Skin Cancer Prevention 2018

Skin Cancer Prevention Progress Report 2018

US Department of Health and Human Services Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control Suggested Citation Skin Cancer Prevention Progress Report 2018. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2018. Links to nonfederal organizations in this document are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the federal government, and none should be inferred. CDC is not responsible for the content of the individual organization web pages found at these links. Reminder: CDC awardees are prohibited from using appropriated federal funds for lobbying activities. Learn more about CDC’s official guidance on lobbying restrictions at https://www.cdc.gov/funding/#ar12.

Skin Cancer Prevention Progress Report 2018 Contents Background �� 1 What’s New This Year?�� 2 Sun-Safety Practices Are Uncommon In Schools�� 2 Adults Who Indoor Tan or Had a Recent Sunburn Are More Likely to Tan Outdoors�� 2 Clinical Counseling on Sun Protection Is Low Among Pediatricians�� 2 Melanoma Rates on the Rise among Non-Hispanic White Adults Aged 55+�� 2 One in Three US Adults Were Sunburned in 2015�� 3 Seven US States Passed Legislation for Sunscreen Use Among Schools in 2017 �� 3 Research Conducted by a CDC-Funded Prevention ResearchCenter Continues to Advance our Understanding of Indoor Tanning Behaviors�� 3 New Recommendations for Behavioral Counseling on Skin Cancer Prevention�� 4 Success Stories from the Field�� 5 Reducing Indoor Tanning on College Campuses�� 5 Shading Children from the Sun’s Harmful Rays�� 6 Building a Culture of Sun Safety for Nevada’s Youth�� 6 Building Shade Structures on Playgrounds and Sports Fields�� 7 Providing Education and Sunscreen Access in Georgia�� 8 Healthy People 2020 Objectives�� 9 Disease Surveillance Indicators�� 10 Melanoma Incidence and Mortality�� 10 United States Cancer Statistics: Data Visualizations�� 14 Behavioral Surveillance Indicators�� 15 Sun Protection�� 15 Indoor Tanning�� 17 Sunburn�� 19 Vitamin D�� 21 Policy and Program Indicators�� 22 Indoor Tanning Restrictions for Minors�� 22 Skin Cancer Prevention Policies in Schools�� 23 Sunscreen Access in Schools�� 24 Comprehensive Cancer Control Programs�� 25 Conclusion�� 26 References�� 27

1 2018 SKIN CANCER PREVENTION PROGRESS REPORT Background In July 2014, the Office of the Surgeon General releasedThe Surgeon General’s Call to Action to Prevent Skin Cancer, establishing skin cancer prevention as a high priority for our nation.1 The Call to Action described prevention strategies that work and called on all community sectors to play a role in protecting Americans from ultraviolet (UV) radiation from the sun and artificial sources, such as indoor tanning devices (Table 1).1 Since the release of theCall to Action, a growing community of partners at the national, state, and local levels has taken great strides toward meeting its strategic goals and advancing skin cancer prevention in the United States. This fourth annual Skin Cancer Prevention Progress Report provides a comprehensive summary of the most recent data available and highlights developments and success stories since the release of the2017 Progress Report. By continuing to update the report annually, we can monitor progress, learn from successes, recognize areas that need improvement, and identify opportunities to work collaboratively with partners to protect the public against skin cancer. Table 1. Strategic Goals and Partners to Support Skin Cancer Prevention in the United States Strategic Goals Goal 1: Increase opportunities for sun protection in outdoor settings. Goal 2: Provide individuals with the information they need to make informed, healthy choices about UV exposure. Goal 3: Promote policies that advance the national goal of preventing skin cancer. Goal 4: Reduce harms from indoor tanning. Goal 5: Strengthen research, surveillance, monitoring, and evaluation related to skin cancer prevention. Partners in Prevention Federal, state, tribal, local, and territorial governments. Businesses, employers, and labor representatives. Health care systems, insurers, and clinicians. Early learning centers, schools, colleges, and universities. Community, nonprofit, and faith-based organizations. Individuals and families. Source: The Surgeon General’s Call to Action to Prevent Skin Cancer.1

