The epidemiology of melanoma in young adults

Abstract

The incidence of melanoma is rising steadily around the world, with varying mortality trends among different populations. Particularly, incidence rates among young adults, below age 40 years, have increased dramatically in the past decades. In young adults, the gender predominance is switched, with the highest incidence occurring in young women. Multiple risk factors are associated with higher risk of developing melanoma. Intermittent sunlight exposure and use of tanning beds early in life increase significantly the risk of melanoma. The prevalence of tanning bed use among young women and adolescents is increasing continuously. This trend may be associated with the increase in melanoma incidence among young women. Efforts to implement new active interventions that will increase public awareness of melanoma and the risks of tanning bed use are crucial; regulations on tanning bed use especially among those underage should be implemented.

Although overall cancer incidence in the USA has annually declined for the past decades, the incidence of melanoma among men and women has increased rapidly and steadily [1–3]. According to estimates from the WHO, 208,251 new melanoma cases were diagnosed around the world in 2010 and with current trends, 233,648 new cases will be expected in 2015 [201]. In the USA, melanoma is the fifth most common cancer in men and the seventh most common cancer among women [1]. The American Cancer Society estimates that 76,690 new melanoma cases will be diagnosed in this country during 2013 (Table 1) [1]. In developed countries, the incidence of melanoma has increased faster than any other cancer in the last 50 years [4–10]. Melanoma has become a worldwide health concern due to the poor prognosis of advanced disease, with one person dying every hour and 9480 deaths estimated for 2013 in the USA [1,11]. In 1935, the lifetime risk of an individual in the USA developing melanoma was 1 in 1500; by 1980, the lifetime risk had increased to 1 in 250 [12]. With the steady increase in rates, currently 1 in 35 men and 1 in 54 women in the USA are diagnosed with melanoma during their lifetime [1].

Table 1.

Melanoma in the USA during 2013.

New cases	76,690
Men	45,060
Women	31,630
Deaths	9480
Lifetime risk
Men	1:35
Women	1:54

American Cancer Society estimate statistics for melanoma in the USA during 2013.

Data taken from [1].

Overall, melanoma risk increases with age and is greater in men and white populations [11]; however, recent reports have shown dramatic increases in incidence of melanoma among young adults with higher incidence in women among this age group [13–15]. When compared to all-cancer incidence rates by age group, the proportion of melanoma peaks between 20 and 40 years of age and then decreases [16]. In adults under 40 years old (hereinafter called young adults), melanoma accounts for over 11% of diagnosed cancers and is the second most commonly diagnosed cancer after breast cancer [13,14]. This increased incidence may be attributable to several causes, including enhanced public awareness, earlier detection and changes in natural and/or artificial UV radiation exposure. This article reviews current knowledge of the epidemiology of melanoma, with particular emphasis on the young adult population from the USA.

Incidence

The dramatic increase in melanoma incidence throughout the world during the last six decades has been well established [17], with incidence rates varying greatly between countries. Currently, Australia has the highest incidence rates in the world with 49.8/100,000 melanoma cases reported annually and a 1 in 17 risk of developing melanoma by the age of 85 years [18]. In the USA, it is estimated that 45,060 men and 31,630 women will be newly diagnosed with melanoma in 2013 [1]. Based on current data from the National Cancer Institute Surveillance, Epidemiology and End Results (SEER) program, the annual age-adjusted incidence rate of melanoma in the USA is 21.1/100,000 [202], increasing from previously reported rates of 19.2/100,000 in 2006 [19]. In the USA, melanoma incidence rates have increased steadily over the last decades increasing by 270% from 1973 to 2002 [11], far surpassing the rise in the incidence rates for most other cancers [6]. Current reports estimate a 2.6% annual increase in incidence from 1975 to 2010 [202], comparable to the 2.3% average annual change observed in Australia [18] and suggesting a worldwide phenomenon. Among young adults, similar trends are observed. In England, the incidence of melanoma among 15–24-year-olds doubled from 10.0 to 20.2 cases per million during the period of 1979 to 1997 [20]. Reports from Northern England show similar trends in incidence rates, particularly among young adult women in which the incidence of melanoma increased at an average annual rate of 5%, rising from 8.3 to 30.8 cases per million during the period of 1968–2005 [21]. However, melanoma incidence, mortality rates and data availability vary significantly between European countries [22]; but consistently across the world white populations have 10-times the risk of developing melanoma than Asian, black or Hispanic populations [11].

