The International Agency for Research on Cancer classified, in July 2009, exposure to artificial tanning devices (sunbeds) as carcinogenic to humans. This classification was based on evidence from epidemiological and experimental animal studies. The present chapter will review these epidemiological evidences. The summary risk estimates from 27 epidemiological studies obtained through a meta-analysis showed an increased risk of melanoma: summary relative risk (SRR) = 1.20 [95% confidence interval (CI) 1.08-1.34]. The risk was higher when exposure took place at younger age (SRR = 1.59; 95% CI 1.36-1.85). The risk was independent of skin sensitivity or population and a dose response was evident. A meta-analysis of 12 studies was conducted for non-melanoma skin cancers and showed a significantly increased risk for basal cell carcinoma (SRR = 1.29; 95% CI 1.08-1.53) and for squamous cell carcinoma (SRR = 1.67; 95% CI 1.29-2.17). As for melanoma, the risk for other skin cancers increased for first exposures at young age. Epidemiological studies have gradually strengthened the evidence for a causal relationship between indoor tanning and skin cancer and they fit with prior knowledge on relationship between UV exposure and skin cancer. Additionally, several case-control studies provided consistent evidence of a positive association between use of sunbed and ocular melanoma, also with greater risk for first exposures at younger age. Preventive measures based on information on risk or by requiring parental authorization for young users proved to be inefficient in several studies. The significant impact of strong actions or total ban, such as performed in Iceland, or a total ban of sunbed use, as in Brazil or Australian states, needs to be further assessed.

Background: Breast cancer mortality is declining in many Western countries. If mammography screening contributed to decreases in mortality, then decreases in advanced breast cancer incidence should also be noticeable.Patients and methods: We assessed incidence trends of advanced breast cancer in areas where mammography screening is practiced for at least 7 years with 60% minimum participation and where population-based registration of advanced breast cancer existed. Through a systematic Medline search, we identified relevant published data for Australia, Italy, Norway, Switzerland, The Netherlands, UK and the USA. Data from cancer registries in Northern Ireland, Scotland, the USA (Surveillance, Epidemiology and End Results (SEER), and Connecticut), and Tasmania (Australia) were available for the study. Criterion for advanced cancer was the tumour size, and if not available, spread to regional/distant sites.Results: Age-adjusted annual percent changes (APCs) were stable or increasing in ten areas (APCs of 20.5% to 1.7%). In four areas (Firenze, the Netherlands, SEER and Connecticut) there were transient downward trends followed by increases back to pre-screening rates.Conclusions: In areas with widespread sustained mammographic screening, trends in advanced breast cancer incidence do not support a substantial role for screening in the decrease in mortality.

646 © 2008 The Authors JEADV 2008, 22, 616–650 Journal compilation © 2008 European Academy of Dermatology and Venereology mofetil 1 g daily was added, but patient did not improve. Results of blood count, chemistry profile, tumoral markers, chest X-ray, abdominal ecography, toracoabdominal tomography and serologic test for HIV and hepatitis were normal or negative. Urinary toxicology screen was positive for cocaine. Informed of the positive toxicology screen, the patient admitted to the regular use of cocaine. Management of cocaine addiction was started, and patient rapidly improved after drug discontinuation. Repeated urinary toxicology screens were negative when patient was discharged and during the follow-up. After 1 year of diagnosis, he has presented with two severe relapses despite maintenance therapy with prednisone 60 mg and micofenolate mofetil 1 g daily. Both outbreaks have coincided with a relapse into cocaine consumption. Cocaine has been found to induce ischemic changes mostly involving the heart or the central nervous system in drug abusers. Most events are attributed to cocaineinduced vasospams. Cocaine can produce ischemic necrosis with perforation of the nasal septum and acral vasospasm. Vasculitic findings have also been documented. Cocaine has been involved in Churg-Strauss vasculitis, Schönlein-Henoch vasculitis, and urticaria-vasculitis. Bullous skin disease in association with cocaine has been reported in one patient, and a case of cocaine-related Stevens– Johnson syndrome has also been reported. We have experience with two patients with pyoderma-like lesions associated with cocaine snorting. Cocaine administered nasally usually consists of cocaine hydrochloride and ill-defined mix of substances as diluents (such as quinine, sugar, procaine and amphetamines). Exposure to cocaine and or more of its diluents probably led to pemphigus in our patient. Supportive data include the sequence of events, the denial of use of other medication, a positive toxicology screen for cocaine, improvement of the disease when toxicology screens were negative and relapse when the patient started again with consumption despite the correct compliance of treatment. We did not find cases of cocaine-related pemphigus at the literature. There is a case by Tomecki et al. about a man who developed bullae after the regular ingestion of cocaine mix. In this case, microscopic examination revealed subepidermic bullae without eosinophilic necrosis and direct immunofluorescence was negative. In conclusion, physicians should be aware of this reaction and should investigate the use of all types of medications including recreational drugs. Management in these cases is difficult because we must treat pemphigus and drug addiction. There is a lack of co-ordinated action regarding the treatment of cocaine dependence and lack of evidencebased treatment specifically for these patients and relapses into consumption are a frequent problem. C Laguna,* JL Sánchez-Carazo, A Pérez-Ferriols, V Alegre Department of Dermatology, Valencia University General Hospital, Spain, *Corresponding author, Department of Dermatology. Valencia University General Hospital, Av. Tres Cruces s/n 46014-Valencia, Spain, tel. +961972000; fax +961972130; E-mail: cecipru@comv.es