2 What’s New This Year? Over the past year, CDC researchers have led or collaborated on numerous peer-reviewed scientific publications, bringing continued attention to skin cancer prevention as a public health priority. Below are some highlights. Sun-Safety Practices Are Uncommon In Schools JAMA Dermatology published an article in March 2017 on the prevalence of sun-safety practices in US schools.2 The findings suggest that most schools have insufficient sun-safety practices for children and adolescents and point to a need for interventions to increase adoption of such practices among schools. Adults Who Indoor Tan or Had a Recent Sunburn Are More Likely to Tan Outdoors An article published in Preventive Medicine in August 2017 described associations among demographic characteristics, behaviors, and beliefs related to skin cancer risk and outdoor tanning behaviors.3 Outdoor tanning was more prevalent among women, nonHispanic white individuals, and those aged 18–29 years compared with other demographic groups. Indoor tanners and those with a recent sunburn were also more likely to tan outdoors. Clinical Counseling on Sun Protection Is Low Among Pediatricians In December 2017, Pediatrics published an article indicating that rates of clinical counseling on sun protection and avoiding indoor tanning are low among pediatricians, with time constraints being the most frequently reported barrier.4 Melanoma Rates on the Rise among Non-Hispanic White Adults Aged 55+ A research letter published in JAMA Dermatology in January 2018 examined the latest national data on melanoma incidence trends among non-Hispanic white individuals.5 More than 70% of the melanoma cases were diagnosed in adults aged 55 years or older. During 2005–2014, melanoma incidence rates increased among non-Hispanic white adults aged 55 years or older and decreased among nonHispanic white individuals under the age of 45.

3 One in Three US Adults Were Sunburned in 2015 In March 2018, JAMA Dermatology published an article examining national data on use of sun protection and the prevalence of sunburn among US adults.6 Shade and sunscreen were the most frequently used sun protection strategies among women; shade and pants were the most frequently used strategies among men. One-third of all adults had been sunburned in the past year; whereas, about half of adults aged 30 years or younger and half of adults with sun-sensitive skin had been sunburned. Sunburn was also associated with aerobic activity, binge drinking, and use of sunless tanning products. Seven US States Passed Legislation for Sunscreen Use Among Schools in 2017 A research letter published in the Journal of American Academy of Dermatology examined state legislation for sunscreen use at school.7 As of December 2017, 11 states had laws in place explicitly allowing students to carry and self-apply sunscreen at school. Of those 11 states, 7 passed the legislation in 2017, and only 2 states addressed other aspects of sun safety (e.g., protective clothing and sun-safety education) in their school sunscreen laws. Research Conducted by a CDC-Funded Prevention Research Center Continues to Advance our Understanding of Indoor Tanning Behaviors Young adults are more likely than other adults to engage in indoor tanning. In an effort to identify strategies for reducing harms from indoor tanning among this demographic group, CDC provided funds to the University of Massachusetts Medical School, Prevention Research Center, to examine frequent indoor tanning among young adults. Over time, the project team collected data on indoor tanning practices and the factors that influence tanning behaviors. Study findings led to numerous peer-reviewed publications and media attention. In addition, these research results prompted some universities to reconsider organizational policies that promoted indoor tanning among their students. Over the past year, additional findings from this work have been published in three new papers. Below are some key findings: More than half of urban schools in Worcester County, Massachusetts, are located within 1 mile of a tanning salon.8 Over one-third of tanners are unaware of their state’s legislation for use of commercial indoor tanning devices.9 Heavy tanners are twice as likely as light tanners to say that they would purchase a tanning bed if indoor tanning was banned in their state.9 Male indoor tanners are more likely than female tanners to engage in other risky behaviors, such as binge drinking.10 *This research was funded by the Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Prevention Research Center grant number CDC U48 DP001933-04 to Sherry L. Pagoto.

4 New Recommendations for Behavioral Counseling on Skin Cancer Prevention Getting the best health care means making smart decisions about preventive services. To help doctors and patients decide together whether a preventive service is right for a person’s needs, the US Preventive Services Task Force (USPSTF) develops recommendations based on reviews of high-quality scientific evidence. In March 2018, the USPSTF released updated recommendations for behavioral counseling on skin cancer prevention.11 The recommendations are outlined in the following recommendation summary. More information is available on the USPSTF website at www.uspreventiveservicestaskforce.org/. Recommendation Summary Population Recommendation Grade (What’s this?) Young adults, adolescents, children, and parents of young children The USPSTF recommends counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer. B Adults older than 24 years with fair skin types The USPSTF recommends that clinicians selectively offer counseling to adults older than 24 years with fair skin types about minimizing their exposure to UV radiation to reduce the risk of skin cancer. Existing evidence indicates that the net benefit of counseling all adults older than 24 years is small. In determining whether counseling is appropriate in individual cases, patients and clinicians should consider the presence of risk factors for skin cancer. C Adults The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults about skin self-examination to prevent skin cancer. I