Published data from the SEER program show that the age-adjusted annual incidence rate for young adult women under 40 years old in the USA has more than doubled from 5.5/100,000 in 1973 to 13.9/100,000 in 2004 [23]. In young men, annual incidence rates increased from 4.7 cases/100,000 persons in 1973 to 7.7/100,000 in 2004 [23]. Recent reports from our group showed even higher rates with a more than sixfold increase in melanoma incidence among young adults in Olmsted County, Minnesota during the past 40 years [15]. In the young adult population of Minnesota, the overall age- and sex-adjusted melanoma incidence was 16.9 cases/100,000 person-years with incidence rates significantly increasing with age and year of diagnosis for both young women and men [15]. Consistent with SEER data that report increases of at least sevenfold in the relative risk of being given a diagnosis of melanoma among young adults between the ages of 15–19 years and 35–39 years [24]; being the fifth most frequent cancer in the 15–19-year age groups and becoming the most frequent in the 25–29-year age groups, when gender is not considered [25]. Similar marked rises in incidence with increasing age and year of diagnosis among young adults have been reported worldwide [13,18,20]. In Australia, incidence rates increase from 11.9/100,000 in the 20–29-year age groups to 28.0/100,000 in the 30–39-year age groups [18]. Overall, the incidence of melanoma increases linearly with age from 20 to 80 years; however, a switch in gender dominance occurs around the age of 40 years [16].

Mortality & survival

Overall, cancer death rates have decreased consistently since 2001 by 1.8% per year in men and by 1.5% per year in women in the USA [1]. Melanoma is one of the few cancers with an increasing mortality rate. Melanoma-related mortality continues to increase consistently with its increasing incidence though at a lower rate [1]. The US melanoma mortality significantly increased annually from 1975 to 1990 by 1.5% and has remained stable from 2005 to 2009 by increasing only 0.4% annually in men and decreasing 0.5% annually in women [202]. Similar mortality trends have been reported in Nordic European countries, Australia, England and Canada, with annual increase rates of 2–4% and stabilization of rising trends in recent birth cohorts [26,27]. However, data from the WHO Cancer Mortality Data Bank suggest great variability in mortality among populations on the melanoma mortality epidemic curve, with some countries having stabilization of the rising trends and others a steep increase [28].

Melanoma represents <5% of skin cancer cases diagnosed in the USA, but it accounts for the vast majority of skin cancer deaths, with approximately one person dying every hour from metastatic melanoma [11,29]. It is estimated that 46,372 melanoma-related deaths occurred worldwide in 2008 and according to WHO estimates, 54,913 deaths will be expected in 2015 [201]. In the USA, 9480 melanoma-related deaths are expected in 2013 and the age-adjusted death rate is estimated to be 2.7/100,000 individuals per year [1,202]. However, survival rates in melanoma patients of all age groups have improved during the past decades [16]; in the USA, 5-year survival rates increased from 81.9% in 1975 to 93.1% in 2009 [202]. Current 5-year survival rates range from 98% for localized melanoma to 62 and 15% for regional and distant stage disease, respectively [29,202].