Skin cancer is the most frequently occurring malignancy. It is influenced by an individual's susceptibility factors (phototype and pigmentary traits) and exposure to solar ultraviolet radiation, although the type of exposure (high intensity and short duration vs. chronic) and pattern of exposure (continuous vs. intermittent) may differ among the three main types of skin cancer. Squamous cell carcinoma is influenced by chronic exposure, while basal cell carcinoma and melanoma are influenced by intermittent exposure, especially during childhood. Artificial UV tanning increases the risk of melanoma and squamous cell carcinomas. The prevention of skin cancer is based on reducing exposure to the sun (seeking shadow and using clothing). There is limited evidence suggesting that the use of sunscreen can prevent squamous cell carcinoma, but its role in preventing basal cell carcinoma and cutaneous melanoma remains uncertain. The use of sunscreen can lead to longer periods of sun exposure. Exposure to solar ultraviolet radiation has been shown to reduce the incidence and lethality of some cancers (breast, colon, prostate and lymphomas). A mechanism involving vitamin D has been hypothesised and is currently under investigation.

Abstract Exposure to solar ultraviolet (UV) radiation is a known cause of skin cancer. Sunbed use represents an increasingly frequent source of artificial UV exposure in light‐skinned populations. To assess the available evidence of the association between sunbed use and cutaneous malignant melanoma (melanoma) and other skin cancers, a systematic review of the literature till March 2006 on epidemiological and biological studies on sunbed use was performed in Pubmed, ISI Web of Science, Embase, Pascal, Cochrane library, Lilacs and Medcarib. Search for keywords in the title and in the abstract was done systematically and supplemented by manual searches. Only case–control, cohort or cross‐sectional studies were selected. Data were abstracted by means of a standardized data‐collection protocol. Based on 19 informative studies, ever‐use of sunbeds was positively associated with melanoma (summary relative risk, 1.15; 95% CI, 1.00–1.31), although there was no consistent evidence of a dose–response relationship. First exposure to sunbeds before 35 years of age significantly increased the risk of melanoma, based on 7 informative studies (summary relative risk, 1.75; 95% CI, 1.35–2.26). The summary relative risk of 3 studies of squamous cell carcinoma showed an increased risk. For basal cell carcinoma, the studies did not support an association. The evidence does not support a protective effect of the use of sunbeds against damage to the skin from subsequent sun exposure. Young adults should be discouraged from using indoor tanning equipment and restricted access to sunbeds by minors should be strongly considered. © 2006 Wiley‐Liss, Inc.

Les cancers cutanés sont les plus fréquents des cancers. Ils sont favorisés par des facteurs de sensibilité de l’hôte (phototype, caractéres de pigmentation) et par l’exposition au rayonnement ultraviolet solaire. Le type d’exposition (forte intensité et courte durée ou exposition chronique) et les conditions d’exposition (continue ou intermittente) jouent un rôle différent pour les trois principaux types de cancers cutanés. Les carcinomes épidermoïdes sont influencés par une exposition chronique, alors que les cancers basocellulaires et les mélanomes sont influencés par une exposition intermittente, en particulier dans l’enfance. Le bronzage en cabine augmente le risque de mélanome et de carcinome épidermoïde. La prévention des cancers cutanés repose sur la réduction de l’exposition solaire (ombre, veêtements). Il existe des preuves limitées d’efficacité des crèmes solaires dans la prévention des carcinomes épidermoïdes, mais il n’est pas possible de montrer un effet de prévention des cancers basocellulaires et des mélanomes. L’utilisation de crème solaire peut permettre une prolongation de l’exposition solaire. L’exposition au rayonnement ultraviolet solaire est susceptible de diminuer l’incidence ou la mortalité de certains cancers: sein, côlon, prostate, et lymphomes. Un mécanisme faisant intervenir la vitamine D a été invoqué, qui fait actuellement l’objet de recherches.