5 Success Stories from the Field Reducing Indoor Tanning on College Campuses Many people begin tanning indoors during their youth, and this practice is most common among young people aged 15 to 25. While many states prohibit minors from using tanning salons, young adults are still vulnerable. Universities have a huge opportunity to curb indoor tanning in this age group. The Indoor Tan-Free Skin Smart Campus is a national initiative supported by theNational Council on Skin Cancer Prevention. It started in response to CDC-funded research that found that tanning beds are available on many college campuses and in nearby apartments and that tanning salons often can be paid with campus debit cards. Led by Dr. Robert Dellavalle, Dr. Sherry Pagoto, and Nazanin Kalani, and modeled after the Tobacco-Free Campus initiative, the Indoor Tan-Free Skin Smart Campus initiative aims to break ties between universities and tanning salons and educate college students about skin cancer prevention. To qualify as a Skin Smart Campus, colleges must meet at least one of the following criteria— n If the college has a list of off-campus housing on its website, housing that offers indoor tanning as an amenity is not included. n The college does not permit tanning salons to be university-affiliated debit card merchants. n The college provides educational programming, such as a website, on the risks of exposure to ultraviolet rays and skin cancer prevention practices to students, faculty, and staff. “Universities can play an important role in creating a culture and establishing norms around healthy behavior,” said Dr. Pagoto. “The purpose of Skin Smart is to give them the tools to do just that.” The first Skin Smart Campuses include East Tennessee State University, University of North Florida, and Temple University. Learn more at www.skinsmartcampus.org/.

6 Shading Children from the Sun’s Harmful Rays The sun’s rays can damage your skin in as little as 15 minutes. Staying in the shade is an easy way to protect your skin, but many outdoor recreation areas do not have enough shade to help visitors stay out of the sun. Since 2003, the Shade Structure Program of the American Academy of Dermatology (AAD) has given money to schools, child care centers, parks, and nonprofit organizations to build more than 350 permanent shade structures in places where children learn and play in 46 US states, the District of Columbia, and Canada. Despite these efforts, the demand from eligible organizations has overwhelmed the organization’s resources. To help meet the demand, AAD member (and current president) Dr. Suzanne Olbricht, MD had an idea in 2015 of how to expand the program. She initiated the idea and provided seed money for a shade structure to be installed over the Seal and Sea Lion exhibit at the Smithsonian Zoo inWashington, DC. More than 2 million people visit this exhibit every year, and the high-profile exposure prompted other AAD members to help fund shade structures in their communities. This support allowed AAD to expand the number of awards from 19 in 2016 to 26 in 2017. “With the steady increases in skin cancer diagnoses, it’s so important to educate the public about the importance of shade,” said Dr. Scott Dinehart. He, along with Dr. Ray Parker and the Arkansas Foundation for Skin Cancer, donated money to install shade structures at athletic fields in their community. AAD also worked with the City of St. Petersburg, Florida, to make shade structures part of the remodeling of the St. Petersburg Pier, which will be completed by summer 2019. About 1.7 million visitors are expected to visit the new pier each year. The city will also include sun-safety messages in its Healthy St. Pete initiatives. AAD will continue to look for outdoor spaces with large numbers of visitors as a way to reach—and protect—as many people as possible. To learn more about these efforts, visit www.SpotSkinCancer.org. Building a Culture of Sun Safety for Nevada’s Youth More Nevada youth are staying sun-safe and lowering their risk of skin cancer thanks to the state’s Sun Smart Schools program. The program is a collaboration between the Nevada Cancer Coalition, the state of Nevada, community partners, and schools. It teaches students about sun safety, encourages schools to adopt sun-smart policies, and promotes access to sunscreen and shade on school grounds. Launched in seven schools across Nevada in the 2015–2016 school year, Sun Smart Schools has grown to include 42 schools and 17,150 students in just 3 years. The program uses age-appropriate, evidence-based lessons to improve knowledge, attitudes, and behaviors about exposure to ultraviolet rays. Schools are encouraged to adopt written policies that support sun-safe practices, like providing shade and encouraging students and staff to use sunscreen and wear sunprotective clothing. In its first year, the seven participating schools (grades prekindergarten through 12) taught nearly 2,500 students about sun safety and changed school policies. Student surveys showed that students wore sun-protective clothing, including long-sleeved shirts,