Contrary to the overall increase in melanoma-related mortality, the death rate among young adults has decreased steadily since the 1970s [15,16,23]; with the greatest reduction in mortality seen in the 20- to 29-year-olds from 1975 to 2000 and the 30- to 44-year-olds from 1990 to 2000 [16]. It is estimated that death rates among young adults decreased by 2.8% per year in men and by 2.0% per year in women from 2005 to 2009 [29]. Likewise, data from the Minnesota young adult population show that each 1-year increase in calendar year of diagnosis is associated with a significantly lower risk of melanoma-related death [15].

It is well known that survival and age of melanoma patients are inversely correlated, with <8% of the melanoma-related deaths occurring in patients younger than 45 years old [202]. Age has been identified in several studies as an independent prognostic predictor of disease-free and overall survival [30–32]. Hence, among young adults, the 5-year survival rate is 94.6% higher than the overall rate [202]. Mortality rates are also lower among young adults, ranging from 0.2/100,000 in the 20–24 age groups, 0.3/100,000 in the 25–29 age groups, 0.6/100,000 in the 30–34 age groups and 0.8/100,000 in 35–39 age groups [202]. These low mortality and high survival rates among young patients have been attributed to the high proportion of thin melanomas and localized disease within this age group. Hence, those with regional involvement and metastatic disease have poorer prognosis and inferior 5-year survival rates similar to those observed overall for all age groups [33].

Gender differences

Gender-related differences in incidence and mortality of cancer are well established and consistent worldwide. It has been well documented that among melanoma patients, women have superior survival over men [34–36]. Overall, the incidence and mortality of melanoma are greater in men than women; men are approximately 1.5-times more likely to develop melanoma than women [1,11,37]. These higher incidence rates in men have been consistent throughout the years; in 1975, incidence rates were 8.54/100,000 for men and 7.4/100,000 for women, increasing to 27.45/100,000 for men and 16.81/100,000 for women in 2010 [202]. Similarly, the annual percent increase in melanoma for all ages is greater in men than women, 6.1 versus 2.8% [202].

However, among young adults, the incidence rate of melanoma in women is twice that in men [19,29]; approximately at the age of 40 years, a switch in gender dominance occurs leading to higher rates in older men as seen in Figure 1 [16,38]. This opposite gender predominance among young melanoma cases has been observed in populations around the world [13,21,38–40]. In the USA, SEER data from 2006 showed age-specific incidence rates greater among women than men prior to the age of 40 years; 6.9 versus 4.6/100,000 person years, respectively [41]. In 2010, incidence rates in adults younger than 44 years old had achieved 8.2/100,000 for women versus 5.3/100,000 per men [202]. This higher incidence among young women is preserved in all racial and ethnic groups [42]

Figure 1. Age-specific melanoma incidence rates in the USA.

Age-specific melanoma incidence rates from 18 SEER areas in 2006–2010. Rates are per 100,000 and are age-adjusted to the 2000 US Standard Population.

Data taken from [202].

According to SEER data, the increase in melanoma incidence among young adults in the last decades may be attributable to the increase in incidence in young women; age-adjusted incidence rates of melanoma among 15–39-year-old women have increased from 5.5 to 13.9 cases/100,000 person-years from 1973 to 2004, with a 2.7% annual increase since 1992, whereas rates among young men of the same age group stabilized after 1980 with an annual percentage change of only 0.4% [23,24]. Within this young adult patient group, age-adjusted incidence rates were superior in women in every race group, ethnicity, age and year of diagnosis [24]. However, in Olmsted County, Minnesota, increasing incidence trends were observed for both men and women from 1970 to 2009 [15]. Over the 30-year period, melanoma incidence increased four-fold in young men and, prominently, during the same period incidence rates rose eightfold among young women; rising from 4.3 to 18.6/100,000 and from 5.4 to 43.5/100,000, respectively [15].

In the past decades, survival rates averaged 90% among young adults diagnosed with melanoma. In all age groups, men have lower survival rates than women; this difference is observed even in young adults with differences in 5-year survival up to 88% versus 96% for men and women, respectively [16]. This significant advantage in survival among younger women is observed in populations around the world [36,43] and is independent of stage of disease, histologic type and decreases in mortality within this age group [23,43].