WM3-PD-08 Objective: To compare measurements of UVA and UVB exposure of children recorded with personal dosimeters with assessment through a detailed questionnaire and satellite measurements. Methods: Twenty-five families with one index child participated in the study. Participants filled a questionnaire detailing daily activities, geographic location, and circumstances of sun exposure. Corresponding satellite measurements of local UVA and UVB irradiation were obtained from the European database SoDa. Results: Of 353 days of sun exposure, 437 episodes were recorded with a dosimeter. Median duration of each session was 2 hours, 62% of exposures occurring between 11 AM and 3 PM. There was a good correlation between measurements from dosimeter and satellite (r = 0.48 for UVA; r = 0.40 for UVB, Spearman correlation P < 0.0001). Dosimeter records tend to underestimate the total exposure measured from the dosimeter (difference per session: 40 Wh/m2 UVA, 1.5 Wh/m2 UVB). The correlation was better for exposure in the sun (r = 0.5 and 0.43 for UVA and UVB, respectively), on the beach (r = 0.57 and 0.42), and at the seashore (r = 0.64 and 0.40). Multivariate analysis adjusting for weather, exposure duration, horizontal or vertical use of dosimeter, shade, environment, and activity showed that satellite measurements were only significantly influenced by the weather. Dosimeter records were essentially influenced by the type of use (81% in UVA and 73% in UVB decrease of measure when dosimeter was worn on the belt), exposures in the shade (54% decrease for both UVA and UVB), and environment (60% decrease for UVA and 34% for UVB for exposure in the country side). When adjusting for all variables, there was a significant independent correlation between dosimeter and satellite measurements (P < 0.0001 for UVA and UVB). Conclusion: Satellite measurements give a good estimate of individual UVA and UVB exposure, independently of exposure conditions and could be used to estimate actual exposure.

P-166 Objectives: The project aims to quantify the spectrum of ultraviolet exposure in the various regions of France and its effects on the incidence of skin cancers and of other cancers possibly influenced by sun exposure (e.g. non-hodgkin lymphomas) and on the incidence of eye conditions likely influenced by exposure to solar ultraviolet radiation (cataract, age-linked macular degenerescence). By monitoring regional changes it would be possible to predict changes in health impact. Methods: A new tool measuring daily ultraviolet exposure in France will be developed in co-operation with the SoDa project, from satellite data. Exposure to the various UV wavelengths will be calculated for every geographical site. A UV-FRANCE database will be created from which exposures to regions and individuals can be assessed and monitored. From this database, an atlas of UV exposure in France, based on UV irradiation values over 5 year periods will be produced. Levels of UV exposure (total and maximal) in individuals will be calculated, by reconstructing past individual exposure over the last 10 years in random samples of population. The level, distribution and trends of sun exposure in populations will be derived from these calculations. The effects of the levels of sun exposure in the populations on the incidence of skin cancers will be estimated by comparing data on sun exposure obtained from the project with the geographical incidence of melanoma and non-melanoma skin cancers. The same comparison between sun exposure and geographical incidence of cataract will be made. Expected Results: UV-FRANCE will provide the first quantification of individual UV exposure of different age and gender population categories, and identify time trends. UV-FRANCE will provide indicators of exposure to the various fractions of the UV radiation, and use past UV exposure experience to predict global burden in future years (non-melanoma skin cancers, melanoma, cataract). By developing a sustainable monitoring of changes in UV exposure dose, likely changes in disease occurrence should be able to be predicted.

