Skin Cancer Determinants

Problem Definition: The incidence of skin cancer in the white adolescent population (age 16-21) has increased over the past decade in the United States.


Over the years, skin cancer has been a cancer that is frequently ignored because non-fatal basal cell and sqaumous cell carcinomas make up 90% of cases and melanoma only about 10% of cases.  Statistics from the past decade indicate a steep rise especially in the adolescent population.  In fact, melanoma has become the second most common cancer for 15 to 29 year-olds in the United States (2).  American adolescents have the lowest skin protection rates of all age groups and skin cancer currently accounts for 11.5% of all cancers in this age group (4, 2).


Identifying key determinants will help to answer why the adolescent population is at such high risk and hopefully point toward interventions to reverse the problem.  Biological determinants refer to the anatomic, physical, or medical/clinical reasons a problem might exist.  Some of the biological determinants of skin cancer include genetic factors, gender, and medical problems like compromised immune system.  Genetic factors make some people more susceptible to skin cancer than others.  For example, melanin--produced by melanocytes-- is a genetic factor that determines an individual's capacity to protect against UV exposure (5).  People with eumelanin can absorb UV radiation and transform energy into heat, thus preventing DNA damage.  This is why there is a lower incidence in darker-skinned populations.  Other people have pheomelanin.  These are the fair-skinned, freckled people whose melanin cannot absorb UV radiation like those with eumelanin resulting in less natural sun protection.  This can help explain why people with personal or family history of melanoma often develop skin cancer (2).  Gender differences are not as paramount, however, research has found that young men are less likely to sunbathe, but also less likely to use sun protection; young females are also more likely to indoor tan (1).


Some social and cultural determinants include normative beliefs regarding sunbathing and the use of sunscreen and also self-efficacy (4).  Most people do not follow sun protection recommendations because American society associates tanned appearance with beauty and people have reported feeling more confident with a tan (1).  In addition to having a tan, there is little social support for using sun protection.  This is often referred to as the 'bikini effect' (2).  There are not been much evidence found for ethnic differences, but whites are most susceptible to skin cancer because of fair skin (1).  


The most obvious environmental determinant is UV light exposure; the intensity of UV radiation tend to increase approaching the equator (1, 2, 4).  Economically,  people of higher socio-economic status are usually more aware of long term risks of sun exposure than lower socio-economic groups (1).  However, wealthier people also have easier access to indoor tanning.  There are not many political determinants to this problem except the lack of national investment in promoting the prevention of skin cancer (6).


In addition, there are also behavioral determinants of skin cancer.  For example, children who grow up in families that do not use sunscreen are less likely to use sunscreen themselves (4).  Also, indoor tanning behavior before age 35 increases risk of melanoma by 75 percent.    


References:
1.http://http://heapro.oxfordjournals.org/content/early/2012/04/11/heapro.das015.long
2. http://www.tandfonline.com/doi/full/10.1080/07448481.2011.596872
3. http://www.sciencedirect.com/science/article/pii/S1054139X11002825
4. http://www.ncbi.nlm.nih.gov/pubmed/22251761
5.http://www.ncbi.nlm.nih.gov/pubmed/22123420
6. http://www.ncbi.nlm.nih.gov/pubmed/22018060

skin cancer 2

Current problem definition (still subject to change): Increased incidence of skin cancer among the white young adult population (age 16-21) of United States over the past decade has contributed to skin cancer being the most common form of cancer.

Skin cancer is a growing problem in the United States; it is becoming such a problem that public health agencies such as the CDC have begun surveillance programs to monitor sun safety and develop policies to maintain a healthy population.  For example, the National Association of State Boards of Education (NASBE) published the report "Fit, Healthy, and Ready to Learn: Sun Safety" in 2002.  In 2006, 53,919 people were diagnosed with melanoma and 8,441 died from it.  The CDC also systematically collects and publishes data of rising incidence of skin cancer that is viewable by the public.  Surveillance data from 1998-2007 indicates a significant increase in incidence among the US white population, however, I have not yet found data strictly for the adolescent population.  On the other hand, I have found some information relating to age significance.  Adolescents, especially high school age, are in the process of gaining independence, which often leads to rejection of parents' rules and messages.  Parents, especially mothers, tend to enforce sun protection, so it seems logical that young people would reject the encouragement.

Some direct indicators could include the percentage of young adults who frequent tanning beds and the percentage of young adults who's skin is tan or burned due to sun or artificial sun exposure. Some indirect indicators include rates of tanning bed business success within a mile radius of high schools, dermatology appointments, and sunscreen and aloe sales.

