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CDC opens a docket for reduction of UV exposure

Posted on: August 16, 2013   by  Vitamin D Council

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The Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services (HHS) announces the opening of a docket to obtain information from the public on preventing skin cancer through the reduction of UV exposure. The information obtained will be used for an anticipated Office of the Surgeon General response to the public health problem of skin cancer.

They invite comments and information on environmental or systems strategies; interventions that reduce exposure to UV radiation; and national-, state-, tribal-, territorial-, community-, organizational-, and individual-level actions.

They claim use of sun protection is low, while excessive sun exposure, indoor tanning, and sunburn are common. HHS/CDC and the Office of the Surgeon General are interested in receiving information on the following topics:

  1. Barriers to reducing UV exposure from the sun and from indoor tanning devices, and;
  2. Evidence-based strategies to reduce UV exposure in the population by increasing the use of sun protection and reducing tanning behaviors.

You can find how to submit your commentary here: https://www.federalregister.gov/articles/2013/08/05/2013-18766/preventing-skin-cancer-through-reduction-of-uv-exposure

Or you can submit commentary online here: http://www.regulations.gov/#!docketDetail;D=CDC-2013-0014

The Vitamin D Council is disappointed in the unbalanced sun exposure message that the Office of the Surgeon General is headed toward. There is emerging evidence that lack of sun exposure and subsequent vitamin D deficiency are leading to many diseases and illnesses.

While skin cancer does need attention, so do many other diseases that show a relationship with lack of sun exposure, including multiple sclerosis, colon cancer, breast cancer and more. Thus, it seems prudent and more evidence-based to promote a sun exposure message that takes skin cancer, multiple sclerosis, colon cancer, breast cancer all into account.

We implore Vitamin D Council members to submit commentary. Dr Cannell submitted his commentary. He wrote:

Dr Cannell’s commentary

Federal register

“Preventing Skin Cancer through Reduction of UV Exposure,” by J. Ronald Campbell, Director, Division of Executive Secretariat, Centers for Disease Control and Prevention.

Federal Register / Vol. 78, No. 150 / Monday, August 5, 2013 / Notices (Notice Posted: 08/05/2013, ID: CDC-2013-0014-0001.

Dear Sir:

This document entirely disregards the role of sunlight in making vitamin D. In fact, Dr. Campbell does not mention vitamin D in the document. The importance of vitamin D in human health is hard to overstate.

Hossein-Nezhad A, Holick MF. Vitamin D for health: a global perspective. Mayo Clin Proc. 2013 Jul;88(7):720-55.

First, I will discuss melanoma. Dr. Campbell claims there is a melanoma epidemic, without mentioning it is an epidemic of stage one disease, that is, more melanoma is being diagnosed by pathologists but not by oncologists. In fact a growing number of experts think the melanoma epidemic is a “midsummer’s night dream.”

Levell NJ, Beattie CC, Shuster S, Greenberg DC. Melanoma epidemic: a midsummer night’s dream? Br J Dermatol. 2009 Sep;161(3):630-4.

Swerlick RA, Chen S. The melanoma epidemic: more apparent than real? Mayo Clin Proc. 1997 Jun;72(6):559-64.

If melanoma were caused by chronic sunlight exposure, then melanoma — like squamous cell skin cancer — would be more common in outdoor workers than indoor workers, and melanoma would be more common — like squamous cell skin cancer — in sun-exposed areas of the body. However, neither is the case.

Rivers JK. Is there more than one road to melanoma? Lancet. 2004 Feb 28;363(9410):728-30. Review.

Don’t misunderstand me; sunburns clearly increase the risk of melanoma, especially blistering sunburns. However, as with other cancers, genetics play a more important role in causing malignant melanoma, especially the number of moles you have.

Shenenberger DW. Cutaneous malignant melanoma: a primary care perspective. Am Fam Physician. 2012 Jan 15;85(2):161-8.

When the author talks about the association of sunlight with non-melanoma skin cancer, he fails to discuss the increased risk of 12 internal cancers that are associated with reduced sunlight exposure.

