SALT LAKE CITY — After years of jostling with Vermont and New Hampshire for the top spot, Utah has emerged victorious in a contest nobody wants to win.
The state has the highest rate of melanoma in the nation, which is why you'll never find Dr. Glen Bowen outside without a hat.
Bowen, a melanoma specialist at Huntsman Cancer Institute at the University of Utah health complex, is diligent about protecting himself from the sun since he spends his days inspecting and treating the jagged, raised growths that are the calling card of the most deadly form of skin cancer. Business, unfortunately, is great.
Utah has had the nation's greatest incidence of melanoma from 2010 to 2014, the last year for which data is available. Its rates of melanoma have more than doubled in the past 17 years, from 20 to 42 cases for every 100,000 people, according to the Utah Department of Health and the Utah Cancer Registry.
And in Summit County, where the resort town of Park City gleams 7,000 feet above sea level, the rate climbs even higher: 76.8 cases for every 100,000 people between 2012 and 2014.
Those numbers are shocking, even to Utah physicians who deal with melanoma and other types of skin cancer every day.
“The data are pretty consistent. If Utah’s not the highest, it’s one of the highest. In the U.S., the average rate for all races is 21.4. Utah's is 42.3. That’s an amazing number,” Bowen said.
The dark areas are freckles and other blemishes caused by sun exposure on the face of Kevin Johns, an instructor and researcher at BYU. The image was taken with a special camera that records damage not visible on the top layer of the skin. | Dr. Jakob Jensen
While melanoma occurs most often in older men, rates are rising in young women, and the disease's foundation is built early in life. Skin cancer experts believe that 80 percent of the risk of developing melanoma is established before a child turns 18. A few blistering sunburns and a round of indoor tanning in advance of a special occasion could result in chemotherapy in a few decades. The advent of indoor tanning in the 1970s is believed to be one reason melanoma rates have spiked.
“Over the past 100 years or so, the average person’s chances of getting melanoma have increased from about 1 in 1,500 to 1 in 55. We’re currently in the midst of a melanoma epidemic, and most people simply don’t know,” said Kevin John, who teaches at Brigham Young University and directs an eye-tracking laboratory that conducts research on the best ways for people to identify melanoma.
However scary, Utah's high rates of melanoma don't mean everyone in the Beehive State should start preparing to move to Texas, the state with the lowest melanoma rate. Even though the rates are high, the raw numbers aren’t: In 2014, 1,070 Utahns were diagnosed with melanoma, and 81 deaths were attributed to the disease.
The data do suggest, however, that, like Bowen, every member of your family should own a couple of hats, and that health officials should look carefully at Australia, another country geographically inclined to skin cancer but which has cut its melanoma rate. It's also important to know if you're in what dermatologists call a "melanoma-prone family."
Leader of the pack
When it comes to melanoma in Utah, 2004 and 2005 were the good old days. That's when Vermont and New Hampshire, other prime ski territory in the U.S., had the nation's highest melanoma rates. In 2010, however, Utah took the lead, and the Beehive State's rates have inched upward ever since.
In 2014, Utah became the first state to have a melanoma rate in the 40s, with a rate of 42.3 cases per 100,000 people. Vermont's rate in 2014 was 35.7 percent.
While Utah's high rates of melanoma are most often blamed on its altitude and a population enamoured of skiing and hiking, this doesn't explain the gap between Utah and the New England states, or why Colorado doesn't even figure into the top 10.
To explain what's happening in Utah, you also have to look at the dominant population, which Bowen describes as "Mormon immigrants from Scandinavia, northern Europe."
Dr. Steven Kern shows some of the sun protection methods he uses, such as sun hats, at Park City Dermatology in Park City, on Tuesday, Oct. 10, 2017. | Kristin Murphy, Deseret News
“Where Utahns came from genetically is not where they’re living. The people who were genetically built to live in Utah were the Paiute Indians, who have much more pigment in their skin and have much less incidence of melanoma," Bowen said.
Although blacks and Hispanics can develop melanoma and other types of skin cancer, most people who get it have fair skin and light eyes, according to the American Cancer Society.
There's also a genetic component. If someone in your immediate family (a parent, sibling or child) has had melanoma, you're at greater risk of developing skin cancer, health experts say. About 10 percent of melanomas occur within family groups, in part because of a heritable gene mutation that allows cancer cells to grow unchecked. That gene, p16, is thought to be involved in about 40 percent of melanomas in a family.
Utah is also not immune to the popularity of indoor tanning services, which the Centers for Disease Control and Prevention found are concentrated near college campuses and most often frequented by women.