Seasonal variation in cutaneous melanoma incidence with a summer peak is poorly understood. It has been hypothesized to be due to increased diagnosis in summer or a late-promoting effect of sun exposure. We analyzed the characteristics of incident cases of cutaneous melanoma and their outcome by season of diagnosis in the population of New South Wales, Australia. Cases of melanoma (25,845 cases; 10,869 females and 14,976 males) were registered by the New South Wales Central Cancer Registry in 1989 to 1998. There was significant seasonal variation in incidence (P < 0.0001, Nam test). The summer to winter ratio was greater for women, younger people, lesions on the limbs, and superficial spreading melanoma. Melanomas were thicker in winter than in summer (medians 0.75 and 0.70 mm, respectively; P < 0.0001, Kruskal-Wallis test). Cases were followed for a median of 63 months and 2,710 (10.5%) died from their melanoma. Fatality from melanoma was lower for melanomas diagnosed in summer than winter (relative fatality = 0.72; 95% confidence interval, 0.65-0.81); the 5-year survival rate was 92.1% for diagnosis in summer and 89.0% for diagnosis in winter. This result remained significant after adjustment for year of diagnosis, age, sex, Breslow thickness, anatomic location, and histologic type (relative fatality = 0.82; 95% confidence interval, 0.72-0.94). Seasonality in melanoma incidence is probably caused mainly by increased and earlier diagnosis in summer, although a late-stage promotional effect of sun exposure cannot be excluded completely. Earlier diagnosis may also reduce fatality when melanoma is diagnosed in summer. Independence of variation in fatality with season from seasonal variation in thickness, however, suggests that sun exposure around the time of diagnosis decreases fatality of melanoma. (Cancer Epidemiol Biomarkers Prev 2006;15(3):524–8)

Susceptibility to solar ultraviolet is an important melanoma risk factor. We investigated the relationship between individual susceptibility to ultraviolet and risk of melanoma by measuring the apoptosis triggered in peripheral lymphocytes by a low-dose ultraviolet B irradiation (50J/m2) in young and older melanoma patients and controls. Melanoma patients below the age of 40 are more sensitive to UVB-induced apoptosis than older melanoma patients and healthy controls. Analysis of data (adjusted for age and phototype) shows that UVB-induced apoptosis is an important risk factor for melanoma (OR 9.1, 95% CI [3–28], P=0.0001). UVB-induced apoptosis is independent of phototype (P=0.11, Wald test) and tumour thickness (P=0.88, Spearman correlation, for all cases and 0.26 for patients younger than 40 years), and may be used as a functional laboratory test for studying the genetic-environment interactions involved in melanoma occurrence.

In an address to the Pathological Society in London in 1874, a distinguished surgeon, Campbell De Morgan, presented his observations that cancers occasionally underwent spontaneous regression [ [1] Pathological Society of London. Discussion on cancer. Lancet 1874, 1, 334–336 and 586–594 Google Scholar ]. He added that such regression was sometimes associated with infections including tuberculosis. Other workers in the late 19th century confirmed the link between infection and cancer regression and one, the American surgeon William Coley, administered extracts of bacteria causing erysipelas (‘Coley toxins’) to patients with sarcoma, with apparent success in some cases [ [2] Coley W.B. Treatment of inoperable malignant tumour with the toxins of erysipelas and Bacillus prodigiosus. Trans Am Surg Assoc. 1894; 12: 183-196 Google Scholar ]. Unfortunately, the advent of radiotherapy and chemotherapy led to Coley’s therapy being sidelined and marginalised and, until relatively recently, this and other attempts to prevent and treat tumours by vaccination or immunotherapy generally met with cynicism and even hostility [ [3] Takeuchi S. A new look at the history of tumour immunotherapy – for its fruitful future through overcoming the widespread cynicism. Hum Cell. 1996; 9 ([In Japanese, with English abstract]): 1-10 PubMed Google Scholar ].

In a large case-control study we found no association between sunbed use and melanoma risk, but indications for potential recall and recruitment biases made the interpretation of the results difficult. Associations with skin phototype (adj OR for skin type I vs. IV: (2.6, 95% CI 1.5–4.8)), hair colour (adj OR red/blond vs. brown/black 2.0 (95% CI 1.4–2.8)) and number of naevi on both arms (OR>10 vs. ⩽10 3.13 (95% CI: 2.47; 3.97)) were comparable to previous studies, but negative associations were found between sun exposure and melanoma risk (adj. OR 0.87 (95% CI: 0.65–1.18)) and in cases between sun exposure and naevus count. These observations led us to speculate that cases may have underreported their sun exposure and, most likely, their sunbed exposure. High percentages of sunbed use among controls indicated possible recruitment bias: eligible controls who were sunbed users were probably more likely to accept the invitation to participate than non-users, possibly due to a feeling of ‘guilt’ or ‘worry’ about their habits. Such selective participation may have strongly influenced the risk estimates of sunbed use in our study.