Tumor characteristics

Pathologic features

Histogenic subtype, tumor thickness, ulceration, level of invasion, mitotic rate, vascular invasion, tumor-infiltrating lymphocytes and lymph node involvement are some of the prognostic factors associated with different outcomes among melanoma patients [31]. In general, younger melanoma patients have a more favorable clinicopathologic profile than older patients, contributing to their increased survival [44,45].

Melanomas are classified according to their gross clinical and pathological features under four main histogenic subtypes: superficial spreading, nodular, lentigo maligna and acral lentiginous [46]. Superficial spreading melanoma is the most common subtype of melanoma, accounting for ~70% of cases followed by nodular melanoma [46,47]. Superficial spreading melanoma is often seen in younger patients and on areas of intermittent sun exposure including the trunk, back and extremities [46]. On the contrary, nodular melanomas are more common in older patients, near the seventh decade of life [46]. As expected, the same distribution of histogenic subtype is maintained among young adults; superficial spreading melanoma is the most common melanoma reported among young men and women followed by nodular subtype, representing 70 and 5% of the cases, respectively [15,24].

Increased tumor thickness is associated with decreased survival; data from the young adult population in Minnesota show that patients with Breslow thickness greater than 2.0 mm were more than nine-times more likely to die of melanoma [15]. However, recent reports have shown increasing incidence rates mainly for thin tumors in young men and women during the past decades [19]. Currently, the higher incidence and superior survival of young women with melanoma are believed to result generally from the increased proportion of thin nonulcerated lesions [19,32], which are associated with better prognosis and could be attributable to earlier detection [48,49]. However, analysis from SEER data has shown that since 1990 the incidence of melanoma among young women increased for both thinner and thicker tumors [23], suggesting that this increasing trend in young women is not only caused by earlier detection but other genetic, environmental and behavioral factors may be involved.

Anatomic distribution

The differential anatomical distribution of melanoma is gender dependent and is mainly attributed to differences in gender-specific patterns of sun exposure, independent of histogenic subtype [50,51]. In general, the most common areas affected by melanoma are the trunk for men and the lower extremity for women [43,50,52–57], and these differences are preserved in countries with widely varying latitudes [58].

Among young adults, differences in the anatomical location of melanoma between sexes are also observed. Between melanomas of the head and neck, young men have higher incidence rates, with proportionately double the number of cases diagnosed in men [24,38]. Though, the head and neck is the least commonly affected site in young adults compared with older individuals in which it is the most common [16,24,43].

Among young adults from Minnesota, the most common location of melanomas in young women is the lower extremity, followed by the upper extremity; on the contrary, young men from the Minnesota population were more likely to have melanomas on the back also followed by the upper extremity [15]. Similar trends are observed in national statistics from 1975 to 2006 [41], although with the increasing incidences, the distribution of melanomas changed over time by anatomic site and gender. The higher shifts are seen in melanoma of the trunk among women younger than 40 years [24,41,59]. Within this age group, truncal lesions increased at a superior rate than any other sites in women, becoming the most common anatomical site among young women from 1999 to 2006, followed by the lower extremities [24,41]. Nonetheless, the extremities are still more likely to be affected in women than in men, with predilection for the lower extremities among this gender [16]. Changes in the anatomical distribution of melanoma in young women over the last decade are believed to be secondary to changes in sun exposure patterns, increased tanning behavior or changes in clothing patterns derived from various environmental, behavioral or cultural factors.

Risk factors

Risk factors for melanoma are well established and include host and environmental factors; these are summarized in Box 1. Phenotypic characteristics, family history, socioeconomic status, exposure to sunlight and several other factors are discussed sub-sequently, with particular emphasis on artificial UV radiation and tanning beds.

Box 1.

Melanoma risk factors.

