Truth, beauty, and skin cancer

We may think sunscreen is the best protection, but researchers in sun-baked Australia say counting on lotions alone is a big mistake.

Queensland, Australia --"It really is a bit of paradise, isn't it?" Nikki Goodwin asks, gazing out over her sunny backyard.

It is. A gracefully arcing mango tree shimmers in brilliant midafternoon sun. Along a fence the crimson flowers of a trumpet vine seem to glow with their own light. In all directions the low hills are ablaze with color: garish bougainvillea, dusky purple jacarandas, scarlet flame trees, and frangipani streaked with pink and yellow. There are fields of sugarcane and pineapple drenched in sunlights so intense you feel you could scoop it up in your hands. A stone's throw away lie the Sunshine Coast and some of the most beautiful beaches in the world, where steep waves unfold across miles of dazzling white sand.

"We're very lucky to live in a climate like this," says Goodwin, 37, an oncology nurse at the local hospital. Still, the note of reserve in her voice is as unmistakable as a broken key on a piano. "We just have to be very, very vigilant."

As if on cue, Angela, age ten, and Mitchell, 11 and a half, burst through the door. Just home from school, they're clamoring to go for a swim at the local pool. Mom recites the familiar litany--"hats, shirts, sunscreen"--and a few minutes later they return dressed in colorful spandex suits that reach from neck to hips and well-worn baseball caps pulled down low to shade their faces.

"Of course it's the kids you really fret about," Goodwin says as soon as the door bangs behind them. With good reason. Like most Australians, the Goodwins come from solid British stock. They have inherited precisely the pallid complexions that, transplanted to the subtropics, put them squarely in the crosshairs of skin cancer risk. Both children are dotted with dark moles, a trait that multiplies the risk of melanoma skin cancer by about 40.

Melanoma haunts Nikki Goodwin. Twelve years ago her mother died of the disease at age 42. Goodwin's brother-in-law, who had a melanoma removed two years ago, has just learned the tumor is back. If it's not detected and removed in time, melanoma can quickly spread to other parts of the body, where it usually becomes fatal. Remembering what it was like caring for her mother and thinking about her brother-in-law's prospects, Goodwin's voice cracks. "Believe me, it's a nasty way to go."

Nikki Goodwin resides in a region with the highest rate of skin cancer recorded anywhere in the world. For more than a decade, in fact, Nambour, population 8,500, has been a living laboratory for skin cancer researchers. It's a quintessential rural Queensland community of mostly modest one-story houses on streets that seem to wander off in any direction they please. A billboard on the road into town proclaims, "The Youth of Nambour Says Hi to You!" No need to wonder why people put down roots and stay here.

Unfortunately, studies conducted over the past 12 years have cast a lengthening shadow over this sunny eden. In examining close to a quarter of Nambour's population back in 1986, scientists from the Queensland Institute of Medical Research discovered that one in 20 adults under 70 had at least one active skin cancer. More than half that population also had actinic keratoses: thickened, reddish spots associated with higher cancer risk. Sure enough, every year since, another 2 percent of the subjects--40 of the Goodwins' neighbors--have developed new tumors. "That's the highest rate ever reported for any kind of cancer anywhere in the world," says epidemiologist Adele Green, who directed the study.

Australians everywhere, in fact, face an extraordinarily high risk of skin cancer. Two out of three Aussies will be diagnosed with some form of the disease during their lifetimes. Basal cell and squamous cell carcinoma are the first and second most common of all cancers in Australia, and though they rarely spread from the ears, lips, and face, where they typically strike, they do form ugly tumors whose removal--by scraping, freezing, or burning procedures--can mar an otherwise flawless complexion. Malignant melanoma, the most deadly form, ranks third among women, fifth among men.

No one here is allowed to forget the threat. This is a country where signs planted at every beach depict a crossed-out lobster red body giving off smoke under a blazing sun. Pet owners are advised to get their dogs' pink noses tattooed deep blue to prevent melanoma. The latest television spot, accompanied by gruesome close-ups of a tumor being routed and replaced by transplanted skin, warns viewers to avoid the sun or end up "wearing your bum on your nose."

