices from class one devicesshown here prior to may of 2014 to a class two device as of mayof 2014. this is remarkable, becausepreviously as you can see here, tanning beds were in the samecategory as tongue depressors and elastic bandages likeband-aids.

changing the classification toclass two devices has meant that tanning beds are now includedwith x-ray machines and other specialty uv lamps fordermatologic disorders. the fda issued a black boxwarning required for use on tanning devices that states"this sun lamp product should not be used on persons under theage of 18 years." to leverage these preventionopportunities we're reaching out to the medical community onissues related to indoor tanning.one example of this is a

recently published editorial inthe march issue of "the annals of surgical oncology" highlightsthe important of educating policymakers of the harmfuleffects of uv exposure for youth and highlight the fda's recentblack box warning. can we improve sun protectionadolescents? recent search has examinedappearance focused interventions to reduce indoor tanning and sunexposure behaviors. uv photography is used as anappearance focus intervention to increase sun protection behaviorand decrease sun bathing and

indoor tanning in adults.moon shot will be done for adolescents in middle school andthe intervention involves taking a standard and uv photo of theface, using a rah with a uv filter that provides an imagerepresentation of skin damage due to uv radiation exposure.we'll study whether the intervention is effective inincreasing adolescent sun protection behaviors and acts todecrease tanning behaviors and sunburns.i also want to mention work related to college anduniversity campus.

the skin cancer prevention toolkit is in development and through a partnership with theamerican cancer society cancer action network, our goal is tomake advances in eliminating indoor tanning devices fromcolleges and university campuses.the tool kit will provide resources and tools for highereducation administrators to adopt skin cancer preventionpolicies and commit to eliminating student use ofindoor tanning devices. the toolkit will include acomprehensive collection of

facts, policy templates,education and resources to implement skin cancer preventionefforts on campus. i'd like to acknowledge themultidisciplinary team that is such an integral part of ourmelanoma moon shot. liz burton is our scientificproject director. mary, susan and ellen led andcurrently lead our prevention flagship, payal and mandy jo onthe right are the program managers and ernie hawk, markmoreno lead the moon shot prevention and control platform.finally as i thank you for your

attention i acknowledge thegenerous support of the multiple individuals who thus far madethe melanoma moon shot possible. i'd like to now introduce deputy surgeon general boris lushniak.>> thank you, jeff. i'm here to be the closer.it's kind of interesting how this is very much akin to whatgoes on with the issuing of call to action.meg was very kind in terms of saying, well, cdc approached theoffice of the surgeon general and we kind of helped out.let me tell you the truth.

right?the truth with surgeon general's reports and calls to action isall, if not most of the work is done by others.that's the truth. and in this case, we have anincredible partnership with cdc in issuing this call to action,but i give kudos to meg, to the whole team that worked on thiscall to action, because ultimately it's akin to what wehave in the football game. i'm not a big sports guy but inthe football game, right, when you start advancing the ballfrom your own 1 yard line, all

this work is done.and that's the way i view call to action.all this work is done in this case by cdc, by several of ourother partners i'll go through quickly, but at the end theybring it down to the 1 yard line and then the fancy guy in thefancy uniform gets to score the touchdown.right? that's the photo image, and atthe end of that, it's back to the concept of the surgeongeneral's office being the bully pulpit, right, that we come outthere in the uniform and say,

listen, america, this is whatneeds to be done with skin cancer prevention.photo-ops are taken, you get the interviews about but i'm thefirst to acknowledge that a lot of the work, the grunt work, thepushing of that ball ahead took place by many others.so what do we know? i'm the finisher here in thisesteemed panel as well, so i'm at the 1 yard line, taking theability to put all this together yet again, lucky guy in theuniform. but in fact, what we epitomizehere in front of you is in fact

how we advance the ball inpublic health. notice the partnerships here atthis very table. it started out with the feds,the cdc approach. we ended up at the state andactivist approach, and then the world of medical prevention andacademic approach to this, and then we bring in the bullypulpit, the ability for the surgeon general's office to berepresented and say here's where we should be heading.so it is a major public health problem.we talked already about the

increasing disease burden, thecosts, the rates of skin cancer being a problem, a public healthproblem in this united states, one that we can't ignore, andonce again, the ability for us to put all this together to saynow's the time to advance it. we're in the 21st century.we're discussing with jeff earlier today saying in the 21stcentury if there's anything that we've learned is the ability towe will do better in diagnostics.we will do better in therapeutics but ultimately theanswer to so many of our

national problems including skincancer is the prevention side of the house.that's where we have to get better and how are we going todo this? through these types of partner-ships, community partners, business, agencies, individualsuniting around a common cause. now this document which i'llrefer to several times, the call to action, why did it takeplace? you know, when i go back in timeand at that meeting dr. howard ko, the assistant secretary forpublic health by the way a

person who has dermatologicaltraining and interested in the subject matter, in the room isthe deputy surgeon general who happens to be a dermatologistand interested in this subject matter and an interested partyin cdc and we walked away from the meeting two plus years agonow saying we can do this. as happened that deputy becamethe acting and things moved much more quick will you but what itis, is a call to action. i love that term because it'snot a surgeon general's report. it's not just coming out theresaying here's the facts.