Fitzpatrick skin types I and II

Red or blond hair

Blue or green eyes

Number of nevi

Dysplastic nevi

Family history of melanoma

Personal history of melanoma or nonmelanoma skin cancers

Inability to tan

Sunlight exposure

Tanning bed use

History of sunburns

Higher socioeconomic status

Risk factors commonly associated with higher risk of developing melanoma. Data taken from [53,70,72,75,80,83,93,112].

Phenotypic characteristics

Worldwide, the highest rates of melanoma are seen in white populations, accounting for >90% of the melanoma cases among young adults [16,202]. The risk of developing melanoma is inversely related to the degree of skin pigmentation [60]. Therefore, non-Hispanic white individuals have higher sensitivity to sun exposure and approximately 10-times greater risk of developing melanoma compared with Hispanic, Asian or black populations [11,61]. Also, presence of freckles, blue or green eyes, red or blond hair, increased sun sensitivity and the inability to tan have been associated with twice the risk of melanoma [9,62–66]. These phenotypic characteristics have been associated with genetic variations in melanocortin-1 receptor, an independent risk factor for developing melanoma [67].

The presence of melanocytic nevi is also known to be risk factor for melanoma, with ~25% of melanomas occurring in conjunction with a preexisting nevus [68]. However, the risk of developing melanoma fluctuates according to the size, number, histologic type and anatomic location of nevi. A high count of melanocytic nevi is associated with increased risk of developing melanoma; the risk is 1.5-times higher among those with more than 10 nevi and increases with higher nevi counts [69–73]. Likewise, nevi larger than 5 mm and dysplastic nevi are associated with a higher risk of melanoma [64,71,72,74–76]. Notably, melanomas that develop with an associated nevus are more likely to occur in younger patients, to be located in the trunk and to be of the superficial spreading subtype [68,77].

Family history

Family history of melanoma is a strong risk factor for developing this tumor. Having a first-degree relative with history of melanoma doubles the risk of developing this cancer when compared with those individuals without family history [78–80]; the risk is highest among patients with a parent with history of multiple melanomas [81]. Personal history of melanoma or nonmelanoma skin cancer has also been associated with higher risk of developing this tumor [82,83].

Up to 10% of all melanoma cases are attributed to familial melanoma syndrome [84]. This syndrome should be suspected in patients with family history who present with melanoma before the age of 40 years, multiple primary melanomas and history of dysplastic nevi [85–87]. Mutations in CDKN2A and CDK4 are the most common genetic abnormalities found in these families [85,86]. However, patients with genetic predisposition are more likely to have a better prognosis and superficially invasive melanomas [82,88].

Socioeconomic status

Melanoma has been identified as a tumor affecting those of higher socioeconomic class in contrast to squamous cell carcinoma of the skin that is associated with lower socioeconomic status. Studies from around the world show a positive association between higher socioeconomic status and increased melanoma incidence [89–92]. Data from national SEER program have shown that the risk of melanoma almost doubles in those with a college education compared with those with less than high school education [93], independent of age or gender [94]. An income gradient was also observed; those with family incomes <$12,500 have almost half the risk than those with a family income of $50,000 or more [93]. However, these associations may result from differences in a variety of factors, including knowledge of melanoma prevention, access to health care, sunbathing attitudes and practices, leisure and vacation time and recreational sun exposure [5,90,94,95].

Sunlight exposure

Exposure to solar ultraviolet radiation (UVR) has been identified as the most important environmental risk factor for the development of melanoma and nonmelanoma skin cancers. It is evident that exposure to sunlight and the skin damage caused by it [96,97], particularly at younger ages, play a crucial role in the development of melanoma with >80% of cases being attributed to sun exposure [98]. Evidence supports that average annual amounts of natural UVR exposure correlate with the incidence of melanoma [17]. Furthermore, areas of higher altitudes and/or lower latitudes, where natural UVR is more intense, have the highest incidence of melanoma [37,99].