Yet in what's widely regarded as the most ambitious skin cancer prevention campaign in the world, Australians have soft-pedaled the advice most familiar to sun-loving Americans: the use of sunscreen. Sure, it's there in Australia's Slip! Slop! Slap! campaign (slip on a shirt, slop on some sunscreen, slap on a hat). But the slick TV and radio ads have deliberately downplayed the slop in favor of the slip and slap. "Between 11 and three, step under a tree," one television spot puts it. "The best sunscreen of all is absolutely free. It's shade."

"In the U.S. people tend to think of sunscreens as a first line of defense," says Graham Colditz, an Australian who now heads the education department of Harvard University's Cancer Prevention Program. "In Australia they're regarded as the very last resort."

Dermatologist and University of Melbourne professor Robin Marks, one of the architects of Australia's prevention campaign, puts it with characteristic Aussie bluntness. "Relying on synthetic chemicals to prevent skin cancer is laughable," he says, making no bones that he is talking about what most Yanks do. "It's like giving people saccharin and then telling them they can eat whatever they want and stay thin. It's the height of human folly."

FOLLY PERHAPS. But there's a reason many of us trust sunscreen. For about 20 years, ever since scientists tallied the hazards of too much sun and began producing transparent lotions to screen out those rays, we've been hearing about sunscreen's importance. By now U.S. organizations from the American Academy of Dermatology and the American Cancer Society to the Food and Drug Administration put sunscreen near the top of their lists of skin-guarding tips--in some cases, alone at the top. "Your first line of defense against the sun," says an FDA brochure called Cool Tips for a Hot Season, "should be a sunscreen."

What sunscreens promise is spelled out right on the label, in the form of a sun protection factor. Slop on some SPF 15, goes the advice, and you can stay out in the sun SPF 15 times as long before the first blush of a burn appears. Ratchet up to SPF 45 and you can stay out 45 times as long. The claims foster a sense of solar invincibility: Even if you're pale or you're freckled or you tend to burn--the most telling signs of cancer risk--these lotions will let you have your day in the sun.

Experts have hoped, indeed, that by preventing sunburn, sunscreen could in time even brake our nation's own runaway epidemic of skin cancer, which currently strikes 1 million Americans a year--a number that nearly equals all other forms of cancer combined. The incidence of melanoma is rising fastest. In 1980 researchers estimated that one in 250 Americans would develop the cancer sometime in their lives. By 1987 the risk had climbed to one in 120. It's predicted to hit one in 75 by 2000.

Ironically, studies by Australian researchers have done more than anything to convince us that sunscreen use could turn the trend around. Six summers ago volunteers in Maryborough, a farming community outside of Melbourne, agreed to put lotion on their faces, necks, hands, and forearms every day for seven months. Half got an SPF 17 sunscreen, the others an inactive lotion. Researchers found that while the control group members picked up an average of one new actinic keratosis each, the number of such spots dropped by an average of one apiece among the sunscreen group, suggesting that regular use can actually reverse some damage.

Meanwhile, in Nambour, Green's team has just completed one of the most ambitious studies of skin cancer and sunscreen ever undertaken. For five years Nikki Goodwin and 800 other Nambourians went beyond their habitual hat-wearing and shade-seeking to apply SPF 15 sunscreen every day, while researchers periodically examined their skin for wrinkles, actinic keratoses, and cancer. The field-work is done. The final results should be ready within a year. The researchers predict that, once again, regular sunscreen use will prevent at least some of the harm.

But in spite of such findings, researchers down under have serious misgivings about sunscreen. And lately experts around the world admit to sharing their qualms. No one's saying you shouldn't wear sunscreen. The latest products absorb more UV light than ever before. But enough to ward off cancer? Don't bet on it. Compared to every other preventive measure--avoiding peak sun, slipping on a shirt, slapping on a hat--sunscreen falls short.