Lin SW, Wheeler DC, Park Y, Cahoon EK, Hollenbeck AR, Michal Freedman D, Abnet CC. Prospective study of ultraviolet radiation exposure and risk of cancer in the U.S. Int J Cancer. 2012 Apr 26.

In 2012, van der Rhee and colleagues reported the following:

“The evidence that chronic (not intermittent) sun exposure decreases the risk of colorectal, breast, prostate cancer and lymphoma is accumulating and gradually getting stronger. We therefore think that, particularly in countries with moderate climate, intermittent sun exposure (and sunburn) should on the one hand be discouraged, because of skin cancer prevention, while on the other hand (moderate) chronic sun exposure possibly should be advised.”

van der Rhee H, Coebergh JW, de Vries E. Is prevention of cancer by sun exposure more than just the effect of vitamin D? A systematic review of epidemiological studies. Eur J Cancer. 2012 Dec 10.

On its website, Cancer Research UK reports that “by enjoying the sun safely and avoiding sunburn, people can reduce their risk of skin cancer and enjoy the beneficial effects of the sun.” In 2005, Cancer Council Australia was the first national cancer council to recognize a balanced recommendation in a statement titled, “Risks and benefits of sun exposure.”

Also, sunlight appears to have independent non-vitamin D benefits for humans. This year, Liu and colleagues reported that sunlight lowers blood pressure with a mechanism other than vitamin D production.

Liu D, et al. UVA lowers blood pressure and vasodilates the systemic arterial vasculature by mobilization of cutaneous nitric oxide stores. Journal of Investigative Dermatology, 2013. Abstract 1247.

Dr. Becklund and Professor Hector Deluca of the University of Wisconsin were the first to discover that vitamin D retarded progression of an animal model of multiple sclerosis called “experimental autoimmune encephalomyelitis” (EAE). While vitamin D suppresses the progression of EAE, continuous treatment with artificial ultraviolet radiation (as in sunbeds) works even better. He concluded that ultraviolet light was likely suppressing EAE independent of vitamin D production, and that vitamin D supplementation alone cannot replace UV light in an animal model of MS. If true in humans, it means that UV light contains something good in addition to vitamin D.

Becklund BR, Severson KS, Vang SV, DeLuca HF. UV radiation suppresses experimental autoimmune encephalomyelitis independent of vitamin D production. Proc Natl Acad Sci U S A. 2010 Apr 6;107(14):6418-23. Epub 2010 Mar 22.

Finally, what about the recent study that showed those with non-melanoma skin cancer were much less likely to get Alzheimer’s disease (OR=5)?

Robert RS, White RS, Lipton RB, Hall CB and Steinerman JR. Nonmelanoma skin cancer is associated with reduced Alzheimer disease risk. Neurology. 2013 May 15.

This is a very one-sided document.

John Cannell

13 Responses to CDC opens a docket for reduction of UV exposure

  1. Rita and Misty

    Thank you Vitamin D Council, and thank you Dr. Cannell.

    I hope every single one of US will consider submitting a commentary. Our comments don’t have to be eloquent, just factual..and I have confidence that we all have the knowledge to submit a comment in favor of appropriate sun exposure to this very one-sided document.

    Please note the following deadline:

    Written comments must be received on or before September 4, 2013.

    Also for those who might need some background, here is my favorite j.a. on sunshine:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2290997/

  2. IAW

    Sorry to hear this Dr. Cannell! Just when you think things can’t get any worse…….! Take care of yourself, we need you for the “long haul” ahead!
    Ivy

  3. Rita and Misty

    From your cyberspace mouth to G-d’s ears, Ivy…

    We truly do need Dr. John Cannell to take very good care of himself…He’s the inspiration behind this entire movement.

    Trust me..I know (now) that this type of outreach is exhausting and frustrating work…

    Dr. Cannell, I chat with tons of people, all over cyberspace–You are beloved by so many.