A large European case–control study investigated the association between sunbed use and cutaneous melanoma in an adult population aged between 18 and 49 years. Between 1999 and 2001 sun and sunbed exposure was recorded in 597 newly diagnosed melanoma cases and 622 controls in Belgium, France, The Netherlands, Sweden and the UK. Fifty three precent of cases and 57% of controls ever used sunbeds. The overall adjusted odds ratio (OR) associated with ever sunbed use was 0.90 (95% CI: 0.71–1.14). There was a South-to-North gradient with high prevalence of sunbed exposure in Northern Europe and lower prevalence in the South (prevalence of use in France 20%, OR: 1.19 (0.68–2.07) compared to Sweden, prevalence 83%, relative risk 0.62 (0.26–1.46)). Dose and lag-time between first exposure to sunbeds and time of study were not associated with melanoma risk, neither were sunbathing and sunburns (adjusted OR for mean number of weeks spent in sunny climates >14 years: 1.12 (0.88–1.43); adjusted OR for any sunburn >14 years: 1.16 (0.9–1.45)). Host factors such as numbers of naevi and skin type were the strongest risk indicators for melanoma. Public health campaigns have improved knowledge regarding risk of UV-radiation for skin cancers and this may have led to recall and selection biases in both cases and controls in this study. Sunbed exposure has become increasingly prevalent over the last 20 years, especially in Northern Europe but the full impact of this exposure on skin cancers may not become apparent for many years.

BACKGROUND Since 1950, the greatest increase in cutaneous melanoma incidence in fair-skinned males took place on the trunk and on the head and neck, whereas in females, it took place on the limbs, mainly on the lower limbs. We examined the influence of sex on numbers and size of nevi on different body sites in white European schoolchildren. METHODS Information about each holiday period since birth to interview was recorded from parents of six hundred twenty-eight 6- to 7-year-old children in four European cities (Brussels (Belgium), Bochum (Germany), Lyons (France), and Rome (Italy)). Number and anatomic location of small (2-4.9 mm) and large (>/=5 mm) nevi and individual susceptibility to sunlight were independently assessed. RESULTS After adjustment for host characteristics, sun exposure, and sun protection habits, males had 7% [95% confidence interval (95% CI), -7 to 19] more small nevi than females. However, compared to females, numbers of small nevi were increased by 17% (95% CI, 1-31) on the head and neck and by 16% (95% CI, 2-27) on the trunk and shoulders. In contrast, in males, the number of small nevi on upper limbs was decreased by -5% (95% CI, -26 to 13), and on lower limbs by -8% (95% CI, -34 to 13). The number of large nevi was 6% higher in males than in females (95% CI, -26 to 30). CONCLUSIONS The sex differences in small nevus distribution in schoolchildren reflect the sex differences in the anatomic distribution of melanoma in adults. Sex differences in sun exposure behaviors, dressing, and clothing would just add their effects to the sex-dependent inherited propensity to develop nevi on a given body site. These results reinforce the hypothesis by which childhood would be a decisive period for the occurrence of sun-induced biological events implicated in the genesis of cutaneous melanoma.

The objective of this study was to investigate the epidemiology of melanoma across Europe with regard to Breslow thickness and body-site distribution. Incidence data from Cancer Incidence in 5 Continents and the EUROCARE-melanoma database were used: 28 117 melanoma cases from 20 cancer registries in 12 European countries, diagnosed between 1978 and 1992. Regression analysis and general linear modelling were used to analyse the data. Melanomas in Eastern Europe were on average 1.4 mm thicker (P<0.05) than in Western Europe and appeared more often on the trunk. From 1978 to 1992, their Breslow thickness had decreased in Western but not Eastern Europe. There was a latitude gradient in incidence, with highest rates in southern regions in Eastern Europe and an inverse gradient in Western Europe, with highest rates in the North. Mortality:incidence ratios were less favourable in southern parts across Europe, especially in Eastern Europe. If Eastern European populations copy the sunbathing behaviour of the West it is likely that in the near future a higher melanoma incidence can be expected there.