Although a suntan is evidence of skin damage, many people believe it makes them more attractive. Dr. Douglas Grossman, an investigator in Huntsman Cancer Institute's Melanoma Program and a professor of dermatology at the University of Utah School of Medicine, said anywhere from one-third to one-half of his young-adult female patients say they've used tanning beds.
Why rates are highest in men
In Utah, as in the rest of the nation, however, melanoma disproportionately strikes men.
Centers for Disease Control and Prevention | Aaron Thorup, Centers for Disease Control and Prevention
Of all new melanoma diagnoses in Utah, the rate per 100,000 people for males was 54.3 in 2014; for females, it was 32.3, according to the CDC.
The gap widens with age. Among those 65 or older, about 81 women in 100,000 develop melanoma, compared to about 217 men.
Melanoma is the second most common cancer for Utah men, behind prostate cancer. (Nationwide, it's fifth.)
There is no clear reason for the differences in gender, but plenty of speculation. One reason may be that men are less likely to wear sunscreen than women, and are less likely to pay attention to their skin, making a suspicious mole more likely to be overlooked. Others posit that there are biological differences in sun penetration, and that women’s skin may be better at repairing sun damage.
Bowen, of Huntsman Cancer Institute, says that 40 percent of all melanomas in men are discovered by women, usually a spouse. In women, only 6 percent of melanomas are found by men. “You can drive a Mack truck through that statistic,” he said.
In rare cases, melanoma isn't visible and its site of origin may be a mystery, as in the case of former President Jimmy Carter, who had melanoma on his brain. But most often, its beginning is visible, Bowen said.
While basal cell and squamous cell carcinomas most often appear on the head and neck, melanomas most often show up in areas that have intermittent sun exposure: the upper torso, shoulders and back. (In women, but not men, another common spot is the calf.)
Dr. Steven Kern poses for a photo at Park City Dermatology in Park City, on Tuesday, Oct. 10, 2017. | Kristin Murphy, Deseret News
Because men are slow to recognize a potential problem, the cancer is often advanced by the time they see a doctor, which is why death rates in men are also higher than in women.
But that, thankfully, seems to be changing. Dr. Steven Kern, a dermatologist at Park City Dermatology, said there is more awareness of melanoma than when he began practicing about 25 years ago.
“Early in my practice, people came to me for specific problems. They wanted to show me this or that, as opposed to now, many patients come in on a routine basis for skin exams, even people who've had no previous experience with melanoma. Therefore, we’re catching them early, much more so than in the past,” Kern said.
Summit County sun
Sun exposure is a cause of melanoma, and there’s one problem that Utahns can’t solve: altitude. Ultraviolet radiation increases by 7 percent for every 1,000 feet of elevation. Salt Lake City residents live more than 4,000 feet above sea level; Park City residents, 7,000.
“It’s much easier to get burned up here than it is in Salt Lake Valley. It’s a huge concern, and I worry about it,” said Jack Thomas, the mayor of Park City. “It’s not only the high elevation but the reflectability of snow as well.”
Snow reflects 80 percent of ultraviolet light back to the face, which means that skiers atop Utah peaks are getting 150 percent or more of the sunlight that people in Los Angeles are getting.
Thomas noted that many Park City residents live there part-time; they are successful people who have other homes elsewhere. That reflects another commonality of many people who get melanoma. Studies have shown that the disease disproportionately occurs in people of higher socioeconomic status, leading researchers to speculate that skin cancer may be related to leisure time spent in the sun.
Bowen said a study of Scandinavian pilots found that they were twice as likely to develop melanoma than the general population. The cancer was not limited to parts of the body that got sun in the cockpit, however; some of the pilots had melanoma on their backs. The researchers inferred that pilots were more at risk because of their increased opportunity to spend their leisure time in sunny places.
What can be done?
Melanoma is the deadliest of the three most common types of skin cancer: the other two are basal cell carcinoma and squamous cell carcinoma. Although each is associated with sun exposure, melanoma arises from melanocytes, the cells that make pigment. Melanoma starts on the surface of the skin and at first grows horizontally, but if untreated, will begin to grow downward and may spread to other parts of the body.
Some researchers suspect that chronic sun exposure promotes non-melanoma cancer of the skin whereas episodic exposure, such as periodic use of tanning beds, promotes melanoma. “But we don’t really know why that would be,” Grossman said.
People should perform a monthly whole-body skin check, looking for any new moles or changes in existing one, Grossman said. “If you notice something changing from month to month, that would be suspicious. Normal moles don’t change that fast, whereas melanomas do,” he said.