The amounts of acute and chronic sun exposure that a person has received in their lifetime are determinants of the risk of melanoma. Particularly, intermittent sun exposure, measured by history of sunburns, seems to have a major causal effect on the risk of developing melanoma when compared with chronic sun exposure [100]. The risk of developing melanoma doubles in those with history of sunburn and is higher among those with history of sunburns in childhood, adolescence and young adulthood [9,66,100–102]. Moreover, the risk of melanoma increases parallel to the number of sunburns; history of more than 10 severe painful sunburns is associated with higher risk of developing melanoma in all body sites, with the highest increment in the upper extremity by up to 6.8-fold [78].

Artificial UVR exposure

Since the 1970s artificial UVR sources, in the form of tanning beds, have gained enormous popularity around the world, with the prevalence of its use varying greatly among different countries [103]. By the end of the 1990s, 50% of men and 60% of women aged 18- to 50-years old in Northern Europe reported using tanning beds at least once during their lifetime [104]. In the USA, the average number of tanning salons per city exceeds the average number of Starbucks or McDonald’s [105], with more than 1 million users per day [106]. By 2005, almost 30 million people in the USA tanned indoors [106], with the highest prevalence among those younger than 35 years old [103]. Over 2.3 million adolescents in the USA use tanning beds [106]; according to the 2011 Youth Risk Behavior Surveillance System, 13% of all high school students and 21% of high school girls reported indoor tanning [107]. Even though tanning bed use is more common in young individuals, it is prevalent among all age groups, including 8% of men and women over 65 years old [108].

The 2010 National Health Interview Survey also reported higher prevalence indoor tanning among women; use of tanning beds were most common in young non-Hispanic white women [109]. Among young white women, those aged 18–21 years had the higher prevalence with 32% reporting use of tanning beds at an average of 28 sessions per year [109]. The highest national indoor tanning rates are seen among residents of the Midwest [109]. Studies from the population of Minnesota, USA have shown that most tanning bed users report first use as adolescents [110]. Also, they report that tanning bed users are more likely to have higher education level or income [110], factors known to be associated with higher risk of developing melanoma.

The UVR emission of a modern tanning appliance is equivalent to the UVR of midday tropical sun [103]; high-pressure tanning units produce UVR levels up to 15-times higher than the radiation emitted by the sun at midday, an exposure this intense is not naturally found in the environment [111,112]. The annual dose of UV-A radiation received by frequent tanning bed users is up to 4.7-times higher than the average UV-A radiation an individual will receive from sunlight, in addition to the radiation received from sun exposure [104]. Hence, these artificial UVR-emitting tanning devices have been included by the International Agency for Research on Cancer, an affiliate of the WHO as a Group 1 carcinogen; classifying them in the same category as well-known carcinogens like plutonium, γ-radiation, asbestos, cigarettes and solar UVR [113]. With the high radiation doses received, 18–55% of tanning bed users in Europe and North America report skin erythema or burns after artificial UVR exposure [114]; these tanning bed-induced burns confer an increased risk of melanoma similar to that of natural sunburns [115].

The skin damage caused by cumulative annual sunlight exposure is augmented by exposure to artificial sources of UVR, like tanning beds, positioning users at a higher risk of developing melanoma and nonmelanoma skin cancers [116]. Multiple reports and metanalysis have shown a higher risk of melanoma among tanning bed users [103,117]. Notably, using a tanning bed just once increases the risk of developing melanoma by 15–22% [104,112,116–119]. A dose–response relationship between hours, sessions or years of tanning bed use and risk of melanoma are observed [115], with the risk of melanoma significantly increasing among those that use tanning beds more than once a month [9]. Tanning bed use is associated with melanomas arising from the trunk [115,120]; the increase in truncal melanoma rates among young women in the last decade correlates with the increasing trends of indoor tanning among this population [24,41].