7 hats, and sunglasses, more often after the program was launched. In the 2016–2017 school year, the program expanded to include 22 public, private, and parochial schools, representing more than 10,000 students. Surveys were expanded to capture demographic characteristics, like gender, race, and grade, and include additional questions about sun-safety knowledge and attitudes. Students, parents, teachers, and school nurses were surveyed. Survey results showed that elementary and middle school students and parents learned about sun safety and did more to protect their skin from the sun. Older students, parents, and teachers were more likely to believe that having tanned skin makes you look better. More than 4 in 5 male teachers said they and their friends look better with a tan, and about 1 in 4 high school boys said they never use sunscreen. “Finding effective ways to change sun-safety attitudes and to improve sun-safe behaviors among older students and male educators will be an ongoing challenge,” said Christine Thompson, Community Programs Manager of the Nevada Cancer Coalition. “But with more Nevada students receiving sun-safety education from a young age, we expect to reduce skin cancer incidence statewide for future generations.” For more information about Nevada’s Sun Smart Schools program, visit http://nevadacancercoalition.org/ sun-smart-nevada. Building Shade Structures on Playgrounds and Sports Fields In his travels around the Northeast, Neil Spiegler noticed that most of the playgrounds and sports fields he saw were “woefully unprotected from the dangerous rays of the sun,” with little shade for the players or the spectators. As the director of thePeggy Spiegler Melanoma Research Foundation in South Jersey—and the grandfather of two boys who spend a lot of time on playgrounds and sports fields—Spiegler was keenly aware of the need to protect children and families from the dangers of too much sun exposure. “I knew something had to be done, and fast!”he said. In 2017, the Foundation decided to take steps to protect the public at outdoor venues. In November, it dedicated the first of what the Foundation hopes will be many shade structures in and around the community

8 in the future. The structure was built at the Albert Bean Elementary School in Pine Hill, New Jersey, where Neil’s wife Peggy taught for almost 20 years. Instead of covering individual pieces of playground equipment, the foundation built a free-standing shade structure that can be used as an outdoor classroom, as well as a place for parents and their children to stay sunsafe when using the playground during lunchtime and after school. It’s very popular with students, who use it often as a favorite spot to read and play. For more information about the Peggy Spiegler Melanoma Research Foundation, visit www.psmrf.org/. Providing Education and Sunscreen Access in Georgia Georgia native Dr. Ravi Patel was surprised when he saw the melanoma statistics on CDC’s United States Cancer Statistics: Data Visualizations website. “I was shocked to learn that Georgia is ranked number 6 in the United States for melanoma incidence according to the CDC,” he said. “I knew we could do better.” After completing a dermatology rotation at the University of Colorado under the guidance of Dr. Robert Dellavalle, the chairman of the Colorado Skin Cancer Prevention Task Force, Dr. Patel looked for ways to apply the lessons he had learned. First, he founded theGeorgia Sunscreen Initiativewith medical residents at Gwinnett Medical Center and his colleagues at theHearts and Hugs Foundation. Their goal was to reduce skin cancer in local communities, and they began by working with skin cancer prevention experts to identify the leading problems in the state. Step by step, their efforts developed into active partnerships with state agencies and universities. They also drafted a resolution titledSkin Cancer Prevention Education and Sunscreen Access, which was passed unanimously by the Medical Association of Georgia. The resolution encourages— Education about skin cancer prevention in communities, schools, and universities. Educational campaigns about the risks of indoor tanning. Ordinances to reduce harms from indoor tanning. Support for public access to sunscreen. Observation of the first Monday in May as Melanoma Monday. The Georgia Sunscreen Initiative has several goals for 2018, including putting a sun-safety plan into action in all 29 of the state’s public universities, expanding educational programs in schools and high sun-exposure industries (e.g., agriculture and construction), and expanding its network of partners. “The response to our initiative has been incredible,” said Dr. Patel. “We are excited about what 2018 holds for the state of Georgia and beyond.” To learn more about the Georgia Sunscreen Initiative, visit www.heartsandhugs.org/georgiasunscreen-initiative/.

