Four years ago when Courtney Rennie, then 26, asked her family doctor about an elevated irregular brown mark on her left shoulder, she was told not to worry, that it was “just a plain old mole.” But Courtney, who was finishing medical school in Ottawa, was worried because it was a new mole, it had an irregular shape and it had started to grow in size.

“I pushed to have something done and was referred to a dermatologist,” says Courtney, who adds that it can be difficult to tell by sight whether a mole is cancerous. In her case, even the dermatologist wasn't sure about the diagnosis until a biopsy confirmed she had basal cell carcinoma, the most common form of skin cancer.

“I remember feeling overwhelmed when I got the call,” says Courtney, who now has her own family practice in Revelstoke, B.C. “I kept thinking to myself, I'm only 26, how can I have cancer?”

Fortunately her treatment consisted of a simple surgical removal of the mole, followed by regular visits with the dermatologist for a few years. Since having her mole removed, her health has been good. Courtney does dress more carefully now to protect her skin; she wears an extra layer to protect her back when she swims, and hats and high SPF sunscreen are her new best friends.

When younger isn't better
There was a time when the type of skin cancer that struck Courtney was only seen in people over 50 years old, but now it's appearing with alarming regularity among those in younger age groups, including teens. A 2005 report from the Mayo Clinic in the United States warns that these cancers have increased significantly among young people over the past three decades, and it blames long-term or intense sun exposure and the use of tanning beds as key culprits.

Overall, skin cancer is the most common form of cancer diagnosed today; the incidence of nonmelanoma skin cancers has doubled in the past 20 years. One in seven Canadians is expected to get skin cancer in his or her lifetime. Last year 900 of the 4,600 Canadians diagnosed with malignant melanoma died from this aggressive form of skin cancer. Another 69,000 were diagnosed with the more treatable basal cell and squamous cell nonmelanomas.

Canadians aren't listening
Despite years of health warnings stressing the link between sun exposure and skin cancer, Canadians don't seem to be getting the message. “It's just not sinking in,” says Dr. Jason Rivers, a clinical professor of dermatology at the University of British Columbia in Vancouver and medical director at Pacific Dermaesthetics. “Young people especially don't think skin cancer is going to happen to them,” he says. “Even though people know the hazards, there's a disconnect between their knowledge and behaviour.”

Why are we still baking in the sun despite the risks? Being in the sun releases endorphins -- brain chemicals that make us feel good. Some of us have a burning desire for a sun-kissed tan. Many kids and adults enjoy outdoor activities such as baseball or swimming, but often don't protect themselves properly. Plus, exposure to UV rays has delayed effects: those hours you spend playing outdoors or tanning as a teen might not affect you for decades and can lull young people into a sense of invulnerability.

“The bottom line is that we're still getting too much sun exposure; 50 per cent of Canadians had a sunburn in the past year,” says Rivers. He has seen firsthand the ravages of skin cancer, from people in their 20s dying of malignant melanoma to those with basal cell and squamous cell carcinoma who have lost noses, eyes and ears to the disease.

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Risk factors and protection
Sun exposure is the key cause of skin cancer, but other risk factors include having fair or freckled skin, light-coloured eyes, lots of moles, using tanning beds or having a family history of the disease. “Some people may have an underlying gene that makes them more susceptible,&" says Dr. Cheryl Rosen, head of the division of dermatology at Toronto Western Hospital and University Health Network. “We can't do much about our genetic risk, nor can we avoid the outdoors altogether, but we can control our level of sun exposure and take appropriate steps to protect our skin,&" she says.

• Use enough sunscreen. “One of the mistakes people make in terms of preventing skin cancer is that they don't put on enough sunscreen,&" says Rosen, which puts them at risk for sunburns. “And the more sunburns you have, the more you increase your chances of skin cancer.&"

Most people apply only about half the amount of sunscreen they should, says Rivers, who notes that we should use copious amounts to thoroughly cover all exposed skin; we should be going through several bottles of the stuff over the course of a summer.

But even if you apply it as thick as a coat of paint, you may still be at risk. That's because while medical research has clearly proven the benefit of sunscreens in protecting against squamous cell carcinoma, no data specifically prove they prevent basal cell carcinoma or melanoma. Though sunscreen hasn't been proven to prevent these two cancers, it does prevent sunburns and the development of sun-induced moles, both of which can contribute to a higher risk for skin cancer. The B.C. Cancer Agency website notes: “Perhaps it is too early to show that sunscreens help to prevent basal cell or melanoma as the use of good sunscreens was not sufficiently prevalent until 10 years ago.&"

• Cover up. “Keep your T-shirt on,&" says Rivers. Wear loose-fitting pants and long-sleeved shirts made from closely woven material for the best protection. Wear a wide-brimmed hat. And continue to use sunscreen.