it's in essence saying we havemore work to do in this arena, a science-based document tostimulate that action nationwide to solve this problem, it raisesawareness because as brian williams, now a controversialfigure, on the "nightly news" that night of the releaselooking sternly into the camera, a tanned brian williams mindyou, and said these words "in the 143-year history of theoffice of the surgeon general, this has never happened."what happened was, an awareness. it's not like we changed theworld by putting out the

information the call to action.lot of this was already known. it's the fact that it ended upin the hands for that last yard for a message to come from amessenger that, for the longest time, was not talking about thisissue. yes there's a million issues inpublic health we could talk about but that was all abouttime and place. in the 14 -year history of theoffice of the surgeon general this has never happened, soprovide clear action steps to move forward on the subjectmatter.

now the partnerships that existout there again, government wide and beyond government.an important role here is the national council on skin cancerprevention that brings multiple organizations together, thatwaves the flag of skin cancer awareness and prevention, andpartnerships with groups like the american cancer society, theamerican academy of dermatology, and now after the report showedeven more so the important impetus that the work is notjust done by the feds here. long ago we've gone beyond thecensus, we're the feds, we can

do it all, no.nothing moves in public health until we establish thosepartnerships and many of our partners are shown here on thisslide. it begins at the local level.one of the first things i did after the issuing of this reportis we went down to do a meeting, down in new mexico, and outsideof albuquerque or in albuquerque bandeller elementaryschool was a sense of what could be done.this was much like your story, right?it was the sense that at an

activist level, it was parentsyears ago saying we have an issue in new mexico and our kidsare playing in these areas that don't have shade.and yes, there was resistance. yes, there was this, you know,inability to make things happen quickly, but ultimately ithappened. now you have this whole schoolthat's really dedicated to teaching kids about playing isimportant, being outside is important, but taking care andpreventing damage from ultraviolet radiation is just asimportant.

you know, there's almost a riteof passage in this student population as newkindergarteners would come in, the older kids, right, the bigkids on campus, the sixth graders would turn to theyounger kids and they would be the ones issuing the sunprotective hat. it was welcome to the school,this is what we do here, and i love this photograph, becausepartially you would say as a photographer, oh, there's toomuch shade in that photograph, but in fact it's shady for areason, folks.

and notice that the only personnot fully protected is the acting surgeon general at thetime, he has a short sleeved shirt on and not a veryprotective head cover. so what do we do?in terms of the strategies we heard from meg earlier todayabout the strategies, in terms of call to action, what do wedo? we talk about what we've donealready, incorporate sun safety education policies in school,support that shade planning in land use development.yes, this is where groups like

architects and planningassociation and parks and recreation people play a role inpartnerships and public health. yes, i grew up at niosh and inthat world of occupational safety and health there's a roleof protecting outdoor workers from that very same exposure andcertainly looking at the indoor tanning laws as described it's akey feature. we have an industry out thereselling a known carcinogen to a vulnerable population.what the hell are we doing about it?right?

what are we able to move aheadon in terms of protecting people, providing to them theright information. i'm not here to overregulateeverybody but at the end of the day, how many of those youngkids who are going to tanning booths realize that this is aknown carcinogen that will be problematic?and certainly providers, their role in terms of counselingpatients and hopefully making break-throughs with furtherinformation about screening, and its ability to play a role interms of prevention.

so millions of teens areexposing themselves to this unprotected ultravioletradiation and yes, there are changes in motion, world healthorganization 2009, this is a known carcinogen.we heard about the fda changes in terms of their regulatoryapproach as a class two device. we certainly have interest incongress, right, looking at groups that exist out therethat, in fact, are supporting an exposure to a known carcinogen.let's be honest here. you know, none of us volunteersto say hey, listen, i want to go

out this weekend and get asunburn. right?nobody says that. sunburn is bad, and yet how manycircumstances is it, you know, i was going through this earlierwith john on the vital signs videotape today, how many timeshave we returned from a vacation.you look great, you look tanned. in essence, tanning is a sign ofskin damage. and you look at the concept oftanning, whether natural light or artificial light, it is beingcondoned.