High-risk people might want to consider total body photography so they (and their doctors) can more easily track changes, said Grossman, who directs the institute's Mole Mapping Program.
Melanoma can be cured in most cases when found early. If the growth has turned inward and spread, the five-year survival rate plummets to around 15 percent.
Because of this, skin cancer experts stress early detection — which could be one reason that melanoma rates are increasing, Grossman said. Because of greater awareness, it's possible that more melanomas are being detected and treated at an early stage.
Of course, for this to occur, people have to be paying attention to every square inch of their skin, which is why public-awareness campaigns are believed to be an integral part of combatting melanoma.
In Australia, which has some of the world’s highest rates of skin cancer, one such campaign was on social media. A group called Melonoma Patients Australia created an online persona called Melanoma, which was set up to “like” photos of people out in the sun. The campaign was called “Melanoma Likes Me.”
This followed a national campaign called “Slip! Slop! Slap!” which featured a animated seagull advising children to slip on a shirt, slop on sunscreen and slap on a hat.
Australia’s melanoma rate, which peaked at 49 cases per 100,000 people in 2005, has dropped to 48 and is expected to continue to decline, the Sydney Morning Herald reported.
Closer to home, the Melanoma Research Foundation launched a long-running campaign in 2014 that has an equally memorable, if provocative, tagline. Its #GetNaked campaign encourages people to sign a pledge committing to a monthly skin check.
At Brigham Young University, John’s eye-tracking lab has been studying how people can be more effective at spotting melanoma on themselves and others, since 75 percent of skin cancers are discovered by people with no medical training.
Two acronyms are commonly used to help people decide if a mole might be cancerous: ABCDE, which stands for asymmetry, border, color, diameter and evolving features; and UDS, which stands for Ugly Duckling Sign, meaning a cancerous mole looks significantly different from other moles.
Google is replete with photographs of melanomas, but John and his colleagues found that people were more likely to be able to pick out a melanoma when looking at an illustration rather than a photograph. Conversely, they were more likely to be able to spot a normal mole when looking at a photograph. The findings could help develop more effective training for laypeople, particularly those who live in rural areas with limited access to a dermatologist.
Another effective intervention is providing opportunities for people to get checked for free, like one Vermont surgeon is doing. Dr. Ovleto Ciccarelli told NPR that he found and removed a half-dozen suspicious moles in clinics over the past summer.
Huntsman Cancer Institute also offered free screenings at an open house it held in August, examining 140 people, spokeswoman Amie Parker said.
The limits of sunscreen
Earlier this year, Utah legislators approved a bill that allows children to take sunscreen to school. Previously, as in many other states, sunscreen was considered a medicine that could only be dispensed by a nurse with a parent’s permission. Increasing sunscreen use is a cornerstone of skin cancer prevention efforts, and many cities now have free sunscreen dispensers, similar to antibiotic wipes that are available in supermarkets.
John, the Brigham Young researcher, recently had a special kind of photograph taken that enabled him to see sun damage below the surface of the skin. Although his damage was considered moderate for a 35-year-old, the images were dismaying enough to prompt John to start applying sunscreen before he goes outside to wash his car or mow the lawn.
But people err when they think sunscreen is all they need, Bowen said, which is why he wears a hat everywhere. Even if you have no history of melanoma in your family and have no visible signs of skin cancer, sun exposure impairs the immune system, and you could be one sunburn away from a previously harmless mole becoming cancerous.
Aggressive prevention requires clothing, he said, noting that in the famous Golden Spike photos taken in 1869 at Promontory, Utah, everyone was covered from head to toe even though it was May.
Modern clothing that reveals lots of skin is believed to play a part in the rise in melanoma, along with the disappearance of the everyday hat. A little modesty, therefore, might help reduce skin cancer rates.
“My patients, they all want to talk to me about sunscreen. Sunscreen is sunscreen; it’s an airbag," Bowen said. "Clothing is the safety belt.”
Likewise, Kern, who grew up in Los Angeles and has had basal cell carcinoma himself, is careful to cover up outside, wearing a broad-brim hat and sunglasses when he’s hiking, avoiding peak sun times, and wearing long pants and long sleeves when it's not oppressively hot.
“I get funny looks from people with this big straw hat,” he said. “But that’s all you can really do. I don’t tell people not to enjoy their activities in Park City because I’d be laughed at. That’s why we live in Park City. Just do what you reasonably can, and the key is surveillance by a dermatologist or physician comfortable doing skin exams.”