Most people, including young adults, are aware of the dangers of UV light exposure, but quantitative studies show that many people --especially adolescents-- perceive their susceptibility to skin cancer to be low.  This information seems accurate, however, it is dependent on self-report and because the socially acceptable norm is to perceive skin protection as unimportant, or even 'uncool,' some people may report false information to avoid having the unfavorable opinion.  The general perception is also that skin cancer is a problem for the older population, so why worry now?  Also, society tells us that tan skin is 'healthy' skin and white skin is unattractive.  Societal norms tell us not to wear sunscreen or protective clothing because its either unfashionable or, with regards to men, not masculine.  Perhaps this is why statistical prevalence rates of white males are substantially higher in the past decade than of white females, although female incidence climbs at about a 1% higher rate annually.  The statistics cited are reliable, however, they measure the total U.S. population and my problem definition aims to focus only on the young adult population.        

Sources:

"Public Health Herald 8th Issue." NCSL Home. 2012. National Conference of State Legislatures. 19 Apr. 2012 <http://www.ncsl.org/issues-research/health/public-health-herald-8th-issue885.aspx>.

"Skin Cancer." Centers for Disease Control and Prevention. 23 Nov. 2010. Centers for Disease Control    and Prevention. 19 Apr. 2012 <http://www.cdc.gov/cancer/skin/statistics/>.

Theo, Lorenc. "Resource provision and environmental change for the prevention of skin cancer: Systematic review of qualitative evidence from high-income countries." 12 Apr. 2012. PubMed. Eisenhower Library, Baltimore. 19 Apr. 2012 <http://http://heapro.oxfordjournals.org/content/early/2012/04/11/heapro.das015.long>.

 

Final Paper: Skin Cancer

For my final paper, I've decided to focus on the issue of skin cancer --also known as skin neoplasms--not only because the topic interests me, but also because of my personal connection.  Currently, skin cancer is the most common form of human cancer; over 3.5 million cases occur annually in the United States.  These annual rates are increasing year by year, making it a major public health concern.  In fact, from 1998 to 2007, incidence of melanoma in the United States has increased significantly primarily in white males and females.  Incidence among men has increased 2.6% per year and 3.2% for women.  It has been estimated that half of all Americans above the age sixty-five will develop skin cancer at least once.  Although the incidence of many cancer in the U.S. is falling, incidence of melanoma continues to grow.  

There are three major types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and melanoma, each named after the type of skin cell from which it arises.  Basal cell carcinoma and squamous cell carcinoma are the most common forms and are also less severe than melanoma form, which tends to metastasize.  Basal cell carcinoma usually presents itself as a raised, pinkish bump, sometimes with visible blood vessels.  Many times it is mistaken for a sore that does not heal, but this form is easily treatable and rarely leads to death.  Squamous cell carcinoma is slightly more dangerous, and it presents as a rapidly growing, thick reddened patch of skin.  In contrast, melanomas are much more aggressive and can be diagnosed using the 'ABCDE' method: Asymmetrical, Borders, Color, Diameter, Evolving.  

The primary and most widely known cause of skin cancer is exposure to ultraviolet light, usually from the sun and tanning beds.  Common risk factors include naturally light skin, family history of skin cancer, personal history of skin cancer, exposure to sun, light eyes, and light hair.  When ultraviolet (UV) rays come in contact with the skin's inner layers, it causes the skin to make more melanin, which moves toward the skin's surface resulting in a tan.  Tan skin may look good, but it does not indicate good health.  In fact, the tan is a response to cell injury.

I am light skinned and my dad had skin cancer, although fortunately his form of skin cancer was not a melanoma.  However, like most people (especially the younger crowd), I love to get a suntan and have gone to the tanning bed countless times.  Why?  Because society views tan skin as beautiful skin.  As a society, we ignore the risk factors thinking it will never happen to us, but the numbers don't lie.            

Problem Definition: Increased incidence of skin cancer among the white population of United States over the past decade has led skin cancer to be the most common form of cancer.

Humans Rights

A human right is a fundamental and universal entitlement to every human being.  Human rights are thus related to public health because often times when human rights are neglected, they become a public health issue.  The article "Maternal mortality and human rights: landmark decision by United Nations human rights body" provides an example of how public health can be jeopardized when human rights are ignored.