here is an example, at unc, 26%of chapel hill, north carolina, apartment complexes provideindoor tanning facilities to their renters.we've made headway in smoking, no smoking allowed in thebuilding, right, because that's a known carcinogen, secondhandsmoke but i have a tanning booth here, here!enjoy! to some extent we changed thesocial norms on smoking and the same thing needs to take placewith other known carcinogens. certainly positive is that ratesof indoor tanning have been

falling, 2009-2013 we've seensome declines. our hope is that we see effectfrom the increased awareness, certainly we look back at 2009and realize that when we look at indoor tanning restrictions forthose under 18, there was only some restrictions in a couple ofstates. we moved to 2012 by 2012,california became the first state to prohibit indoor tanningfor all minors younger than 18. vermont implemented an under 18ban in that same year, and then we move ahead now to 2014 and'15, note that blue is good

here.42 states implemented new laws or strengthened existing lawsabout indoor tanning amongst those minors.so in essence, we are pushing ahead and making this betterfrom a policy perspective, and how is that then translates toan effect on health? we know in states that havethose multiple youth restrictions with youth accessrestrictions the odds of indoor tanning among teen girls were42% less and our hope is that's going to be translated to adecrease of that burden of

disease.and still, we still have this concept of the social norms,even beyond the indoor tanning, more than one in three americansreport getting sunburn each year.who here got sunburned in the last year?raise your hand. guess what?the deputy surgeon general did, too, so i blew it, right?i blew it. but the reality is that's not agood thing. we have to have that sense ofawareness when we're outdoors,

and we condone from the oppositesurgeon general, go out, have a good time.it's about physical fitness, it's about getting outdoors,it's about bicycling and kayaking and swimming andrunning and walking, but protect yourself from that knowncarcinogen, and certainly when it comes to indoor tanning, onceagain, we have to look at it for a fact.it's an industry that is selling a known carcinogen.so overall we still have a lot to do in the realm of healthcommunication and health

education.so the next steps. we continue on this pathway,using the call to action. i ask you all, look it uponline. look through it.implement it into your own lives.certainly we at cdc have to be those examples for a healthylife, an active life, but a healthy life.comprehensive community-wide efforts to prevent skin cancercan work and with adequate support and a unified approach,we will be successful.

and we look at success storiesout there, right? we looked at the ability forarizona to turn the tide. we looked at the ability form.d. anderson to be able to implement laws within the stateof texas. we look internationally atcommunity programs within sunsmart in australia shows thatskin cancer prevention saves lives and saves money.every dollar invested in sunsmart australia saves morethan double in health care costs in that nation.so i finish where i started.

right?the guy in the uniform, passing this message through on thatlast 1 yard line. i thank you first and foremostfor your attention for being here.i thank you for organizing all this, cdc, but most importantly,the message really is, take care of ourselves.summertime, it's a beautiful spring day here, summertime isaround the corner, just be careful with your skin, and oneof the images i didn't portray here but spent two monthscommanding our monrovia medical

units in liberia and one of thephotographs i have is in the midst of the ebola crisis,right, our officers go into the hot zone fully covered,protecting themselves against this microbe, this deadlybiologic agent. and that's not how i want themto protect themselves against ultraviolet radiation but at thesame time, the other imagery i have is of those same officersin the very hot liberian sun, putting on their sunscreen.yes, rolling down their sleeves on their field uniforms.yes, wearing the goofy booming

hats which provide shade.that's the image that at the same time you protect yourselffrom ebola, you're also protecting yourself fromultraviolet radiation. it is doable by all of us.i thank you so much for your attention.[ applause ] i changed the slide.>> thank you, admiral lushniak. i want to open the floor forquestions. i think we've got about fiveminutes if you're in the room or online.please remember to keep your

questions brief so we have timeto answer as many questions as possible.>> we have a question from our online audience for admirallushniak. "you mentioned that tanned skinis a sign of damaged skin and yet artificial tanning hasbecome a part of societal norms. what can we do individually andas a society to change the norms and behaviors?">> you know, to a large extent we almost have to look back atthe tobacco situation. what helped us with tobacco withsocial norms was in fact what?

the messaging of secondhandsmoke when it became a bigger issue.when you light up, you bother me.i don't think we'll see that help coming out of the skincancer world. i think part of it is the ideaof, from a health communication aspect and health literacyaspect, we throw in the issue of disparities, how do we getmessaging out when things are not good for people, and i thinkit really, that's the approach we need to look at this, it's ahealth communication endeavor,

how do we sell this idea this isa known carcinogen, from several perspectives.we know certainly in the teen and young adult population theconcept of skin cancer is not necessary.we've tried this with tobacco. you'll die of cancer, don'tlight up. that message doesn't work bututilizing other effects which is, everyone's deathly afraid --so why do you tan? i have two daughters.couple weeks ago we're vacationing in key west, both ofthem are lying out "but dad, we