The first problem with relying on sunscreen has nothing to do with biology or dermatology and everything to do with human nature. As Marks puts it, "Sunscreens are just too bloody hard to get people to use properly." When researchers ascertain a lotion's SPF in the lab, for instance, they glop on the equivalent of one ounce for full-body coverage--one-quarter of a standard-size tube. Most of us apply half that amount, studies show. And even if you make a valiant effort, sunscreen's transparency makes it hard to tell whether you're sufficiently covered. Finally, experiments like the Maryborough or Nambour studies can count on obedient volunteers and carefully measured dollops; in real life most of us are far less conscientious.

Take Nikki Goodwin. During the five-year study she was a model sunscreen user. She spread it on her face, neck, and hands every morning and reapplied it whenever she'd been in the sun for long. "Oh, I was very religious about it," says Goodwin. Of course it helped that researchers from the Queensland Institute of Medical Research supplied the sunscreen and weighed the tubes periodically to make sure the subjects were using enough. Now that the study's over, Goodwin is back to rounding up her car keys and wallet and rushing out to run her afternoon errands wearing a hat and a long-sleeve shirt--but not sunscreen. "I know I should be better about it," she says, shaking her head.

Around the corner from the Goodwins, Bob and June Glanville and their daughter-in-law, Karen, also members of the sunscreen group, tell the same story. "You forget. You get busy," says Karen, a mother of four.

But researchers have more than such practical concerns. Many now doubt sunscreen adequately protects against cancer even if properly used. "People must be cautioned that currently available sunscreens do not eliminate the hazards of ultraviolet radiation," University of Pittsburgh dermatologist Arthur Rhodes told an American Cancer Society meeting in 1994. Sunscreens on the `market, he warned, "appear weakly effective or ineffective" at safeguarding against cancer.

The latest hand-wringing reflects a better understanding of how sunlight does its dirty work. By now most of us know that too much exposure can leave our skin lined and mottled before its time, a process called photoaging. Under the assault of ultraviolet radiation, the skin's underlying layer, called the dermis, becomes inflamed just as it does after a cut or scrape. Immune cells rush in to get rid of damaged skin cells. To prevent undamaged cells from being destroyed in the skirmish, the cells in the dermis churn out enzymes to coat the intricately woven fibers that give skin its bounce and suppleness. "Unfortunately, after each assault some of those enzymes stay behind," says Robert Lavker, a University of Pennsylvania dermatology professor. They gum up the fibers and make skin increasingly stiff. Over time, as skin loses resilience, fine lines, then deep wrinkles, and finally bags and sags appear.

A craggy face is the least of our worries. As sunlight wallops baby-smooth skin, it also mucks up the genetic instructions contained in DNA, the intricate code that tells cells how to grow and divide. This alone doesn't spell doom, since the cells contain a genetic fail-safe switch, called p53, that tells wounded ones to stop reproducing--or even to commit suicide--when they haven't been able to repair their mangled DNA. So what's the problem? This fail-safe system itself is vulnerable to ultraviolet radiation. It probably worked well when you got roasted in the sun as a toddler. But repeated exposure over many years can knock p53 out, leaving damaged cells free to multiply out of control, producing cancer. Sunlight's wear on p53 almost certainly contributes to the development of most squamous and basal cancers. Up to 90 percent of squamous cell carcinomas show signs of damage to p53.

Sunlight also clearly plays a role in melanoma: The cancer gets more common the closer you get to the equator. But, inexplicably, melanomas often show up on places that rarely see the light of day--palms, buttocks, even the soles of the feet. And the risk isn't neatly tied to how much sun you've gotten in your lifetime, the way it is for the other skin cancers. True, people whose skin is never exposed to much bright sunlight have the lowest risk. Yet people who spend hours in the sun every day--farmers and gardeners, for instance--are actually less likely to develop melanomas than pale-faced office workers who hit the beach for only a week or two each year, prompting some scientists to speculate that severe sunburn is often the trigger.

For years, in fact, the sunscreen display in your local drugstore was a monument to that speculation. Experts assumed that sunburn was the main culprit not just in melanoma but in all sunlight-related damage, from photoaging to basal cell cancer. So the first transparent sunscreens were purposely designed to absorb only the burning rays of ultraviolet, called UVB. By slathering the lotions on, we were told, we could get a safe tan.