Several studies have suggested a higher vulnerability to the oncogenic effects of artificial UVR in young individuals. Having a first exposure to artificial UVR before the age of 35 years increases the risk of melanoma by at least 75% and is associated with earlier tumor development [104,112,119,121]. The higher susceptibility to artificial UVR among young adults and the increasing use of tanning beds play an important role in the current increasing trends in melanoma incidence among younger women [23,104,122]. Despite the multiple attempts to increase public awareness of the harms of UVR exposure, young women appear oblivious of the risks related to tanning bed use and uninformed about the specific risk factors, signs and seriousness of melanoma [123]. Hence, further active interventions are needed to increase awareness and decrease risk factors associated with melanoma in young individuals.

Expert commentary

Melanoma incidence rates continue increasing at alarming rates around the world. Particularly, among young women who are at higher risk than young men. This population of young women also has higher practice of risky behaviors associated with increased risk of melanoma, like indoor tanning. In the past decades, tanning bed use has spread throughout the world becoming a common practice among the young in countries of North America, Europe and even sunny regions like Australia. The highest prevalence of indoor tanning practices is seen among women, particularly young women who are also responsible for the rising incidence of melanoma in this age group. Even though tanning devices have been classified as carcinogenic, and multiple studies have attributed the higher incidence of melanoma to their widespread use, there still are very few to nonexistent laws regulating their use, which makes the future of melanoma worrisome. This issue is particularly critical among adolescents who have unrestricted access to tanning beds in most states and countries. For example, currently in the USA, only a few states ban or regulate the use of tanning beds among those under 18 years old and those that do possess regulations can still use them with parental consent [124]. Worldwide regulations are also limited with only 11 countries having laws that restrict indoor tanning in those younger than 18 years old and only one country, Brazil, banning indoor tanning for all age groups [125]. The parallel increasing trends in melanoma incidence and tanning bed use emphasize the necessity of new active interventions and laws that can be implemented in our communities to eradicate modifiable melanoma risk factors like indoor tanning. In addition, primary care providers and the public should be aware of the increasing trends of skin cancer among young individuals so screening exams and education campaigns on sun protection techniques can be reinforced.

Five-year view

Although many have argued that the increase in incidence of melanoma among young adults is the result of increased surveillance and the identification of thin tumors, with inherent good prognosis, recent data showed increases in both thick and thin melanomas suggesting a real increase in incidence [23]. Natural and, most importantly, artificial UVR exposures play a critical role in the increasing incidence trend observed among young adults, particularly young women. If the current trends continue the number of incidence, then cases will increase around the world. However, with the current advances in therapy and the stabilization of mortality rates among this age group, the prevalence of melanoma survivors will also increase. Hence, efforts to improve the public awareness regarding the harms of indoor tanning and unprotected sunlight exposure should be enhanced. Since skin checks are more prevalent among older adults, particular focus should be given to increase the awareness of primary physicians who can identify patients with risk factors, educate them and refer them to a dermatologist when necessary. Regulations on tanning bed use should also improve and expand worldwide. Current media support and advertisement promoting tanning practices and their widespread availability at homes, spas, gyms and tanning salons make age regulations and parental consents insufficient. Hence, countries around the world should follow Brazil’s example and should create tighter laws that will prohibit indoor tanning in all age groups. More education also needs to be provided to the general population educating them about the harms of this activity and unsafe sun exposure.

Key issues.

• The incidence of melanoma continues to increase worldwide.

• Young women, under 40 years of age, are at increased risk of developing melanoma compared with men. However, higher survival is observed among women in this age group.

• Tanning bed use is associated with higher UVR exposures and higher risk of developing skin cancer; even one use of a tanning bed increases the risk of melanoma.

• Sunburns caused by natural sunlight or artificial UVR are both associated with higher risk of melanoma, particularly if those occurred before the age of 35 years.

• Knowledge of the risks associated with indoor tanning and unprotected sunbathing, may decrease the prevalence of its use and may decrease the incidence of melanoma.