Individuals who have had basal cell carcinoma (BCC) are at high risk of subsequent BCCs and melanoma.1 Indoor tanning is an established risk factor for BCC, squamous cell carcinoma and melanoma.2 As such, continuing to tan indoors after a BCC diagnosis may elevate one’s risk for future skin cancers. Skin cancer survivors have sun protection behaviors that are similar to those of the general population,3 but little is known about their indoor tanning behavior. Notably, research suggests some individuals develop tanning dependence, analogous to substance dependence,4 which could be related to continued indoor tanning. To understand better the patterns of and reasons for indoor tanning after BCC diagnosis, we assessed indoor tanning and symptoms of tanning dependence in people who had at least one BCC before age 40.
Methods
Non-Hispanic whites in Connecticut diagnosed with BCC before age 40 who participated in a case-control study of BCC5 were recontacted 1– 4 years post-diagnosis to complete an online survey (response rate= 80.9%). The study was approved by the Yale School of Medicine Human Investigation Committee. We assessed indoor tanning in the past year, and lifetime symptoms of tanning dependence using the modified 4-item “Cut down, Annoyed, Guilty, Eye-opener” (mCAGE) Questionnaire4. Participants were classified as having symptoms of tanning dependence with two or more affirmative responses on the mCAGE. History of indoor tanning prior to BCC diagnosis (e.g. age at initiation, number of indoor tanning sessions) had been collected during the case-control study.
This analysis is limited to those who reported indoor tanning prior to BCC diagnosis. We evaluated differences by indoor tanning after BCC diagnosis using the chi-squared test, Fisher’s Exact Test, and Wilcoxon Rank Sum Test.
Results
Among the 178 individuals who had tanned indoors prior to BCC diagnosis, 26 (14.6%) reported tanning indoors in the past year. The median number of indoor tanning sessions in the past year was 10 in those who tanned indoors [interquartile range (IQR) = 3–20]. Those who reported tanning indoors after BCC diagnosis were similar to those who did not (Table 1), with the exception of the frequency of indoor tanning prior to BCC diagnosis being much higher in those who continued to tan indoors after diagnosis (p-value=0.001). In addition, those who tanned indoors after BCC diagnosis were more likely to have symptoms of tanning dependence (57.7%) than those who had not tanned indoors since diagnosis (38.2%) (p-value=0.06).
Table 1.
Selected characteristics by indoor tanning after diagnosis
| Tanned Indoors After BCC Diagnosis N=26 N1 (%) or Median (IQR) |
Did Not Tan Indoors After BCC Diagnosis N=152 N1 (%) or Median (IQR) |
|
|---|---|---|
| Age at online survey (y) | 40.0 (34.4–42.6) | 40.1(36.4–41.8) |
| Age at BCC diagnosis (y) | 37.5 (30.9–38.9) | 36.3 (33.1–38.4) |
| Female | 21(80.8) | 132 (86.8) |
| >1 BCC under age 40 | 7 (26.9) | 62 (40.8) |
| Skin color (inner upper arm) | ||
| Olive | 8 (30.8) | 48 (31.6) |
| Fair | 18 (69.2) | 94 (61.8) |
| Very fair | 0 (0.0) | 10 (6.6) |
| Family history of skin cancer | 3 (11.5) | 38 (25.0) |
| Age started indoor tanning (y) | 17.5 (16.0–20.0) | 18.0 (16.0–21.0) |
| Indoor tanning sessions before BCC | 175 (111–324) | 33.5 (8–150)2 |
| Burned from indoor tanning before BCC | 14 (53.8) | 60 (39.5) |
| Symptoms of tanning dependence | 15 (57.7) | 58 (38.2)3 |
May not sum to total due to missing data.
P-value=0.001; Wilcoxon Rank Sum Test.
P-value=0.06; X2 test.
IQR: Inter-quartile Range
Comments
Despite mounting evidence of the harmful effects of indoor tanning, in this group of young people who already had at least one BCC, nearly 15% tanned indoors after their skin cancer diagnosis and 7.9% would be defined as frequent indoor tanners (≥10 sessions/year). Notably, individuals with BCC who tanned indoors after diagnosis were more likely to have symptoms of tanning dependence than those who did not tan indoors following BCC diagnosis, suggesting that tanning dependence may contribute to continued indoor tanning in spite of health consequences. A similar phenomenon is observed wherein nicotine dependent individuals sometimes continue to smoke after a tobacco-related cancer diagnosis.
Our findings would benefit from replication, but suggest that clinicians should discuss the risks of tanning indoors with BCC survivors who continue this behavior and be cognizant of tanning dependence, which can be assessed clinically with a recently validated measure6.
Acknowledgments
Funding/Support: This study was supported in part by NIH/NCI: R21 CA155952 and P50 CA121974
Footnotes
Author Contributions: Dr Cartmel had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Bale, Cartmel, Ferrucci, Gelernter, Leffell, Mayne and Pagoto. Analysis and interpretation of data: Cartmel and Ferrucci. Drafting of the manuscript: Cartmel, Ferrucci, and Mayne. Critical revision of the manuscript for important intellectual content: Bale, Cartmel, Ferrucci, Gelernter, Leffell, Mayne, Pagoto, Spain. Study supervision: Cartmel, Spain.
None of the authors have any financial disclosure or conflict of interest to report.
Contributor Information
Brenda Cartmel, Yale School of Public Health, New Haven Yale Cancer Center, New Haven.
Leah M. Ferrucci, Yale School of Public Health, New Haven
Peter Spain, Yale School of Public Health, New Haven.
Allen E. Bale, Yale Cancer Center, New Haven Yale University School of Medicine, New Haven.
Sherry L. Pagoto, University of Massachusetts Medical School, Worcester
David J. Leffell, Yale Cancer Center, New Haven Yale University School of Medicine, New Haven.
Joel Gelernter, Yale University School of Medicine, New Haven
Susan T. Mayne, Yale School of Public Health, New Haven Yale Cancer Center, New Haven.
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