Then, about five years ago, researchers discovered there's no such thing. Even before the first flush of color appears, it turns out, sunlight is already setting off serious damage. And the culprit of this largely invisible wreckage isn't UVB but UVA, the other type of ultraviolet radiation. Though it barely causes any reddening, UVA penetrates deeper into the skin than UVB--all the way into the structural support layers of collagen--and inflames the skin. (It's now considered the principal cause of wrinkles.) And in studies done on mice, UVA has been shown to contribute to basal and squamous cell cancers and even to trigger melanoma.

As this bad news about UVA spread, dermatologists uttered a collective uh-oh. For years the lotions they'd touted so fervently had let millions of us play on the beaches and ski slopes without burning. Yet all the while, our skin was being zapped by undetectable UVA.

Almost as soon as the findings hit the medical journals, sunscreens that absorb both UVA and UVB were on the shelves. Today such broad-spectrum sunscreens dominate the market. But once burned, scientists remain wary. Even these new and improved products, many say, offer less protection than we'd like to believe.

Lavker, at the University of Pennsylvania, says the problem is that broad-spectrum sunscreens still aren't broad enough. It's convenient to talk about UVA and UVB, but ultraviolet radiation consists of more than 100 separate frequencies--something akin to the stations on an FM dial. The original sunscreens did a pretty good job of jamming the higher frequencies at the upper, UVB section of the band--to extend the metaphor, up there near 107.7. The new sunscreens block out transmissions from the top to well below the middle of the dial, where the UVA band begins. But most, he says, do nothing about the lowest UVA frequencies--down there at 88.5, where the public radio and strange alternative music stations lurk.

The so-called broad-spectrum lotions have now been studied, and the results aren't good. In one study Lavker spread an SPF 22 broad-spectrum sunscreen onto a patch of skin on the backs of 23 volunteers and then exposed the skin to short doses of simulated UVA-rich sunlight--about what you'd get puttering in the garden for an hour a day. After 28 days Lavker examined both protected and unprotected skin under a microscope. "The first surprise was that quite low levels of UVA, repeated over time, caused significant inflammation and injury to fibers," he says. "The second was that a fairly high-protection sunscreen didn't prevent the bulk of that damage." The frequencies of UVA not blocked by the lotion caused abnormally fast cell growth, a sign of cancer risk.

You'd still think that by absorbing a wider band of sunlight current sunscreens would lower cancer risk somewhat. And they very well may. Researchers at M.D. Anderson Cancer Center in Houston have just learned that SPF 15 sunscreen cuts the number of p53 mutations in mice exposed to UV. That in turn could lower the risk of basal and squamous cell cancers. Moreover, the famous Maryborough study found that lotions reversed the growth of some actinic keratoses. Marks, one of the study's authors, is convinced that fewer of those patches will mean fewer skin cancers. But the evidence remains circumstantial. While actinic keratoses are associated with higher levels of sun exposure and elevated cancer risk, says epidemiologist Adele Green, only a small percentage of them actually become cancers. And despite high hopes and more than two decades of widespread sunscreen use, she points out, "There's no substantial evidence that sunscreen protects against any of the three forms of skin cancer."

Frighteningly, the notion that sunscreen wards off melanoma is the most rickety of all. "The truth is, we don't even know with certainty which wavelengths of sunlight may be involved in melanoma," admits Martin Weinstock, an associate professor of dermatology at Brown University. If the lowest frequencies of UVA play a role, sunscreen offers only partial defense. If the danger skulks beyond the ultraviolet spectrum, as some suspect--in light's infrared spectrum or in visible light, for example--the lotions in which we put our faith aren't protecting us at all. In fact, by creating a false sense of security about going out in the sun, sunscreen could be increasing the incidence of melanoma.