    🙂 Always remember that when mainstream medicine gets you down…there are many of us willing to go to bat for you.

  4. mbuck

    Sent one in, loosely based on my recent letter.

    mbuck

  5. Rita and Misty

    This is one of my favorite blogs written by Dr. Cannell:

    https://www.vitamindcouncil.org/blog/proceed-at-your-peril/

  6. John

    If the CDC truly wanted to help the public they would not do it in this manner. Their tone is that all UV exposure is bad. Clearly the CDC is getting paid to promote that UV exposure is bad, except that used by phototherapy Doctors. These are the same Drs that suggest purchasing a phototherapy machine similiar to a sunbed that you can use at home because they say it is safe.

  7. Rita and Misty

    To VDC readers, I plan to post this response later on today…if there are any suggestions I might incorporate, please let me know! Rita.Umile@Yale.edu.

    Dear Sir,

    I am disappointed in the CDC’s one-sided response to sun exposure. Currently much of the world suffers from vitamin D deficiency. So, I find it disturbing that Dr. Campbell neglected the role of sun exposure in vitamin D production. He does not once mention vitamin D in his entire document. I question why Dr. Campbell has chosen to ignore the necessity of vitamin D, which is a very important nutrient and so essential for our good health?

    To quote Dr. Michael Holick: “Vitamin D has received worldwide attention not only for its importance for bone health in children and adults but also for reducing risk for many chronic diseases including autoimmune diseases, type 2 diabetes, heart disease, many cancers and infectious diseases. Vitamin D deficiency is pandemic due to the fact that most humans have depended on sun for their vitamin D requirement which they now either avoid or wear sun protection for fear of skin cancer….” (April 2012 in Dermatoendocrinol.4(2): 183–190).

    In my opinion, Dr. Campbell’s document will only serve to ensure that vitamin D deficiency continues to be the #1 public health issue of this century.

    Please allow me to present the positive side of sunshine that Dr. Campbell has so willfully neglected.

    However, I will first agree with Dr. Campbell–no one may dispute that melanoma cases are on the rise, and that excessive sun exposure is an established risk factor for cutaneous malignant melanoma. I simply choose to also examine and note the benefits of sunshine, and request that scientists, researchers and healthcare professionals consider the evidence in favor of appropriate sun exposure:

    • High sun exposure was linked with increased survival rates in patients with early-stage melanoma in a study reported by Marianne Berwick, an epidemiology professor at the University of New Mexico, in the February 2005 Journal of the National Cancer Institute.

    • Dr. Michael Holick has observed that most melanomas occur on the least sun-exposed areas of the body, and occupational exposure to sunlight actually reduced melanoma risk in a study reported in the June 2003 Journal of Investigative Dermatology.

    • There is increasing evidence that at least 12 other cancers, for example: Hodgkin Lymphoma, breast, ovarian, colon, pancreatic, prostate cancers, all could result from too little sun exposure. (Lin SW, Wheeler DC, Park Y, Cahoon EK, Hollenbeck AR, Michal Freedman D, Abnet CC. Prospective study of ultraviolet radiation exposure and risk of cancer in the U.S. Int J Cancer. 2012 Apr 26.)

    • It known that there is a latitudinal gradient for MS, as well as for type 1 diabetes, with higher incidence at higher latitudes; and, there also appears to be a connection with type 2 diabetes and cardiovascular disease, as there are studies which have demonstrated high prevalence of low vitamin D levels in people with type 2 diabetes.

    • According to Thomas Wang, MD, “People living at higher latitudes throughout the world are at higher risk of hypertension, and patients with cardiovascular disease are often found to be deficient in vitamin D”( 29 January 2008 issue of Circulation.)

