More than Thirty Years in the Making


The Growth of The Skin Cancer Foundation

By Perry Robins, MD

From the 2009 edition of The Skin Cancer Foundation Journal

It all started with an elderly patient.

In the mid-1960s, I was a young Mohs surgeon at New York University Medical Center. Many of my patients were older, and had grown up believing that sun exposure was healthy. Their convictions hailed back to the late nineteenth and early twentieth centuries, when the sun's ultraviolet radiation (UVR) was suggested as a treatment for ailments such as acne, psoriasis, and certain forms of tuberculosis. Parents also thought it was a good idea to encourage their children to play outdoors in the sun.

I informed my patient that she had skin cancer, and that it was probably the result of years of sun exposure. She was distressed. "Why wasn't I told?" she demanded. "Why didn't anyone tell us that the sun isn't good for you?"

The "Dark" Ages

When I started my practice at NYU's Department of Dermatology in the mid-1960s, I saw a number of patients who were poorly informed about the widespread effects of sun exposure. At that time, there was little information available. I approached the American Cancer Society and the American Academy of Dermatology about initiating a program to educate people about the dangers of long-term sun exposure, but there was no interest from the organizations, nor did either have any literature on skin cancer.

In 1979, with the help of a handful of appreciative patients and Dr. Alfred W. Kopf, we established The Skin Cancer Foundation, a non-profit organization designed to educate the public and the medical profession about preventing, detecting and treating the world's most common cancer. We had a staff of one part time employee. Our timing was fortuitous: Melanoma mortality had been climbing steadily since 1950 and, coincidentally, in 1979 the first tanning salons opened in the US.

Early in the Foundation's history, patients started requesting information on choosing appropriate sunscreens. A bright young photobiologist by the name of Madhukar Pathak, MB, PhD, of Harvard University, said he had developed criteria to help patients determine what sunscreen to use. SPF, which stands for Sun Protection Factor, measures protection against the sun's UVB rays. This method of gauging protection against skin reddening was introduced to the US in 1974, but not until the late 1970s were sunscreens first labeled with SPF numbers.

SPFs were numbered 4, 8, 12 and 15, meaning that a person using a sunscreen with an SPF of 15 would be protected from skin reddening 15 times longer than if he or she was not using sunscreen. At the time, sunscreens included active ingredients like PABA (which would eventually be phased out due to concerns about skin irritation) and titanium dioxide. We knew that most sun damage occurs between 10AM and 4PM, and Dr. Pathak determined that a sunscreen with an SPF of 15 would offer sufficient UVB protection, provided it was reapplied every two hours.

With the establishment of SPF, some sunscreen manufacturers indiscriminately applied higher SPF numbers than could be verified under strict testing. In response, The Skin Cancer Foundation assembled a photobiology committee, whose members were authorities on the effects of ultraviolet radiation on the skin. Under the leadership of Dr. Pathak, the Photobiology Committee (now chaired by Warwick L. Morison, MD, professor of Dermatology, John Hopkins Medical School) established SPF 15 as the minimum acceptable standard for sun protection among the medical and scientific communities, and developed stringent testing requirements to validate SPF numbers. This was another innovation, since the FDA did not verify SPF claims made by sunscreen manufacturers. The Committee soon determined that an SPF of 15 would be required to obtain the Foundation's newly instituted Seal of Recommendation, a program designed to help consumers recognize and select safe and effective sun protection products. Today, the Committee verifies the claims of the products submitted by confirming test results on SPF levels, phototoxicity and contact irritancy, as well as claims of water- or sweat-resistance. The Committee is now working towards determining The Skin Cancer Foundation's standards for UVA protection in sunscreens.

In 1981, Mitzi Moulds, who had vast foundation experience, joined The Skin Cancer Foundation as Executive Director. We were a unique foundation then, and to this day The Skin Cancer Foundation is still the only international organization devoted solely to skin cancer.

perryrobinsmd_1985 alfredwkopfmd_1985 madhukarpathakmbphd_1985 mitzimoulds_1982 warwicklmorisonmd

Perry Robins, MD,
in 1985

Alfred W. Kopf, MD, in 1985 Madhukar Pathak, MB, PhD, in 1985 Mitzi Moulds
in 1982
Warwick L. Morison, MD

For the Record

With the invaluable support of Dr. Kopf, then a professor in the Department of Dermatology at New York University School of Medicine, we began to make educational materials available to the public. The Foundation launched several publications, including the quarterly The Melanoma Letter, founded in 1983 to provide doctors with medically reviewed clinical articles on the latest in melanoma research. That year we also produced the first annual The Skin Cancer Foundation Journal, with articles on sun protection and skin cancer written by physicians. The Sun & Skin News, a quarterly consumer newsletter on sun safety issues, debuted in 1984.

