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CME / CE

Is Avoiding Sun Exposure a Risk Factor for Death?

  • Authors: News Author: Marcia Frellick
    CME Author: Laurie Barclay, MD
  • CME / CE Released: 4/15/2016
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 4/15/2017
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Target Audience and Goal Statement

This article is intended for primary care clinicians, diabetologists, endocrinologists, cardiologists, hematologists, oncologists, neurologists, obstetrician-gynecologists, nurses, pharmacists, public health officials, and other members of the healthcare team involved in the care of women seeking advice on sun exposure.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Evaluate the differences in survival and in main causes of death as a function of sun exposure in women, based on a prospective follow-up study
  2. Determine the clinical implications of findings from this prospective follow-up study regarding differences in survival and in main causes of death as a function of sun exposure in women


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author(s)

  • Marcia Frellick

    Freelance writer, Medscape

    Disclosures

    Disclosure: Marcia Frellick has disclosed no relevant financial relationships.

Editor(s)

  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.

CME Author(s)

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Owns stock, stock options, or bonds from: Pfizer

CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.


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CME / CE

Is Avoiding Sun Exposure a Risk Factor for Death?

Authors: News Author: Marcia Frellick CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / CE Released: 4/15/2016

Valid for credit through: 4/15/2017

processing....

Clinical Context

It is still controversial regarding whether or not avoiding sunlight or vitamin D deficiency is a major health risk factor. Although women with active sunlight exposure habits appear to have lower all-cause mortality than those who avoid sun exposure, they are at greater risk for skin cancer.

Most studies have examined the association between the upper extreme of sun exposure and skin cancer and have shown increased incidence. The objective of this study by Lindqvist and colleagues was to examine the differences in main causes of death based on sun exposure in women.

Study Synopsis and Perspective

Nonsmokers who stayed out of the sun had a life expectancy similar to smokers who soaked up the most rays, according to researchers who studied nearly 30,000 Swedish women during 20 years.

This indicates that avoiding the sun "is a risk factor for death of a similar magnitude as smoking," write the authors of the article, published March 21 in the Journal of Internal Medicine. Compared with those who had the highest sun exposure, life expectancy for those who avoided the sun was decreased by 0.6 to 2.1 years.

Pelle Lindqvist, MD, of Karolinska University Hospital in Huddinge, Sweden, and colleagues found that women who seek out the sun were generally at lower risk for cardiovascular disease (CVD) and noncancer/non-CVD diseases such as diabetes, multiple sclerosis, and pulmonary diseases, than those who avoided sun exposure.

In addition, one of the strengths of the study was that results were dose specific -- sunshine benefits went up with amount of exposure.

The researchers acknowledge that longer life expectancy for sunbathers seems paradoxical to the common thinking that sun exposure increases the risk for skin cancer.

"We did find an increased risk of...skin cancer. However, the skin cancers that occurred in those exposing themselves to the sun had better prognosis," Dr Lindqvist said.

Some Daily Exposure Important for Health

Given these findings, he told Medscape Medical News, women should not overexpose themselves to sun, but underexposure may be even more dangerous than people think.

"We know in our population, there are three big lifestyle factors [that endanger health]: smoking, being overweight, and inactivity," he said. "Now we know there is a fourth -- avoiding sun exposure."

Sweden's restrictive guidance against sun exposure during the past 4 decades may be particularly ill advised, the study finds, in a country where the maximal ultraviolet (UV) index is low (<3) for up to 9 months out of the year.

Use of sunscreen is also widely misunderstood in the country and elsewhere, Dr Lindqvist said.

"If you're using it to be out longer in the sun, you're using it in the wrong manner," he said. However, "If you are stuck on a boat and have to be out, it's probably better to have sunscreen than not to have it."

Women with more pigmentation would be particularly well served to stop avoiding sunshine, he said, adding that many people in India, for instance, follow guidelines like those in Sweden to avoid sun year round.

In addition, because melanomas are rare among women with darker skin, the benefit goes up in those populations when weighing sun exposure's risk against benefits, Dr Lindqvist said.

Age and Smoking Habits

The researchers studied sun exposure as a risk factor for all-cause mortality for 29,518 women with no history of malignant disease in a prospective 20-year follow-up of the Melanoma in Southern Sweden cohort.