9 Healthy People 2020 Objectives Table 2 presents the skin cancer-related objectives included in Healthy People 2020, the national agenda for improving the health of all Americans. Table 2. Progress Toward the Healthy People 2020 Skin Cancer-Related Objectives Objective for 2020 Target Baseline Current Data Data Source C-8Reduce the melanoma cancer death rate 2.4 deaths per 100,000 population 2007: 2.7 deaths per 100,000 population 2015: 2.4 deaths per 100,000 population National Vital Statistics System-Mortality C-20.1Reduce the proportion of adolescents in grades 9 through 12 who report sunburn NA 2015: 55.8% 2017: 57.2% Youth Risk Behavior Surveillance System C-20.2Reduce the proportion of adults aged 18 years and older who report sunburn 33.8% 2010: 37.5% 2015: 35.3% National Health Interview Survey C-20.3Reduce the proportion of adolescents in grades 9 through 12 who report using artificial sources of ultraviolet light for tanning 14.0% 2009: 15.6% 2017: 5.6% Youth Risk Behavior Surveillance System C-20.4Reduce the proportion of adults aged 18 and older who report using artificial sources of ultraviolet light for tanning 3.6% 2010: 5.6% 2015: 3.6% National Health Interview Survey C-20.5 Increase the proportion of adolescents in grades 9 through 12 who follow protective measures that may reduce the risk of skin cancera 11.2% 2009: 9.3% 2013: 10.1% Youth Risk Behavior Surveillance System C-20.6 Increase the proportion of adults aged 18 years and older who follow protective measures that may reduce the risk of skin cancer 73.7% 2008: 67.0% 2015: 70.8% National Health Interview Survey ECBP-4.4 Increase the proportion of elementary, middle, and senior high schools that provide school health education in sun safety or skin cancer prevention to promote personal health and wellness 79.6% 2006: 72.4% 2014: 66.0% School Health Policies and Practices Study Abbreviation: NA, not available. Source: Healthy People 2020.12 aCurrent data for this objective refers to answers of “always” or “most of the time” to the question, “When you are outside for more than 1 hour on a sunny day, how often do you wear sunscreen with an SPF of 15 or higher?”

10 Disease Surveillance Indicators Melanoma Incidence and Mortality Health care providers and pathologists who diagnose or treat melanomas are required to report cases to a central cancer registry in all 50 states, the District of Columbia, and Puerto Rico. These melanoma surveillance data allow for long-term evaluation of skin cancer prevention efforts. Because melanomas often develop after years of exposure to UV radiation, it will likely be several decades before melanoma incidence rates reflect the effects of current prevention efforts. Table 3 shows invasive melanoma incidence rates by sex and race/ethnicity. The highest rates are among nonHispanic white men (33.8 per 100,000) and lowest are among black individuals (1.0 per 100,000) and Asian/Pacific Islanders (1.4 per 100,000). Non-Hispanic white men also have the highest death rates (4.8 per 100,000; Table 4). Among both men and women, incidence rates have continued to increase over time (Figure 1), and the gender gap in overall melanoma incidence and death rates has persisted (Figures 1 and 2). Figure 3 shows recent trends in melanoma incidence rates among non-Hispanic white individuals aged 15 years or older, by sex and age group during 2006–2015. The recent declines in melanoma incidence rates among non-Hispanic white individuals under the age of 35 years contrast the steady increases observed among older age groups. Table 3. Invasive Melanoma Incidence, by Sex and Race/Ethnicity, United States, 2011–2015a Race/Ethnicity US Population Male Female Rate Average Annual Count Rate Average Annual Count Rate Average Annual Count All Races 21.2 74,175 27.2 43,675 16.8 30,500 White 24.1 70,000 30.5 41,477 19.4 28,523 White, Hispanicb 4.5 1,496 4.9 680 4.4 817 White, non-Hispanicb 27.0 68,499 33.8 40,794 22.0 27,705 Black 1.0 371 1.1 176 0.9 195 American Indian/Alaska Native 5.4 175 6.8 95 4.4 80 Asian/Pacific Islander 1.4 233 1.5 114 1.2 119 Hispanicb 4.5 1,619 4.8 734 4.4 885 Source: United States Cancer Statistics 2001-2015 Public Use Research Database.13 a Data are from population areas that meet United States Cancer Statistics publication criteria for 2011–2015 and cover about 99.1% of the US population. Rates are per 100,000 population and are age-adjusted to the 2000 US Standard Population. b Race and ethnicity are not mutually exclusive. Counts may not always sum to the total because of rounding and because cases with other and unknown race are included in totals.