Campaigns

By the mid-1980s, we were regularly producing patient education materials, including posters, books, and brochures such as Preventing Skin Cancer and Basal Cell Carcinoma: The Most Common Form of Skin Cancer. Today, we distribute a million pieces of literature annually, and our website, www.skincancer.org, receives three million visitors a year.

We instituted a number of nationwide campaigns, beginning with our Melanoma Awareness Campaign, which featured the "ABCDs" (now the "ABCDEs"), a brochure showing the key warning signs of melanoma. In 1985 we launched The Children's Sun Protection Program, the first program of its kind, with the brochure "For Every Child Under the Sun". Then, in 1989 we created the instructional poster "The Sun Day News", which was sent to 60,000 elementary schools across the country. The Children's Sun Protection Program is still an important part of our educational agenda: In the 1990s, we developed a teaching module for the Girl Scouts of the USA and in 2008, we partnered with Columbia Sportswear and Scholastic to provide sun safety educational materials to 10,000 elementary school classrooms. Currently, in partnership with Eucerin, the Foundation is developing a new children's sun safety education program with both classroom and online activities.

Last year, we also launched a crosscountry skin screening tour, The Skin Cancer Foundation's Road to Healthy Skin Tour, presented by AVEENO (a Johnson & Johnson product) and the Rite Aid Corporation. In 2008, we visited 81 locations in 20 states, where our 130 volunteer dermatologists provided free skin exams to thousands of attendees, and detected more than 300 basal cell carcinomas, squamous cell carcinomas, and melanomas.

International Outreach

Our first World Congress on Cancers of the Skin, which the Foundation cosponsors with organizations from the host nation, took place in 1983, and has been held on a biennial basis ever since. At the World Congress meetings, doctors from all over the world share the most recent information on skin cancer. Our World Congresses not only bring together doctors from the international community but also alert the host country's local media (television, newspapers, magazines, radio), who help spread the message about skin cancer and The Skin Cancer Foundation.

Our International Advisory Council members from 23 countries work to make skin cancer education a priority around the world. Physician members come from countries including Australia, Brazil, Germany, Ireland, Israel, Portugal, The Philippines, Spain, the U.K., Greece, and Sweden.

We also publish versions of several patient education brochures in Spanish, French, German and Italian, and sponsor the International Dermatology Exchange Program, featuring professional conferences held annually at many venues worldwide.

Research

Since 1981 The Skin Cancer Foundation has also funded nearly 100 pilot research and clinical studies. Over the years we've supported several studies on the genetics of melanoma, and in 2004 we funded research on a differential diagnostic technique for melanoma that was published as "Melanocytes in Long-standing Sun-Exposed Skin: Quantitative Analysis Using the MART-1 Immunostain" in the July, 2006 issue of Archives of Dermatology.

Our fellowship program, instituted in 1987, has awarded hundreds of thousands of dollars to doctors for research or advanced training.

Advocacy

As leaders in the fight against skin cancer, we take our role in promoting sun safety seriously. We have consistently battled the tanning industry, countering their claims with facts and working to prevent children from using tanning booths. And as core members of the National Council on Skin Cancer Prevention, we work with other national organizations to raise awareness of skin cancer and promote sun-safe behavior across the country. Last year, the National Council's advocacy efforts led to a $4 million government appropriation for melanoma research.

Today

Skin cancer is still on the rise, but thanks to our ongoing work, information about skin cancer prevention, detection and treatment is also gaining ground. Our Professional Membership Program now includes 800 of the country's foremost dermatologists, Mohs surgeons, general physicians and other medical professionals committed to skin cancer education and prevention. I think that today my elderly patient would be aware of the sun's dangers rather than taken by surprise, and I hope that one day there will be fewer skin cancers to diagnose on all of our patients.