Some research offers reason to worry. Three years ago another study at M.D. Anderson Cancer Center reported that though an SPF 8 sunscreen protected mice from sunburns, the animals eventually got melanoma. Then research done in several European nations found that people with melanoma were actually more likely to have used sunscreen than healthy subjects--even after accounting for skin type and time spent in the sun. Similar findings have turned up in the United States.

Of course, the people most inclined to use sunscreen are those at highest risk of melanoma--those with a family history or previously diagnosed cancer. So such findings may not be as alarming as they sound. Still, relying on sunscreen to shield against melanoma is a little like testing out a bulletproof vest by stepping directly into a firing range. You have no idea if the vest will save your life. Why walk into the line of fire when you don't have to?

In the end there's only one thing you can put between yourself and the sun that's guaranteed to prevent melanoma, and the evidence comes not from Australia but from a world away. Researchers at Chaim Sheba Medical Center in Tel Aviv once compared the skin cancer histories of different groups of Israelis. Israel is roughly the same distance from the equator as Queensland, and there, as in Australia, immigrants of European descent, transplanted to a climate bleached by intense sunlight, face high risk for skin cancers of all sorts. All of them, it turned out, except a small group of Orthodox Jews of European or American ancestry.

The men in this group had one-sixth the risk of developing melanoma as other men in Israel. The women faced half the risk of other women. And the explanation for the difference was as obvious as the clothes on their backs. Orthodox Jews wear heavy, dark coats and wide-brimmed hats or head coverings all year round. Dressing defensively, said the researchers, promises something the most religious sunscreen use cannot: a lower risk of every type of skin cancer.

No one expects Hasidic fashions to become the rage, of course, here or down under. But styles, both fashion and otherwise, can change. People can cover up. They can stay out of the midday sun. And in Australia, at least, people don't seem to think these adjustments are that big a deal.

At eight-thirty on a dazzling Saturday morning, Surfer's Paradise on Queensland's Gold Coast is thronged with beachgoers. But here the renowned surf rescue teams have given up briefs and bikinis in favor of baggy shorts, long-sleeved sweatshirts, and hats straight out of Crocodile Dundee. On and off the beach, toddlers and teenagers sport colorful, cover-all spandex shirts called rashies, first adopted by surfers who were tired of getting chafed skin while paddling out to catch a wave. And couples pitch tentlike coverings to rest under between walks to the snack bar or sprints into the warm waves.

Sure, there's plenty of sunscreen on plenty of exposed flesh. But even more prevalent are floppy hats. And by 11 most of the locals have headed for the shade, leaving only the obvious tourists from Tokyo or Toledo to turn lobster red. The crowds won't surge back to the beach until well after two. For now, families take siestas in the dappled shade of banyan trees.

Up the road, Queensland kids romp in a playground shaded by a huge canvas canopy. Structures like this, graceful as sails, are fast becoming a fixture at public pools and parks across Australia. Communities have also begun planting shade trees along thoroughfares from Brisbane to Perth. Cricket and soccer teams have even adopted new uniforms that hide more skin.

"The best part about covering up is that it gets to be second nature," says Marks, donning a sporty panama hat. It's noon. Outside the window of his ninth-floor office, Melbourne glitters in sparkling sunshine. Off to meet a colleague, Marks rolls down the sleeves of his shirt and adjusts his hat.

"Protecting yourself needn't be difficult," he says. "It should be something you do by habit. I hardly need to think about avoiding direct sun at midday. That alone reduces exposure by some 60 percent. And when I go out during the day I wear a shirt like this and a good hat, which eliminates more than 90 percent of the rest. That's all you need."

Emerging from the elevator, Marks admits to smearing sunscreen on his face and the backs of his hands if he's going to be outside for long. But only after taking every other precaution. And not today. "Shouldn't have to worry," he says. "It's a short dash from here to there." He gives the brim of his hat a jaunty tap, then steps out into the blazing sun.

What's It Look Like? The Three Faces of Skin Cancer
One in five Americans will hear the scary diagnosis of skin cancer in his or her lifetime, but, in truth, there's skin cancer, and then there's skin cancer. Basal and squamous cell carcinomas are common but seldom fatal; you may carry an unsightly scar after their removal, but you'll probably be fine. Melanoma, on the other hand, is rare but often deadly.