11 Table 4. Melanoma Death Rates, by Sex and Race/Ethnicity, United States, 2011–2015a Race/Ethnicity US Population Male Female Rate Average Annual Count Rate Average Annual Count Rate Average Annual Count All Races 2.6 9,196 3.9 6,045 1.6 3,151 White 3.0 8,988 4.5 5,940 1.9 3,048 White, Hispanicb 0.8 234 1.0 137 0.6 97 White, non-Hispanicb 3.3 8,740 4.8 5,794 2.0 2,947 Black 0.4 137 0.5 69 0.3 68 American Indian/Alaska Native 0.6 16 0.7 10 0.4 6 Asian/Pacific Islander 0.3 55 0.4 26 0.3 29 Hispanicb 0.7 238 1.0 139 0.6 99 Source: National Cancer Institute. Surveillance, Epidemiology, and End Results Program.14 a Data are from population areas that meet United States Cancer Statistics publication criteria for 2011–2015 and cover about 99.1% of the US population. Rates are per 100,000 population and are age-adjusted to the 2000 US Standard Population. b Race and ethnicity are not mutually exclusive. Counts may not always sum to the total because of rounding and because cases with other and unknown race are included in totals.

12 Figure 1. Age-Adjusted Melanoma Incidence Rates, by Sex, United States, 1975–2015 0 5 10 15 20 25 30 35 1975 1980 1985 1990 1995 2000 2005 2010 2015 Male Female Figure 1. Age-Adjusted Melanoma Incidence, by Sex, United States, 1975-2015 Rate per 100,000 Year of Diagnosis Male (AAPC = 3.0*) Female (AAPC = 2.3*) Abbreviation: AAPC, average annual percentage change. Source: National Cancer Institute. Surveillance, Epidemiology, and End Results Program.15 Note: Rates are per 100,000 population and are age-adjusted to the 2000 US Standard Population. *Denotes statistical significance (P < .05). Figure 2. Age-Adjusted Melanoma Death Rates, by Sex, United States, 1975–2015 Figure 2. Age-Adjusted Melanoma Death Rates, by Sex, United States, 1975-2012 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 1975 1980 1985 1990 1995 2000 2005 2010 2015 Male Female Year of Death Rate per 100,000 Male (AAPC = 0.6*) Female (AAPC = -0.3*) Abbreviation: AAPC, average annual percentage change. Source: National Cancer Institute. Surveillance, Epidemiology, and End Results Program.16 Note: Underlying mortality data provided by the National Center for Health Statistics. *Denotes statistical significance (P < .05).

13 Figure 3. Average Annual Percent Change in Melanoma Incidence Rates Among Non-Hispanic White Individuals Aged ≥ 15 Years, by Sex and Age Group, United States, 2006–2015 -6 -4 -2 0 2 4 6 Average Annual Percent Change * * * * * * ** * * 15-24 25-34 35-44 45-54 55-64 65-74 75-84 ≥85 * * * Male Female Source: United States Cancer Statistics 2001-2015 Public Use Research Database.13 *Average Annual Percent Change is statistically significant (P < .05). Incidence data are from population areas that met United States Cancer Statistics publication criteria for 2006-2015 and were reported to the National Program of Cancer Registries (Centers for Disease Control and Prevention) and the Surveillance, Epidemiology, and End Results Program (National Cancer Institute), which cover about 99.1% of the US population.

14 United States Cancer Statistics: Data Visualizations Explore the data further using the official federal cancer statistics, United States Cancer Statistics (USCS). USCS combines NCI Surveillance, Epidemiology and End Results (SEER) and CDC National Program of Cancer Registries (NPCR) data, providing cancer information on the entire U.S. population. You can create maps, examine trends, and more at national, state, and county level using the interactive USCS Data Visualization website (www.cdc.gov/cancer/dataviz). Cancer researchers can analyze data of over 20 million de-identified cancer patients using the USCS Public Use Databases. Information on how to access the data is available at our website: www.cdc.gov/cancer/public-use. United States Cancer Statistics: Data Visualizations The official federal statistics on cancer incidence and deaths, produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). Leading Cancer Cases and Deaths, Male and Female, 2015 In2015, the latest year for which incidence data are available, 1,633,390 new cases of cancer were reported, and595,919 people died of cancer in the United States. For every 100,000 people, 438 new cancer cases were reportedand159 died of cancer. Cancer is the second leading cause of death in the United States, exceeded only by heart disease. One of every four deaths in the United States is due to cancer. Rate of New Cancers in the United States All Types of Cancer, All Ages, All Races/Ethnicities, Male and Female Rate per 100,000 people DC MD DE NJ CT RI MA VT NH Rate per 100,000 people 348.8 -405.1 408.5 -449.4 452.8 -467.7 468.0 -51

