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2/27/2017 Disclosures I have no relevant conflicts of interest or financial interests to disclose Ultraviolet Radiation Exposure in Work and Life Giorgia Louise Garrett MD Saturday March 11 th 2017 Occupational and Environmental Respiratory Disease and Updates in Occupational and Environmental Medicine 1 2 Sunlight is the main source of UVR Overview • UV radiation UVC UVA VISIBLE IR UVB • The story and biology of skin cancer 100 290 320 400 800 2500 • Cataracts • Artificial UVR in the workplace: welding arcs, • Miscellaneous germicidal lamps, devices for curing and drying printing ink, plastics, paint, UV lasers, mercury vapor lamps, medical UV therapy machines • Artificial UVR used recreationally: tanning beds 3 1

2/27/2017 UVR has numerous effects UVR and the skin Only UVA and UVB reach the earth’s surface UVB: UVA: ‐ 10,000 times ‐ 95% of natural more UV radiation carcinogenic ‐ Penetrates than UVA deeper ‐ Promotes ‐ Responsible for vitamin D photo ‐ aging synthesis Lim et al., JAAD, 2011 6 Acute vs. chronic exposure Skin cancer Non ‐ melanoma Skin Malignant melanoma Cancer (NMSC) • Most common cancer • Common deadly skin cancer Incidence rate • • Incidence rate 23/100,000 100/100,000 person ‐ year 1 person ‐ year 2 • Mortality rate • Mortality rate 3/100,000 ~0.5/100,000 person ‐ year 4 person ‐ years 3 1 Madan et al. Lancet 2010 2 National Cancer Institute. Surveillance, Epidemiology, and End Results Program. 2016 Diepgen et al. Dtsch Arztebl Int. 2012 3 Glazer et al. JAMA Derm 2016 7 8 4 Weinstock et al. JID 2007 2

2/27/2017 Squamous cell carcinoma Actinic keratosis • Arise from normal skin or from actinic keratosis • 0.5% metastasize (esp. to lips, eyelids, and other mucous • Rough, reddened plaques membranes) on sun exposed skin • Pre ‐ malignant: contain morphologically cancer cells but invasion is limited to the most superficial part of the dermis • ~13% develop into SCC 9 10 Basal cell carcinoma Malignant melanoma • Smooth, shiny • Nodular or • Rarely metastasizes but lesion with ulcerated lesion can be locally very telangiectasia destructive 11 12 3

2/27/2017 Is it benign or malignant? The ABCDE Risk factors for skin cancer tool. • UVR is the most important risk factor for skin cancer – Cumulative: SCC – Intermittent: melanoma, BCC • 1992: International Agency for Research on Cancer (IARC) accepted solar UVR as a human carcinogen 1 • Fair skin type, family or personal history of skin cancer, male gender, southern latitude, age >50 and immunosuppression increase the risk further • Behavior related to UV exposure: preventable 1 http://www.iarc.fr/ 13 14 Occupational UV exposure increases the Skin cancer: an occupational disease? risk of cutaneous SCC • 1890, Unna: changes of the skin were observed in 18 studies sailors P for heterogeneity <0.001 • Skin Cancer Foundation: outdoor workers are twice as likely to contract skin cancer as indoor workers • Outdoor: >3 hours/day on a typical work day • Long outdoor hours, shifts at 10am ‐ 2pm, working Pooled OR 1.77 (95% CI 1.40 ‐ 2.22, p<0.001) in altitude, near the equator, and doing repetitive tasks in the same position increases the risk further Schmitt et al. BJD. 2011 15 4