    • William Grant, PhD, Director of the Sunlight, Nutrition, and Heath Research Center and Board Member of the Vitamin D Council, thinks that sun exposure and higher 25(OH)D levels may be protective against illnesses such as rheumatoid arthritis (RA), asthma, and infectious diseases by inducing cathelicidin, which is a polypeptide that effectively combats both bacterial and viral infections. Grant has written that: “This mechanism explains much of the seasonality of such viral infections as influenza, bronchitis, and gastroenteritis, and bacterial infections such as tuberculosis and septicemia.” Evidence points to RA being more severe in winter when 25(OH)D levels tend to be lower, and is also more prevalent in the higher latitudes. In addition, 25(OH)D levels are inversely associated with the clinical status of RA patients, and greater intake of vitamin D has been linked with lower RA risk. (January 2004 in Arthritis & Rheumatism)

    In my opinion, the Office of the Surgeon General will be delivering not only an unbalanced, but also unsafe, message to the general public if it succeeds in its strategies to reduce UV exposure in the population by increasing the use of sun protection and reducing tanning behaviors.

    There is simply too much evidence emerging on the benefits of appropriate sun exposure, as well as sufficient vitamin D blood levels, in the prevention of many diseases and illnesses.

    Certainly, everyone will agree that skin cancer is quite serious and does demand attention. However, astute scientists, researchers, and healthcare professionals will realize that so do diseases which indicate a relationship to lack of sun exposure, for example: autoimmune diseases such as multiple sclerosis, cancers such as colon cancer and breast cancer, and neurological conditions such as autism and Parkinson disease.

    Perhaps a more sensible sun exposure message would consider not only skin cancer, but also our overall health and wellbeing! To negate the health benefits of the sun is to foolishly take our good health for granted.

    Sincerely,

    Rita Celone Umile

  8. Mama18

    Posted – I appreciated Rita’s template. Thank you for sharing.

  9. Rita and Misty

    You are welcome, Mama18…I so hope we members of the Vitamin D Council inundate that CDC website.

    We must.

    Unite, Support, Direct, Push Forward.

  10. IAW

    Sent comment to CDC on 8/25/2013.
    Ivy Walsh

  11. Rita and Misty

    It concerns me that as of August 26, 2013 at 10:00 a.m. ET there are only 29 comments on the CDC site. VDC members–please consider posting a comment on this site. There is strength in numbers. It is one of the very few things I do believe.

  12. Rita and Misty

    Melanoma as a genetic disease

    A Brief History of Melanoma: From Mummies to Mutations
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303163/

    “The recent years have seen melanoma research undergo a renaissance. What was once viewed, at least in the metastatic setting, as an intractable and untreatable disease is now revealing its molecular weaknesses. 2011 was a landmark year for melanoma therapy with two new agents, the anti-CTLA4 antibody ipilimumab and the BRAF inhibitor vemurafenib, shown to confer a survival benefit in randomized phase III clinical trials. Forgotten in the recent flurry of interest that has accompanied the development of these drugs, melanoma is in fact an ancient disease that has long frustrated attempts at therapeutic intervention. In this article we trace the history of melanoma; from the earliest known cases of melanoma in pre-Colombian South America, through the explorations of the Victorian anatomists right up to the molecular biology revolution of the 20th century that allowed for the identification of the key driving events required for melanomagenesis. We further outline how observations about melanoma heterogeneity, first made over 190 years ago, continue to drive our efforts to reduce melanoma to the level of chronic, manageable disease and ultimately cure it entirely.”

  13. Rita and Misty

    I am submitting a second comment on the matter of Preventing Skin Cancer through Reduction of UV exposure in an effort to better define the scope of the problem, as originally presented by Dr. Campbell.

    To quote Dr. Campbell: “Skin cancer rates, including rates of melanoma, are increasing in the United States and worldwide. An estimated 3.7 million cases of basal and squamous cell carcinomas and about 60,000 cases of melanoma are diagnosed in the U.S. annually, with approximately 8,500 deaths from melanoma. Melanoma, which causes more deaths than other types of skin cancer, is one of the most commonly diagnosed cancers among U.S. adolescents and young adults”

    Dr. Campbell further states:

    “A majority of skin cancers are caused by exposure to ultraviolet (UV) radiation from the sun or from indoor tanning devices, and are therefore preventable. Evidence clearly links exposure to UV radiation and a history of sunburn (indicating both intensity of UV exposure and skin sensitivity to radiation) to an increased risk of skin cancer.”

