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Published 22 July 2008, doi:10.1136/bmj.

a764
Cite this as: BMJ 2008;337:a764

Head to Head
Is sun exposure a major cause of melanoma? No
Sam Shuster, honorary consultant
1

Department of Dermatology, Norfolk and Norwich University Hospital, Norwich NR4 7UY

Every summer we are reminded about the dangers of the sun. Scott Menzies (doi: 10.1136/bmj.a763)
argues that the risks of malignant melanoma are real, but Sam Shuster is unconvinced
The list of harmful things grows daily, freshly mined by descriptive epidemiology, a substitute for
research that confuses association with cause. Although most disappear under the weight of their own
inconsequence, the alleged increase in melanoma from ultraviolet radiation has survived on the life
support of regular promotion. I am therefore setting out what is known, which is rather different from
what is believed.

Does ultraviolet light cause melanoma?


There is solid descriptive, quantitative, and mechanistic proof that ultraviolet rays cause the main skin
1

cancers (basal and squamous). They develop in pale, sun exposed skin, are related to degree of
2

exposure and latitude, are fewer with avoidance and protection,

3 4

are readily produced experimentally,

and are the overwhelmingly predominant tumour in xeroderma pigmentosum, where DNA repair of
ultraviolet light damage is impaired.
None of these is found with melanoma. Variation is more ethnic

56 7

than pigmentary, and 75% occur on

relatively unexposed sites, especially the feet of dark skinned Africans.


small and inconsistent in, for example, Europe
greater exposure

7 8 9 10 11 12 13 14 15 16 17

10

The relation to latitude is

11

and the United States ; incidence and mortality fall with

; incidence is unaffected or increased by use of sunscreens

and the effect of sun bed exposure is small and inconsistent.


produce experimentally with ultraviolet

6 7

20

19

18

In addition, melanomas are difficult to

light and are far less common than non-melanoma cancers in

xeroderma pigmentosum.
Therefore, the effect of ultraviolet light can only be minimal, and the case against a major role is clear.
Attempts to relate light exposure to surface area and site are irrelevant, since the cell of origin of
melanoma and its distribution are unknown. The suggestion that the poor correlation of melanoma to
ultraviolet light is because the causal event is sunburn from intermittent exposure in early life
21

13 14 15 16 17

is easily excluded, because the melanomas would then occur at the burn sites; there is no evidence

for this, and it is unlikely that any will be found, because sunburn occurs in sun exposed sites, and these
are not the sites at which melanomas occur.

7 8

There is an association between melanoma and number of naevi,


to ultraviolet light

22 23

13 22

and naevi increase after exposure

; but this does not implicate ultraviolet light in the aetiology of melanoma, for the

same reasons related to site. The likely explanation of the association is that stimulation of naevus

growth by ultraviolet light simply increases the number of visible (and therefore countable) lesions. The
associated histological changes can be indistinguishable from melanoma, as is the case with the benign
lesions of lentigo maligna in elderly people, sun bed users, and psoriasis patients treated with psoralen
and ultraviolet A; benign naevi stimulated by shave excision; and juvenile melanoma. Thus, unlike for
squamous and basal cell cancers, there is no proof that ultraviolet light exposure is a significant cause of
melanoma.

Is the reported increase in melanoma real?


In the past, naevi were left untreated and usually caused no harm. Then, fear of litigation and the search
for early lesions led to removal of benign lesions; this introduced an ambiguity into histological
classification, which eventually changed the definition of malignancy. Those who observed the process
24

believe misdiagnosis of benign naevi explains the melanoma epidemic. This view is supported by the
findings of the Eastern region of England that the increase in new "melanomas" during 1991-2004 was
entirely due to benign naevi (Levell et al, personal communication); a melanoma mountain in Australia
has also been attributed to confusion with a benign disease.
melanomas and higher social class

26

25

The relation between incidence of new

is best explained by removal of benign naevi after health warnings

and encouragement to attend "pigmented lesion clinics"the middle classes are always first on the
scene.

27

The subjective histopathological criteria used to diagnose melanoma have become too vague for use
and are commonly found in benign disease. This problem can be resolved only by research, including a
blind re-examination of histological slides used for past and present diagnoses, and a better distinction
between benign and malignant changes in naevi.

24 27

Meanwhile, it can only be concluded that the

reported increase in melanoma is probably an erroneous reclassification of benign naevi. Thus the
question of whether ultraviolet light causes melanoma becomes irrelevant, because there is no case to
answer.

Balancing the effects of ultraviolet light


Of course we know that ultraviolet light causes the common, virtually benign, and mostly trivial skin
cancers and that, like smoking, it makes the skin look as if it has been well lived in. But is this enough to
justify blanketing the sun when balanced against the possible advantages? We know the sun makes us
28

feel better, although not how ; we need skin synthesis of vitamin D for our bones; ultraviolet light may
protect against some forms of cancer

29

14

including melanoma ; and it has important, unexplained

30

immunological effects. We need to know much more before we can balance the biological books on
ultraviolet radiation, even if we can now close the chapter on melanoma.

24

Competing interests: None declared.

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