• Teach your children well. It's easy to protect your children's skin from the sun's rays when they are little. Most of the time they'll stand there passively while you slather them with sunscreen. But the trick is to instil positive sun protection habits that last into their teen years and beyond. The best way to do that is to be a good role model and apply sunscreen to yourself as well. “There is data to prove that if parents take care, kids are more prone to do so as well when they get older,&" says Rivers.

A 2000 study by B.C. Cancer Agency researchers involving 309 Vancouver children in grades 1 to 4 found that kids who use a broad-spectrum sunscreen with sun protection factor (SPF) of 30 as a matter of routine develop fewer moles and can have a lower cancer risk later in life.

Common types of skin cancer
There are three main types of skin cancer: basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Treatments usually include surgery, and may also include radiation and chemotherapy, depending on the type and extent of the cancer.

• Basal cell carcinoma: The most common form of skin cancer. It grows slowly and rarely spreads.
Prime cause: UV radiation from the sun.
Who's most at risk: People who are fair-skinned with blond or red hair. Incidence increases with age.

• Squamous cell carcinoma: When this type arises it rarely spreads,
but treatment is required to prevent the possibility.
Prime cause: Frequent sun exposure.
Who's most at risk: Those who have had frequent sun exposure.

• Malignant melanoma: This potentially fatal skin cancer may spread and can invade lymph nodes and other organs.
Prime cause: Excessive sun exposure and blistering sunburns -- especially in childhood.
Who's most at risk: People who have many (more than 50) moles, an immediate family member with the disease and those with sun-sensitive skin such as redheads. If caught early, the five-year survival rate is almost 90 per cent.

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What to look for in a sunscreen
The Canadian Dermatology Association recommends sunscreens with an ultraviolet B (UVB) SPF of at least 15 to protect against the sun's UVB burning rays and a broad spectrum UVA block. A sunscreen with SPF 15 filters out more than 93 per cent of the UVB in sunlight, while one with SPF 30 filters out 97 per cent -- which means an SPF of 30 is not twice as effective as an SPF of 15.

Here are basic SPF guidelines to follow:
Wear SPF 15 if:
• you rarely burn
• you have daily limited exposure, such as a short walk to the bus stop

Wear SPF 30 if:
• your skin burns easily
• you engage in outdoor activities, such as a half-hour walk at lunchtime

Wear SPF 45 if:
• you have sensitive skin that burns easily
• you spend extended periods of time outdoors; for instance, gardening or running

Wear SPF 60 if:
• you have reactive skin that burns easily
• you're pregnant, are using antiacne medication or have had a cosmetic procedure, such as a chemical peel or microdermabrasion

Where to put sunscreen
Don't forget to put it around your hairline and along the part in your hair; on your ears and eye contours; on the nape of your neck; under bathing suit straps; along your collarbone, shoulders and décolletage; on the backs of your arms, including elbows; along the backs of your hands; and on feet and legs, including the crease behind your knees.

Because sunscreens have chemicals that eventually deteriorate, do not store them in hot places, such as a glove compartment, and do not use them if they are past their expiry date.

Look for products that are noncomedogenic (don't block pores), nonirritating and hypoallergenic.

Skin cancer prevention tips
The good news is that skin cancer is highly preventable. In addition to liberally applying a broad-spectrum sunscreen to all exposed body areas 15 to 30 minutes before going into the sun, here are other steps you can take to decrease your risk.

• Keep babies under a year old out of direct sunlight.

• Try to avoid peak UV exposure, which occurs from 11 a.m. to 4 p.m. from late spring to early fall and during winter. (Snow reflects up to 80 per cent of the sun's rays, so you could be at extra risk if you spend time outdoors in winter without protection.)

• Use sunscreen on cloudy days because the sun's rays are still harmful.

• Health Canada guidelines recommend that you reapply sunscreen 20 minutes after you go out to maximize protection. If you are swimming or sweating heavily, reapply sunscreen more frequently.

• Head for the shade whenever possible and cover up with clothing and a wide-brimmed hat. (Look for a brim with a dark underside to prevent sun from reflecting back up onto your face.)

• Protect lips with lip balm that has at least SPF 15, and reapply every hour.

• Protect your eyes; wear sunglasses with a UV rating of 100 per cent.

• Avoid tanning parlours and sunlamps.

So what about that mole?
If you have a mole you are concerned about, says Dr. Courtney Rennie, a family doctor in Revelstoke, B.C., carefully monitor its size. “Take a picture of it with a ruler beside it, so you remember how big it is.” If anything changes, see your doctor again. If she's skilled at removing moles, she can remove it and send it off for a pathology test; if not, she can refer you to a dermatologist.

Check your skin for moles once a month. Visit the Canadian Dermatology Association's website for a guide to moles and skin cancer self-examination. Have an annual checkup by a family doctor or a dermatologist.

For more information, visit:
• Canadian Dermatology Association
• Canadian Cancer Society
• Skin Cancer Guide

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