2/27/2017 Occupational UV exposure increases the risk Strength of the association increases with of basal cell carcinoma decreasing (more southern) latitude 23 studies P for heterogeneity=0.0001 Pooled OR 1.43 (95% CI 1.23 ‐ 1.66, p<0.0001) *Log ‐ odds ratio (OR) of the relationship between occupational UV light exposure and SCC †Absolute value of latitude Bauer et. al BJD. 2015 Schmitt et al. BJD. 2011 Germany, 2015: skin cancer is a new What about occupational melanoma? occupational disease • Trakatelli et al., 2016: outdoor workers • Cutaneous SCC and multiple AK (>6 within a chronically exposed to UVR are not at increased 12 month period) due to solar UVR risk of melanoma compared to indoor workers established as a new occupational disease • Sanlorenzo et al., 2015: airline pilots and crew • BCC, melanoma and all skin cancer caused by cabin have twice the incidence and mortality of artificial UV radiation are not melanoma compared to the general population • UK: compensation scheme for war veterans • Outdoor workers: head and neck melanoma, who served in tropical countries and later indoor workers: chest or limb melanoma developed skin cancer Trakatelli et al. BJD. 2016 Sanlorenzo et al. JAMA Derm. 2015 19 20 5

2/27/2017 Establishing the occupational causation of Work ‐ related criteria contributing to skin cancer occupational skin cancer • The individual has to have worked a substantial part of their Work activity needs to double the risk of skin cancer work life outdoors Occupational UV exposure is >40 % of recreational UV • Greater exposure is attributed to working closer to the exposure at the equator or at high altitude time of diagnosis (A carc ) • If only part of the day was spent working outdoors the occupational activity has to have been performed for a longer period of time Diepgen et al. JDDG . 2016 Diepgen et al. JDDG . 2016 21 22 Clinical requirements for the diagnosis of Occupational skin cancer in the US occupational skin cancer • Clinical criteria must be met: • 5 million outdoor workers in the US Location of tumor On irradiated sites • UVR: one of the most frequent occupational Confirmation of diagnosis SCC: by histopathology Multiple AK: clinical diagnosis* carcinogens in American workplaces • Other factors included in the report that are taken into account: • Not formally recognized, but Howard Maibach Signs of chronic UV damage Distribution in occupationally exposed body areas corroborate MD has called it occupational for 40 years the diagnosis Fitzpatrick skin phototype Provided with the report, does not form part of the diagnosis Non occupational risk factors These are taken into account: immunosuppression, presence of photosensitizing drugs Additional 40% occupational UV As calculated by the occupational accident insurance exposure Differences with respect to vacation Number and location of vacation and leisure activities activities • Medical experts, accident insurance, court make a final decision Diepgen et al. JDDG. 2016 23 24 6

2/27/2017 ICNIRP: preventing occupational skin Shade and long sleeves are best sun cancer protection measures • Education on health hazards resulting from the sun • Minimize outdoor work during midday hours in spring and summer (staggering shifts) • Lunch breaks in the shade • Clothing: long sleeve, hats • Eye protection: wrap around design, UVR protection • Broad spectrum sunscreens (SPF> 30), no sun beds Linos et al., Cancer Causes Control, 2006 25 Shade and long sleeves increase risk of My advice for patients vitamin D deficiency Stay in the shade Avoid midday sun Wear a hat Wear long sleeves Use sunscreen (say this last) Take vitamin D in those who ‘look’ deficient Linos et al., Cancer Causes Control, 2006 7

2/27/2017 Tanning beds Cataracts • UV radiation of wavelength <300nm can damage the • Indoor tanning beds: increased risk of skin corneal epithelium cancer • This is most commonly the result of exposure to the sun at high altitude or in areas where shorter • Melanoma: risk even higher if use begins wavelengths are reflected by bright surfaces (snow, before age 35 years 1 sand, water) • Exposure to radiation to a welding arc can cause • WHO, 2009: tanning beds are carcinogenic to welder’s flash burn, a form of keratitis human beings 2 • Sudden onset of pain after a latent period of several hours due to epithelial cell sloughing • Treatment: antibiotic ointment, patches until the epithelium heals 1. Green. Int J Cancer, 2007 2. Ghissassi et al., Lancet Oncol. 2009 29 30 Miscellaneous Thank You • UVR acts as an immunosuppressant: used to Occupational Medicine: Dermatology: treat inflammatory skin conditions such as Paul Blanc, MD Howard Maibach, MD psoriasis Sarah Arron, MD PhD Eleni Linos, MD MPH • UVR and burns 31 32 8