The women were recruited from 1990 to 1992 when they were 25 to 64 years old. Detailed information was available at baseline on sun exposure habits and potential confounders such as marital status, educational level, smoking, alcohol consumption, and number of births.

When smoking was factored in, even smokers at approximately 60 years old with the most active sun exposure habits had a 2-year longer life expectancy during the study period compared with smokers who avoided sun exposure, the researchers note.

However, the authors do acknowledge some major limitations. Among them, it was impossible to differentiate between active sun exposure habits and a healthy lifestyle, and they did not have access to exercise data.

Role of Vitamin D Still in Question

The results add to the longstanding debate on the role of vitamin D in health and the amount that people need, but this study does not resolve the question.

"Whether the positive effect of sun exposure demonstrated in this observational study is mediated by vitamin D, another mechanism related to ultraviolet radiation, or by unmeasured bias cannot be determined. Therefore, additional research is warranted," the authors write.

"From Irish studies we know that vitamin D deficiency makes melanomas more malignant," Dr Lindqvist said.

"This is in agreement with our results; melanomas of [those not exposed] to the sun had a worse prognosis."

This study was supported by the Clintec at the Karolinska Institute; ALF (Faculty of Medicine, Lund University, Region Skane); the Swedish Cancer Society; and the Swedish Medical Research Council. Funding was also received from Lund University Hospital, the Gustav V Jubilee Fund, the Gunnar Nilsson Foundation, the Kamprad Foundation, and the European Research Council. The authors have disclosed no relevant financial relationships.

J Intern Med. Published online March 16, 2016.[1]

Study Highlights

  • This prospective 20-year follow-up of the Melanoma in Southern Sweden cohort used a competing risk scenario to evaluate differences in sun exposure as a risk factor for all-cause mortality.
  • From 1990 to 1992, a total of 29,518 Swedish women (ages 25-64 years at enrollment) were recruited and provided detailed information on sun exposure habits at baseline and on potential confounders including marital status, educational level, smoking, alcohol intake, and number of births.
  • The researchers used modern survival statistics for data analysis.
  • Compared with women who avoided sun exposure, those with active sun exposure habits had a lower risk for CVD and noncancer/non-CVD death.
  • Women with active sun exposure habits had an increased relative contribution of cancer death because of their increased survival time.
  • Although the risks for nonmelanoma skin cancers and total skin cancers were increased, skin cancers that occurred in those with greater sun exposure yielded a better prognosis.
  • Compared with the group with the highest sun exposure, those who avoided sun exposure had a lower life expectancy by 0.6 to 2.1 years, with a 2-year longer life expectancy in smokers at age 60 years with the highest sun exposure.
  • There was a dose-dependent relationship between sun exposure and life expectancy.
  • Avoiding sun exposure is a risk factor for death comparable in magnitude to smoking, because nonsmokers who avoided sun exposure had a life expectancy similar to that of smokers in the highest sun exposure group.
  • On the basis of their findings, the researchers concluded that a longer life expectancy in women with active sun exposure habits was because of decreases in CVD and noncancer/non-CVD mortality, causing the relative contribution of death from cancer to increase.
  • Study limitations include the inability to differentiate between active sun exposure habits and a healthy lifestyle; observational design, precluding causal inferences; and lack of exercise data from study initiation.
  • The findings suggest that guidelines recommending sun avoidance need to be reconsidered, especially in women with more pigmentation and in countries with low maximal UV index and sunlight levels.
  • However, the authors warn that the study cannot determine whether the apparent benefit of sun exposure is mediated by vitamin D, another mechanism related to UV radiation, or by unmeasured bias.
  • Therefore, they recommend additional research.

Clinical Implications

  • Findings of a prospective follow-up study suggest that women with active sun exposure habits have a longer life expectancy than those who avoid sun exposure, the result of a decrease in CVD and noncancer/non-CVD mortality, causing the relative contribution of cancer deaths to increase.
  • The findings of this follow-up study suggest that guidelines recommending sun avoidance need to be reconsidered, especially in women with more pigmentation and in countries with low maximal UV index and sunlight levels.
  • Implications for the Healthcare Team: Additional research is needed to confirm these findings regarding sun exposure and life expectancy and determine the underlying mechanism.

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