    Although Dr. Campbell is correct in stating that the majority of skin cancer cases reported in the US and worldwide are basal and squamous cell carcinomas, he neglected to include that both of these cancers are easily treated and cured in most cases. In other words, they are not life threatening cancers.

    Dr. Campbell also neglected to consider the benefits that sun exposure provides against many cancers, including melanoma.

    This is a point worth arguing.

    It is true that melanoma is a life threatening cancer; and, current research does indicate that cutaneous malignant melanoma has increased more than three-fold in the past 35 years. There is also evidence that because damage is cumulative, exposure to ultraviolet radiation early in life elevates a risk that is increased further as individuals use artificial sources of ultraviolet radiation.

    However, if as Dr. Campbell states, there are approximately 60,000 new cases of melanoma diagnosed annually in the U.S., with 8,500 deaths, this represents only a 14% mortality rate on a small number of annually-diagnosed cancers. In other words, although melanoma does cause more deaths than any other type of skin cancer, the percentage of mortality is still very low.

    Perhaps the melanoma epidemic referred to by Dr. Campbell is really an epidemic of stage one disease, being diagnosed by pathologists but not by oncologists. In other words, the majority of people diagnosed with melanoma are cured from melanoma.

    It is also important to note that the epidemiology of cutaneous malignant melanoma is contradictory.

    While sufficient evidence does indicate that sun exposure, specifically ultra-violet (UV) exposure, is a major environmental cause of melanoma, especially in high-risk populations; and melanoma incidence and mortality among Caucasians correlate with latitude of residence and dose of UV radiation, the highest rates being near the equator, other studies have found that melanoma does not occur more frequently on the areas of the body most often exposed to sunlight. Additionally, indoor occupations are at higher risk than outdoor occupations for melanoma diagnosis; and, a high lifetime exposure to sunlight has also been shown to decrease risk of melanoma.

    Furthermore, current research indicates that recreational (intermittent) sun exposure, (as well as multiple sunburns) is a strong predictor of melanoma, with more consistent exposure conveying a protective effect.

    This is because while sun exposure does increase the risk of melanoma, it also potentiates cutaneous synthesis of vitamin D, which can inhibit melanoma cell growth and also promote apoptosis.

    “There is, indeed, evidence that vitamin D produced in the skin acts by way of local autocrine or paracrine effects to protect kerathinocytes from UV carcinogenesis.” Mandelcom-Monson, Rochelle, et al, “Sun Exposure, Vitamin D Receptor Polymorphisms Foki and Bsmi, and Risk of Multiple Primary Melanoma,” Cancer Epidemiology, 2011

    I find this to be one of the major faults of Dr. Campbell’s document. He neglects to consider the great importance of sun exposure with respect to cutaneous synthesis of vitamin D, which has been shown to provide both a preventative and curative effect for melanoma.

    He also neglects to consider the increasingly good evidence that at least 12 other cancers, such as Hodgkin Lymphoma, breast, ovarian, colon, pancreatic, prostate cancers, all could result from too little sun exposure.

    To quote Dr. Michael Holick: “Vitamin D has received worldwide attention not only for its importance for bone health in children and adults but also for reducing risk for many chronic diseases including autoimmune diseases, type 2 diabetes, heart disease, many cancers and infectious diseases. Vitamin D deficiency is pandemic due to the fact that most humans have depended on sun for their vitamin D requirement which they now either avoid or wear sun protection for fear of skin cancer….” (April 2012 in Dermatoendocrinol.4(2): 183–190).