The aim of our study was to analyse seasonal variations in melanoma incidence in Europe. Data from 28117 cutaneous melanoma cases reported during 1978–1993 to the EUROCARE group of registries were analysed. There is a clear summer peak in incidence in Western countries (summer–winter ratio: 1.31 P<0.0001; Nam’s test), which was not observed in Central Europe (ratio: 1.06; P=0.0699). The amplitude of seasonality is higher for females (ratio=1.38, 95% Confidence Interval (CI) [1.31–1.44]) than for males (ratio=1.21 95%CI [1.14–1.29]). It is also higher for upper and lower limbs (1.44 and 1.46, respectively), than for head and neck or trunk regions (1.09 and 1.20, respectively). The amplitude of seasonality also varies with latitude and increases with time: in a linear regression adjusting for age, gender and anatomical localisation, the date of diagnosis was significantly closer to summer solstice with decreasing latitude (P=0.0005) and for more recent year of diagnosis (P=0.0123). The effect of latitude on the amplitude of the seasonal variation in melanoma incidence in Europe may be an indicator of ultraviolet B (UVB) exposure. Furthermore, an increase in intentional sun exposure could lead to an increase in melanoma promotion and thus to an increase in the amplitude of seasonal variation.

Skin cancer is conventionally separated into two categories: melanoma and non-melanoma skin cancer (NMSC). Cutaneous melanoma, which comprises over 90% of all melanoma, is divided into three major histological types. The majority of melanomas in white-skinned populations are superficial spreading and nodular melanomas. Lentigo maligna melanoma (Hutchinson's melanotic freckle) occurs later in life than the other types and more specifically on exposed sites. Acral lentiginous melanoma has not been studied epidemiologically: it is rare in white-skinned populations although it comprises a substantial proportion of melanomas in Japan [1.Elwood J.M. Epidemiology and control of melanoma in white populations and in Japan.J Invest Dermatol. 1989; 92: 214S-221SAbstract Full Text PDF PubMed Scopus (26) Google Scholar]. Non-melanoma skin cancers are generally considered as squamous cell carcinomas (SCC) and basal cell carcinomas (BCC). There is much more known about the epidemiology of melanoma than non-melanoma skin cancers. It is estimated that in 2000there were 132000 cases of melanoma diagnosed world-wide and 37000 deaths caused by melanoma. In Europe, it is estimated that in 2000 there were 35000 cases of melanoma diagnosed and 9000 deaths caused by melanoma. The annual world-wide melanoma burden is split unevenly between high-resource countries (104000 cases and 25000 deaths) and low- and medium-resource countries (28500 cases and 12000 deaths) [2.Ferlay J. Bray F. Pisani P. Parkin D.M. GLOBOCAN. Cancer Incidence, Mortality and Prevalence Worldwide, Version 1.0.IARC CancerBase. 5. France: IARC Press, Lyon2000: 2001Google Scholar]. The death:incidence ratio is strikingly different in these categorizations. There are no similar data available for NMSC. The highest incidence rates of melanoma are reported from (essentially European migrant populations in) Australia and New Zealand (non-Maori population) where the annual incidence is more than double the highest rates recorded in Europe [3.Parkin D.M. Whelan S.L. Ferlay J. et al.Cancer Incidence in Five Continents.VIII. Lyons, France: IARC2003Google Scholar]. Incidence rates have been increasing rapidly for several decades in all Caucasian populations [4.P Boyle, JF Dore, P Autier et al. European Institute of Oncology Advisory Group Report on Prevention and Control of Melanoma. Eur J Cancer (in press).Google Scholar] although there is now an indication that in those areas where the incidence is highest, the mortality rate is beginning to stabilise or fall [5.Giles G.G. Armstrong B.K. Burton R.C. et al.Has mortality from melanoma stopped rising in Australia? Analysis of trends between 1931 and 1994.Br Med J. 1996; 312: 1121-1125Crossref PubMed Scopus (168) Google Scholar]. In Europe, during the 1990s, incidence rates were higher in northern and western Europe whereas mortality was higher in men in eastern and southern Europe. Mortality rates have been rising steadily and in Northern Europe a deceleration took place from the early 1980s. Mortality rates have also leveled off in western Europe whereas in eastern and southern Europe both incidence and mortality are still rising [6.De Vries E. Bray F.I. Coebergh J.W. Parkin D.M. Changing epidemiology of malignant cutaneous melanoma in Europe, 1953–1997: Rising trends in incidence and mortality but recent stabilizations in Western Europe and decreases in Scandinavia.Int J Cancer. 