The United Nations Universal Declaration of Human Rights (UDHR) is a document created as a result of the atrocities experienced during World War II.  Article 25 addresses the right to an adequate standard of living.  This includes the basic rights to food, clothing, shelter, and medical care.  Medical care makes an obvious connection to health.  It is important for everyone to have rights to medical care because, from the public health perspective, if a person or group of persons do not have access to health care (most likely for financial reasons) it could lead to spreading of unidentified diseases and increased rates of mortality.  Health care, however, has been a very controversial issue lately.  Besides medical care, food and shelter can also relate to health.  Over spring break I experienced first-hand the relationship  between shelter and health.  In the poor, rural areas of Belize, many communities live in homes can could be detrimental to their health.  For example, most families I visited had outdoor bathrooms without seat covers.  This is a major health issue because these bathrooms can lead to parasites and other diseases with negative health effects; what's worse is that most families are not aware of these dangers until it's too late.

The second article we read discussed how maternal mortality was handled as a human rights issue.  The specific case surrounding the issue was that of Brazilian Alyne da Silva Pimentel -- known as Alye da Silva Pimentel v. Brazil -- a woman who died of pregnancy-related causes that may have been prevented with proper emergency obstetric care.  Her mother took her case to the CEDAW committee, which established the human rights obligation to guarantee women of all racial and economic backgrounds equal access to appropriate maternal health services.

I think motherhood is specifically mentioned in the UDHR and addressed by the CEDAW because unlike men, mothers and mothers-to-be are responsible for another human being who also deserves rights.   Article 3 of the UDHR states that "everyone has the right to life, liberty, and security of person, so proper health care to pregnant women is imperative in order to enforce this right.  Maternal mortality also effects the child’s life, if it lives through childbirth, because infants need their mothers. 

Contagion

While watching the movie Contagion for the first time this week, I was most definitely on the edge of my seat.  I can't imagine a disease so deadly spreading across the globe and science not having the means to stop it or even determine its origin.  The movie did a sufficient job conveying how public health issues are handled from both the political and scientific prospective.  I especially liked the last scene of the movie that revealed the origin of the disease.  

The concepts of outbreak and outbreak investigation are important to public health and relevant to the movie.  An outbreak exists when the number of cases of disease exceeds the expected for a given time, place, or population; it is a sudden rise in the incidence of disease.  In the movie, the outbreak was a result of humans consuming an infected food.  The disease was highly contagious with a short period between contraction of the disease and death.  Once the outbreak was known, public health officials began an outbreak investigation starting with confirming the existence of the outbreak, defining and identifying cases and populations at risk, and eventually evaluating a hypothesis and beginning control and prevention measures.  In the movie, the public health officials realized that the disease did not target any specific group; every person was equally likely to become exposed once it started to spread.  However, scientists could not create a vaccine for the disease before lives were lost on a grand scale.  Isolation and quarantine are also important concepts.  Isolation separates people from other people to prevent the spread of infection.  Isolation is used for people who have already been sick from the disease.  In the movie, the sick were often isolated socially as more and more people became sick; nurses and doctors did not want to help at the risk of contracting the highly contagious, untreatable disease themselves.  Quarantine, however, is for people who have probably been exposed, but are not yet sick.  In the movie, the man who lost his wife and son had probably been exposed and there is a scene that shows him being quarantined.  

On another note, a major sector of public health is preparedness.  In his lecture on public health preparedness and disaster management, Dr. Barnett stressed epidemiological investigations and surveillance as a means for preparedness.  He mentioned that in Maryland - and many other states - it is required by law that a physician must report certain diseases to the local health department.  The only problem with this measure, however, is that many diseases are unreported.  In the movie, it was evident that at first that the disease was unreported because the first symptoms were similar to the common flu.  Also, there were a few situations in the movie where public health agencies could have been better prepared.  There was a scene where the father mentioned before and his daughter attempted to get food being distributed by the army.  It was evident that the distribution was chaotic and ineffective when they ended up not being able to obtain any food.  Public health agencies also could have been better prepared on the political front.  For awhile, doctors were faced with prophet versus profit accusations.  

      

Climate Change: The Public Health Response

Global climate change has become one of the more recent public health issues in society.  When it comes to climate change, effects on human health spread far and wide.  There are different regional and population variations and complexity issues that make it such a threat.  Humans are at increased risk directly for injury by severe weather, heat exposure, and food and water-borne illnesses.