15 Behavioral Surveillance Indicators Increasing the use of sun protection and decreasing the prevalence of sunburn and indoor tanning are critical to preventing future cases of skin cancer. These behavioral surveillance indicators can provide timely information about our progress in reducing exposure to harmful UV exposure. The latest data on use of sun protection (shade, clothing, wide-brimmed hats, and sunscreen), indoor tanning, and sunburn among US adults are available from the Cancer Control Supplement of the 2015 National Health Interview Survey (NHIS). The most recent data on sunscreen use, indoor tanning, and sunburn among US high school students are available from the 2013 and 2017 national Youth Risk Behavior Survey (YRBS). Sun Protection According to the 2013 YRBS (the latest year for which data are available), 10.1% of high school students use sunscreen with an SPF of 15 or higher when outside for more than 1 hour on a sunny day.17 Sunscreen use was higher among girls (13.2%) than boys (6.9%). The prevalence of sunscreen use among high school students did not change significantly from 2005 to 2013. Although use of sun protection appears to be increasing slightly among adults (Figure 4), there is still room for improvement. Sun protection strategies differ by sex, and more than one-quarter of women and one-third of men do not consistently use any form of sun protection (Figure 5). Figure 4. Percentage of US Adults Who Protect Themselves from the Sun Always or Most of the Time, by Sex and Age, 2005, 2008, 2010, 2015 Figure 4. Percent ge f US Adults W o Pr tect Themselves from the Sun Always or Most of the Time, by Sex and Age, 2005, 2008, 2010, 2015 40 45 50 55 60 65 70 75 80 2005 2008 2010 2015 Percentage Males, Ages 18–24 Females, Ages 25+ Females, Ages 18–24 Healthy People 2020 Males, Ages 25+ Overall Source: National Health Interview Survey.2 Note: Data are age-adjusted to the 2000 US Standard Population. Ages 18–24 are age-adjusted using age groups 18–19 and 20–24. Ages ≥25 are age-adjusted using age groups 25–34, 35–44, 45–64, and ≥65.

16 Figure 5. Percentage of US Adults Who Use Sun Protection Always or Most of the Time When Outdoors on a Warm Sunny Day for More Than 1 Hour, 2015 Figure 5. Percentage of US Adults Who Use Sun Protection Always or Most of the Time When Outdoors on a Warm Sunny Day for More Than 1 Hour, 2015 Shade Sunscreen with SPF 15+ One or more sun protection measures Protective Clothing 0 10 20 30 40 50 60 70 80 Percentage Men Women 31.9 46.0 66.7 74.8 23.4 43.6 43.6 33.4 Sun Protection Strategy Source: National Health Interview Survey.18 Note: Data are age-adjusted to the 2000 US Standard Population.

17 Indoor Tanning Data from the national YRBS and NHIS show that indoor tanning has decreased among high school students19 (Figure 6) and adults20 (Table 5). Decreases among high school students may be caused, in part, to increased state restrictions on the use of indoor tanning among minors.21 Indoor tanning remains highest among women aged 18 to 29 years and non-Hispanic white individuals (Table 5). Figure 6. Percentage of US High School Students Who Used an Indoor Tanning Device in the Past Year, by Sex, 2009, 2011, 2013, 2015, 2017 Figure 6. Percentage of US High School Students Who Used an Indoor Tanning Device in the Past Year, by Sex, 2009, 2011, 2013, 2015, 2017 0 5 10 15 20 25 30 2009 2011 2013 2015 2017 Both Sexes Healthy People 2020 Target Girls Boys Year Percentage Source: National High School Youth Risk Behavior Survey.19 Note: Indoor tanning is defined as using an indoor tanning device (such as a sunlamp, sunbed, or tanning booth) one or more times during the 12 months before the survey. It does not include getting a spray-on tan.

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