2003; 107: 119-126Crossref PubMed Scopus (318) Google Scholar]. The net effect is that melanoma mortality rates in the mid-1990s (1993–1997) are highest in Nordic countries and lowest in southern European populations, such as Greece, Spain and Portugal [7.Boyle P. Smans M. Cancer Mortality Atlas of European Union.1993–1997. Oxford University Press, Oxford, UK2003Google Scholar]. There is little information systematically collected and available regarding NMSC in populations although there have been some very recent publications giving insight into the epidemiology of this topic. Although skin cancer is not unknown in children and young adults, where melanoma predominates, it is essentially a disease of ageing populations [8.Pearce M.S. Parker L. Cotterill S.J. et al.Skin cancer in children and young adults: 28 years' experience from the Northern Young Persons's Malignant Disease Registry.UK. Melanoma Res. 2003; 13: 421-426Crossref PubMed Scopus (48) Google Scholar]. In Maastricht, the Netherlands, squamous cell cancer was the commonest form of cancer among the very elderly (aged over 95) [9.Boi S. Cristofolini M. Micciolo R. et al.Epidemiology of Skin Tumours: Data from the Cutaneous Cancer Registry in Trentino, Italy.J Cutan Med Surg. 2003; 167: 339-388Google Scholar]. The commonest type of NMSC is basal cell carcinoma. In Trentino, Italy, the Skin Cancer Registry calculated (for the period 1993–1998) that the incidence rate of BCC was 88 per 100000, of SCC it was 29 per 100000 and it was 14 per 100000 for melanoma [10.de Rijke J.M. Schouten L.J. Hillen H.F. et al.Cancer in the very elderly Dutch population.Cancer. 2000; 89: 1121-1133Crossref PubMed Scopus (57) Google Scholar]. This tendency was confirmed in Izmir, Turkey, where nearly half the lesions appeared on the face and, while SCC was equally common in men and women, BCC were nearly three times more frequent in men [11.Ceylan C. Ozturk G. Alper S. Non-melanomatous skin cancers between the years of 1990 and 1999 in Izmir, Turkey: demographic and clinicopathological characteristics.J Dermatol. 2003; 30: 123-131Crossref PubMed Scopus (28) Google Scholar]. In Vaud, Switzerland, BCC were the commonest form of skin cancer reported in both men and women and the incidence has been rising steadily since registration was introduced in the mid 1970s [12.Levi F. Te V.C. Randimbison L. et al.Trends in Skin Cancer Incidence in Vaud: an update, 1976–1998.Eur J Cancer Prev. 2001; 10: 371-373Crossref PubMed Scopus (53) Google Scholar]. In Sweden, 39805 SCC were registered between 1961 and 1995 [12.Levi F. Te V.C. Randimbison L. et al.Trends in Skin Cancer Incidence in Vaud: an update, 1976–1998.Eur J Cancer Prev. 2001; 10: 371-373Crossref PubMed Scopus (53) Google Scholar]. Incidence rates increased substantially in men (by 42%) and in women (by 146%) during this period and interpretation of mathematical models led the authors to conclude that these increases could probably be explained by increased cumulative sun exposure and increasing incidence among the elderly [13.Wassberg C. Thorn M. Johansson A.M. et al.Increasing incidence rates of squamous cell carcinoma of the skin in Sweden.Acta Derm Venereol. 2001; 81: 268-272Crossref PubMed Scopus (55) Google Scholar]. Between 1978 and 1995, the Slovakian Cancer Registry registered 38629 cases of NMSC (19 600 in men and 19029 in women). During this period, incidence rates of BCC increased by 70.4% in men and 65% in women while incidence rates of SCC increased by 13.5% in men and 18.8% in women. Head and neck were the most common sites (84.2% BCC and 74.7% SCC) followed by the trunk for BCC (17% in men and 11% in women) and upper limbs for SCC (12% in men and 12.5% in women) [14.Plesko I. Severi G. Obsitnikova A. Boyle P. Trends in the incidence of non-melanoma skin cancer in Slovakia, 1978–1995.Neoplasma. 2000; 47: 137-142PubMed Google Scholar]. Mortality from NMSC is almost always from SCC, a form of cancer whose risk is strongly linked to cumulative lifetime sun exposure [15.Rosso S. Zanetti R. Martinez C. et al.The multicentre south European study 'Helios'. II: Different sun exposure patterns in the aetiology of basal cell and squamous cell carcinomas of the skin.Br J Cancer. 