Table 1 depicts weather events and their health effects.  Two events that may directly affect my friends and family include heat waves and increased ozone pollen formation.  Living in the Ohio River valley region of Kentucky, heat waves and pollen can be a dangerous problem.  My family has bad allergies, so high pollen directly effects our attitudes and motivations to be active.  Increased pollen formation and heat waves are two of the contributing factors to my own development of asthma as a sophomore in high school.  As an athlete, this effected my performance.  Also, in past summers, my high school field hockey team could not practice sometimes as a result of intense heat waves.  One thing in the table I had not thought about before was climate change affecting mental health.  It was mentioned in the article that there is not much data on this effect at present, but I am interested to hear if there is a true correlation.

In terms of climate change, mitigation suggests reducing greenhouse gas emission through structures like energy companies, transportation, and architecture.  The idea of mitigation corresponds to primary prevention, which aims to prevent onset of injury or illnesses through means such as immunizations.  On the other hand, adaptation is a concept homologous to secondary and tertiary prevention, which aim to diagnose disease early to control its advance and reduce morbidity after the disease is diagnosed.  Adaptation is different from mitigation in that it aims to anticipate the effects of climate change and reduce the associated health burden through more conventional medical and public health practices.

Most of the article focused on the ten essential public health services that can provide the framework for climate change adaptation and other public health issues.  One specific example of how public health professionals help people adapt to climate change is through the mobilization of community partnerships and action to identify and solve health problems.  For example, collaborations between architects, city planners, transportation cabinets, and even the faith community all work toward this goal.  I found the impact of faith communities particularly interesting because this partnership did not readily come to mind; however, I understand how they would be an effective tool.  By working with faith communities, public health advocates can more effectively disseminate information about how to maintain a 'greener' community.

My home town, and cities all across the country, are taking measures to respond to global climate change.  In 2005, the mayor of Louisville, Kentucky signed the US Conference of Mayor's Climate Protection Agreement, which obligated our city to take measures to reduce our communities greenhouse gases.  Since then, the Climate Change Committee has aggregated and organized a more intricate process for reducing the issue climate change.  Some of the things I do to help mitigate or adapt to climate change is unplug electronics when not in use, conserving water, and using water bottles rather than plastic bottles.  I encourage my friends and people around me to do the same.

Greatest Public Health Achievements

This week's assignment focused on the achievements our country has made on the public health front, specifically within the past decade.  The article was very informative.    It provided statistics to show improvement in several areas.  I found the article a little boring because it was basically just a list, but it presented the achievements in a clear, concise manner.  Most public health articles are concerned with what still needs to be fixed, so it was refreshing to see a paper that reflected on the positive outcomes of what we have already accomplished.  The world is a lot safer and healthier now, not because of health care, but because health advocates have changed the structures of the world to make it a healthier and safer place.

Two of the achievements from the list that particularly resonate with me are tobacco control and motor vehicle safety.  Tobacco use has been very prevalent in my home town in Kentucky in the past.  I have witnessed first-hand the effects of smoke-free laws and tax increases on tobacco products.  As an asthmatic, second-hand smoke can make me feel incredibly uncomfortable and even spark an attack.  Smoke-free laws in restaurants have made it easier for me to go out without worrying about having my inhaler by my side.  Also, many of my friends in high school used tobacco products.  However, when prices began to increase, less and less people continued to smoke.  Not only do I see this as an achievement for tobacco control, but tax like these are also preventing young people like my friends from developing health problems, like lung or mouth cancer, later in life.  Tobacco-use is still an issue in towns like mine across the country, however, the obvious improvements point toward a positive direction.

Achievements in motor vehicle safety also resonates with me personally.  The development of the seat belt and other safety features make the roadways safer and have saved thousands of lives.  Unfortunately, I've already seen some of my own friends die or become seriously injured in accident related deaths, usually as a result of not wearing seat belts.  While motor vehicles themselves have become much safer, enforcement of these safety features must be more strongly emphasized.  Newer cars use negative reinforcement by making an obnoxious beeping sound until the driver and passenger put on their seat belts.  

One public health problem that is not stressed enough currently is the issue of obesity.  Obesity is a major public health issue because it leads to costly health complications--like diabetes or high blood pressure--that are usually otherwise preventable.  Small improvements have begun, but I think it must be treated more aggressively in upcoming years to be considered an achievement by 2020.  For instance, by the time I graduated high school, soda was no longer available in vending machines.  Because our only options were water or other juices, students drank less soda.  Also, some fast food restaurants like Chipotle have added calorie counts to their menus, so that customers are aware how much they are consuming.  I think an effective way to combat obesity is to focus on the younger generations.  If we encourage kids to exercise on a regular basis, they will be more likely to make the choice to stay fit later in life.