want to look pretty because theprom's coming up." right?even the acting or the deputy surgeon general has that issueand ultimately, i'm still battling that, but the sense is,guess what? you know, this prettiness"prettiness" in the short run, i'm not bringing out the cancerthing yet but i'm saying you want to have really ugly skin?it's going to happen quickly. you want to be wrinkled andappear older than you are? my younger child bought off onthis, she is proud her skin is

actually very pale and prettyand i'm working on my older one, so when you figure it out, letme know. do we have any otherquestions? yes, another question fromour online audience, "if you build a slow tan using thetanning bed so that you won't burn when outside, is that worsethan burning?" i'll tackle it initially andmaybe we can go to -- you know the reality is that this idea ofhaving a protective tan, so it was common for a while there,i'm not sure how common, i'm

heading off on this cruise, i'lldo a few sessions so that i don't burn.yes, there is a protective effect.the spf factor of a tan is on the order of two to six.so even though you think you're out there protecting yourself,the reality is you're just allowing yourself to actuallyhave excessive ultraviolet exposure even more.you still can break through with a burn based on exposure andgives you this false sense of awareness i'm fully protected.you're not protected.

you're protected when you're inthe shade enjoying that cruise, when you're putting onprotective clothing while enjoying that cruise, whenyou're putting on the spf factored sun broad-based, sunprotective products, right, so there is a way to have fun andyet not have to subject yourself to known carcinogen.>> next question, i see a question in the room.>> yes, hi, thank you. so it does seem like the beautyculture specifically with teenaged girls is going to beone of the hardest to combat.

i was guilty of being one ofthose teenaged girls going to prom.has there been any movement in promoting alternatives, so inpromoting spray tanning or any kind of products that sort offake the tan but are safer, and do we know whether or notthey're safer? so the fda regulates theingredients that are in spray tans but they're not used to be inhaled. if you've ever been in a spraytanning both, i haven't, but i understand it's very difficultto avoid inhaling those so we

cannot recommend that as analternative. i should also say that althoughwe don't specifically recommend it, there are products on themarket which can be applied directly to the skin, you know,diy, over-the-counter, which may be an alternative for somepeople. and i think there's also alittle bit of debate over do we recommend alternatives or do wework on sort of changing social norms so we're comfortable inthe skip that we're in. another one from our socialmedia audience.

it was mentioned that screeningis not recommended for the general public.should it be recommended for individuals with a large numberof risk factors such as pale skin, family history, and thehistory of many sunburns? that's a great question toask your family doctor. i'm going to step into thisone, all right? so far, u.s. preventativeservices task force is looking at data, right?as a dermatologist, right, or as a surgical oncologist, we lookat data and say okay, it hasn't

been proven to be cost-effectiveto have everybody screened, and yet, you know, wearing my otherhat i'm a member of the american academy of dermatology thatevery year conducts cancer screening as part of theircommunity engagement. i, for the longest time when iwas at niosh in cincinnati did annual screening within ourfacility there, and so the idea is that, you know, we realizethat we're waiting on data. the u.s. preventative servicestask force is looking at the recent data from germany on thisand our hope is there will be

some modifications on thescreening concept. until now, because we do believein the u.s. preventative services task force and its highcriteria of proving what works and what doesn't, what it saysabout general screen something inconclusive.what it says about counseling is conclusive for specific agegroups and specific fair-skinned populations.in the clinical world, what you'll see is someone who hashad a preskin cancer, for example keratosis, usually thereare multiple, someone who had a

basal cell, squamous cell ormelanoma is often time counseled by their physicians to followup. there's two roles of sort ofroutes of following up. one is the cell screening, whichis all of you here should be doing that, there is no economiccost associated with that, there is no sense of, you know,reimbursement, no sense of insurance cost, which is get toknow your bodies. get to know your skin.if you have somebody who is not, where it's not problematic forthem to check you out, if you

know what i mean, have them helpyou look at the areas you can't see.if not, strategic use of mirrors is great, and all you're doingin this case is, if there's anything that looks kind ofweird to you, note it. and there's two routes.take it to your physician, to your health care provider andsay hey, listen, i noticed this spot, or if it's been there fora while, take a photograph of it.everybody's doing selfies. do selfies of your lesions,right, and monitor it yourself,

right, which is you're lookingfor changes, changes in size, shape, color, or symptomsassociated with it, signs associated with it.so we have a burden here as well, but certainly anybody whohas had a history oftentimes will be consulted, follow upwith me, six months, a year from now, and in the meantime monitoranything. i'd like to thank ourspeakers/heroes one more time. [ applause ]and all of the material associated with this sessionwill be posted on the web within

the next 72 hours or so, andplease join us next month for the next session of cdc publichealth grand rounds.