Still, nearly 100 percent of skin cancers can be cured when they're caught early. Here's how to stay ahead of the threat. If you see something suspicious, see a dermatologist to have it checked out.

Malignant Melanoma
Strikes 32,000 people a year and kill nearly 7,000 Occurs when pigment cells multiply uncontrollably for reasons that aren't yet known Usually fatal when caught late

RISK FACTORS
A family history of melanoma.

Three or more blistering sunburns before age 20.

Three or more summers as a teen spent working outdoors.

Exposures to intense sun.

Fair skin or hair; blue eyes.

The presence of several large, brown moles at birth.

More than 25 moles larger than 1/16 of an inch across.

WHAT TO LOOK FOR
A mole that's asymmetrical or has irregular borders, has uneven color or changes color, or is wider than the end of a pencil eraser.

WHERE TO CHECK
Everywhere on your body.

Squamous Cell Carcinoma
Diagnosed in more than 100,000 Americans each year; kills more than 2,000

Develops when ultraviolet light causes cells in the skin's top layer to reproduce faster, resulting in a tumor

When ignored can spread to major organs

RISK FACTORS
Decades of sun exposures.

Fair skin; freckles; blue eyes.

WHAT TO LOOK FOR
A red or white sore of almost any kind that doesn't heal in three weeks.

A scaly or crusty patch.

A small nodule that progresses into a wartlike lump.

WHERE TO CHECK
Parts of the body most often exposed: scalp, ears, face, neck, back, and shoulders.

Basal Cell Carcinoma
Diagnosed in 500,000 Americans a year; rarely spreads or leads to death

Develops in much the same way as squamous cell cancer

RISK FACTORS
Decades of sun exposure.

Fair skin; freckles; blue eyes.

WHAT TO LOOK FOR
Any sore that changes in size or color; hurts, itches, or bleeds; and doesn't heal in three weeks.

A translucent, flesh-colored, pearly, or red nodule.

A scaly, off-white or yellow patch resembling scar tissue.

A blue, brown, or black lesion.

WHERE TO CHECK
Parts most often exposed.

Broaden Your Protection
Though experts now caution against depending solely on sunscreen to protect yourself from skin cancer, lotions still have a place in any personal skin-preservation program. After you've covered up with a hat and long sleeves, be sure to apply sunscreen to your ears, lips, face, and the backs of your hands. And consider using one of the handful of specially manufactured sunscreens that block the broadest possible spectrum of UV light. Until recently dermatologists were concerned only about UVB rays, the kind that gives you a sunburn. Then they found that UVA also damages skin, leading to wrinking and possibly skin cancer. But most of the so-called broad-spectrum sunscreens that have reached the market since that discovery still let some UVA light through. (You can't tell how much; the SPF rating on a sunscreen's label refers to its ability to block out UVB.) Here are the products that go the extra step.

ZINC OXIDE shields against the full UV spectrum. The familiar white smear is a terrific sanctuary for the nose and, unlike clear lotions, lets you know when you're covered. The downside: Most of us don't want to go to the beach looking like extras from The Night of the Living Dead, so it's really not an option for the rest of the body.

PRODUCTS CONTAINING Z-COTE block all but the longest wavelengths of UVA. Z-Cote is a transparent form of zinc oxide manufactured with a new technique that breaks molecules into tiny, see-through particles. It's used in several brands of sunscreen as well as moisturizers and lipsticks. Look for zinc oxide on the label.

SHADE UVA GUARD is the only product approved by the FDA so far to contain avobenzone (also called Parsol 1789), a chemical that screens out more UVA wavelengths than any other sunscreen ingredient except zinc oxide. Other products with avobenzone are expected soon. Shade UVA Guard comes in SPF 15.

PHOTO (COLOR): Woman walking in the seashore

PHOTO (COLOR): Woman lying on the sand

PHOTO (COLOR): Woman weraing a white dress with long sleeves.

ILLUSTRATION

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BY PETER JARET

Peter Jaret is a contributing editor

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