    Dr. Campbell must consider what the total disease burden would be if the CDC encourages even further sun avoidance by the general public, as nearly all vitamin D derives from the action of UVB on steroid precursors in the skin, with subsequent conversions in the kidney, liver, or target tissues to produce the active hormone. Only a very small amount of vitamin D is available from food sources, such as fatty fish (which is not a staple of the standard American diet); and currently most, if not all of our population is at suboptimal vitamin D blood serum levels, even utilizing the IOM sufficiency level of 20 ng/ml. As there is good evidence indicating vitamin D is necessary for bone health, autoimmune diseases, type 2 diabetes, heart disease, cancer and infectious diseases, the total disease burden stands to be quite high with very low UVR exposure, if such a plan is not accompanied by a compensatory plan to increase vitamin D through oral supplementation or food fortification.

    Yes, we can conclude that skin cancer rates, including rates of melanoma, are increasing in the United States and worldwide. But, it is also true that basal and squamous cell carcinomas are not life-threatening cancers, and that cutaneous synthesis of vitamin D can protect us from melanoma (which is a life-threatening cancer) and possibility 12 other internal cancers, autoimmune diseases, high blood pressure and cardiovascular disease.

    And, it is also true that vitamin D deficiency is at pandemic levels.

    Although Dr. Campbell does have a valid point with respect to reducing dangerous levels of UV exposure from the sun and from indoor tanning devices, he presents his point in an unbalanced message. A healthier message would include appropriate sunning protocols, designated by skin levels, to accommodate the production of cutaneous synthesis of vitamin D, as well as a compensatory plan to improve vitamin D sufficiency within the population through oral supplementation and/or food fortification.

    In my opinion, Dr. Campbell’s document contains serious flaws by his neglecting to consider the following points:

    1. The role of sun exposure as necessary for production of cutaneous synthesis of vitamin D;
    2. The evidence that cutaneous vitamin D has both a preventive and possibly curative effect with respect to melanoma;
    3. That optimal vitamin D blood serum levels play important roles in reducing risk of bone disease, autoimmune diseases, type 2 diabetes, heart disease, many types of cancers and infectious diseases;
    4. That there is currently a vitamin D pandemic;
    5. That his recommendations do not consider a compensatory vitamin D plan through oral supplementation and/or food fortification.

    If accepted as presented, Dr. Campbell’s recommendations will ensure that that vitamin D deficiency continues to be the #1 public health issue of this century.

    Sincerely,
    Rita Celone Umile

    Chan, Yu-mei, et al, Sun exposure and melanoma risk at different latitudes: a pooled analysis of 5700 cases and 72156 controls, Int J Epidemiology, 2009, June 38(3) 814-830.

    Garland, Frank C. and Garland, Cedric F. “Occupational Sunlight Exposure and Melanoma in the US Navy” 1990 Archives of Environmental Health (Vol. 45 #5)

    Michael Holick, “Evidence-based D-bate on health benefits of vitamin D revisited”
    Dermato-endocrinoly , April 2012 in 4(2): 183–190).

    Levine, Hagai, et al, “Country of origin, age at migration and risk of cutaneous melanoma: A migrant cohort study of 1,100,00 Israeli men” International Journal of Cancer, 2013

    Lin SW, Wheeler DC, Park Y, Cahoon EK, Hollenbeck AR, Michal Freedman D, Abnet CC. “Prospective study of ultraviolet radiation exposure and risk of cancer in the U.S.” Int J Cancer. 2012 Apr 26.

    Lucas, Robyn M, et al, “Estimating the global disease burden due to ultraviolet radiation exposure” Int. J. Epidemiology (2008)37(3) 654-667

    Mandelcom-Monson, Rochelle, et al, “Sun Exposure, Vitamin D Receptor Polymorphisms Foki and Bsmi, and Risk of Multiple Primary Melanoma, Cancer Epidemiology, 2011

    Taddeo, Daniell, et al “Banning children and young younger than 18 years of age from commercial tanning facilitie” Paediatr Child Health, 2012 February 17(2):89.
    Garland, Frank C. and Garland, Cedric F. “Occupational Sunlight Exposure and Melanoma in the US Navy” 1990 Archives of Environmental Health (Vol. 45 #5)

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