1996; 73: 1447-1454Crossref PubMed Scopus (335) Google Scholar]. NMSC mortality in Europe presents an entirely different picture than melanoma. The rates are higher in men and women in southern European countries (Greece, Spain, Portugal and Italy) and low in the Nordic countries [7.Boyle P. Smans M. Cancer Mortality Atlas of European Union.1993–1997. Oxford University Press, Oxford, UK2003Google Scholar]. Although morbidity and mortality are low, skin cancers are far more common than other malignancies. Representative Medicare claims data were obtained from the Medicare current beneficiary survey (1992–1995) and weights were applied to give nationally representative estimates [16.Housman T.S. Feldman S.R. Williford P.M. et al.Skin cancer is among the most costly of all cancers to treat for the Medicare population.J J Am Acad Dermatol. 2003; 48: 425-429Abstract Full Text Full Text PDF PubMed Scopus (405) Google Scholar]. Average Medicare expenditure on cancer management was $13 billion per year and the five most costly cancers to Medicare were lung and bronchus, prostate, colon and rectum, breast and NMSC. Such considerations give NMSC a far higher public health significance than can be obtained from consideration of death statistics. Skin cancer has several unique epidemiological features. Skin cancers range from the potentially very serious melanomas, through squamous carcinomas, to the low-morbidity and low-mortality BCC. While a patient with a primary melanoma has a 10-fold increased risk of a second primary, such second cancers are rare in absolute terms and in comparison to the many people who can have multiple BCC. Although cutaneous malignant melanoma is still a relatively rare neoplasm in many populations, incidence rates are increasing in Caucasian populations around the world. Melanoma continues to be a major public health issue given the large increases in incidence and the notable case fatality rate. NMSC are also increasing in incidence in Caucasian populations and these trends may be exacerbated by further increases in both acute and prolonged exposure to sunshine (see Rosso et al. [15.Rosso S. Zanetti R. Martinez C. et al.The multicentre south European study 'Helios'. II: Different sun exposure patterns in the aetiology of basal cell and squamous cell carcinomas of the skin.Br J Cancer. 1996; 73: 1447-1454Crossref PubMed Scopus (335) Google Scholar]) together with the increasing number of older people in the population. This latter observation is of crucial significance in Europe. Although the population of the (25 Member State) European Union will remain constant at around 500 million between 2000 and 2015, there will be a 22% increase in the numbers aged 65 and over and a 50% increase in those aged 80 and over [17.Quinn M.J. d'Onofrio A. Møller B. et al.Cancer Mortality Trends in the EU and Acceeding States up to 2015.Ann Oncol. 2003; 14: 1148-1152Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar]. Consequent to this ageing of the European population, there will be a notable increase in the number of skin cancers to be diagnosed and treated. Although not life-threatening, BCC is an important public health problem due to the frequency of the cancers and the costs of their treatment on national health resources. It is important that NMSC do not remain forgotten forms of cancer. Skin cancer is clearly identified as one form of cancer thatwill become more important in public health terms in the coming decades in the absence of effective intervention today. Enough is known about the causes of skin cancers to shift the focus of population research activity from aetiology to prevention. The European Code Against Cancer [18.Boyle P. Autier P. Bartelink H. et al.European Code Against Cancer and Scientific Justification: Third Version (2003).Ann Oncol. 2003; 14: 973-1005Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar] recommends that 'Care must be taken to avoid excessive sun exposure. It is specifically important to protect children and adolescents. For individuals who have a tendency to burn in the sun active protective measures must be taken throughout life'. Widespread implementation of this recommendation would lead to a reduction in NMSC incidence, as has been demonstrated in Australia [19.Staples M. Marks R. Giles G. Trends in the incidence of non-melanocytic skin cancer (NMSC) treated in Australia 1985–1995: are primary prevention programs starting to have an effect?.Int J Cancer. 1998; 78: 144-148Crossref PubMed Scopus (246) Google Scholar], and have a significant impact on making more resources available to treat clinical cancers, of this and other organs. It is a pleasure to acknowledge that his work was conducted within the framework of support from the Italian Association for Cancer Research (Associazone Italiana per la Ricerca sul Cancro).