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Advances in dermatology and venereology Acta Dermato-Venereologica
Impact of Gliding on the Prevalence of Keratinocyte Carcinoma and its Precursors : A Cross-sectional Study Among Male Pilots in Bavaria
Alexander ZINK 1 , Ivonne HÄNSEL 1 , Markus ROTTER 2 , Christoph D . SPINNER 3 , Alexander BÖHNER 1 and Tilo BIEDERMANN 1 Departments of 1 Dermatology and Allergy , and 3 Medicine II , University Hospital Klinikum rechts der Isar , Technical University of Munich , DE-80802 Munich , and 2 Research Unit of Molecular Epidemiology , Institute of Epidemiology II , Helmholtz Zentrum München , Neuherberg , Germany . E-mail : alexander . zink @ tum . de Accepted Oct 12 , 2016 ; Epub ahead of print Oct 14 , 2016
Skin cancer is the most common type of cancer in the fair-skinned population ( 1 ). One-third of diagnosed cases of cancer worldwide are skin cancer and this incidence has increased continuously over the last decade . Keratinocyte carcinoma ( KC ) is 18 – 20 times more frequent than melanoma ( 1 ), and a significant increase in both has been observed worldwide , as well as in Germany ( 1 , 2 ). Although KC has a huge impact on societal costs and can be lethal ( 3 , 4 ), cancer institutes worldwide usually do not systematically register data on KC . Therefore , incidence and prevalence rates are rare ( 1 ). Solar ultraviolet ( UV ) radiation is considered to be the main factor in the development of KC ( 5 ). Glider pilots are heavily exposed to solar UV radiation because they fly at altitudes of up to 5,000 m , flights that can last several hours , and lack UV protection ( Fig . 1 ). At these altitudes , they are less protected from UV-B radiation due to a thinner atmosphere with reduced filtering of UV radiation ( 6 ). High levels of exposure to UV-B radiation increase the risk of photo-damage to the skin ( 6 , 7 ).
Although some research has been carried out on military or commercial airplane pilots , no study has yet investigated the risk to glider pilots ( 8 – 10 ). The present study evaluated the prevalence of KC and its precursors in pilots of glider aircraft in Bavaria , Germany to assess the role of UV exposure at higher altitudes and the need for awareness and prevention campaigns .
PATIENTS AND METHODS
A cross-sectional study of adult pilots of glider aircraft was performed between May and July 2015 . A random sample of 82 male pilots aged 18 – 83 years from 4 larger gliding clubs in Bavaria ( Königsdorf , Erlangen , Dachau , and Unterwössen ), Southern Germany participated in an on-site full-skin examination . The study was approved by the local ethics committee of the Technical University of Munich , and written informed consent was obtained from all participants prior to study inclusion . On the day of examination , every attending adult member (> 18 years old ) of the randomly chosen gliding clubs was invited to attend a volunteer skin cancer screening . No female pilots were included because most members of the participating gliding clubs were men . The full-body skin examination ( 11 ) was performed by an experienced dermatologist using a dermatoscope , and each participant ’ s skin type categorized from I to VI according to Fitzpatrick . If the screening test result was abnormal , a histological examination was recommended . To determine KC , every suspicion of actinic keratosis , basal cell carcinoma , and squamous cell carcinoma was indicated as a positive test result . Prior to the skin cancer screening , all participants were given a standardized questionnaire about general personal data ,
Fig . 1 . “ Selfie ” taken by a glider pilot during a 5-h flight over 3,000 m above ground , illustrating typical severe UV exposure during flights ( courtesy of Michael Sturm ).
their individual risk behaviour , and about their knowledge and awareness of skin cancer ( Table SI 1 ). Additional questions were inserted to control for bias ( e . g . “ How many hours do you spend outside on a usual day ?”). The age of the participants was classified into the categories used by the German Centre for Cancer Registry Data . The characteristics of participants and frequencies were stratified by age group and compared using Fisher ’ s exact test . After testing the variables from the questionnaire and skin cancer screening for significance , logistic regression models were used . All statistical analyses were performed using SAS version 9.2 software ( TS1M0 ) ( for details see Appendix S1 1 ).
RESULTS
The overall prevalence of KC and its precursors in glider pilots in this study was 49 % ( 40 / 82 ). In all affected pilots ( 40 / 40 ), the skin lesions were found on sites that are typically exposed during gliding , i . e . the face and back of the hands . Stratification by age showed that KC and its precursors was more prevalent in older age groups and among those with sunburn during childhood . Headgear ( usually a small hat ) was worn by 99 % ( 81 / 82 ) of pilots . Almost half of pilots ( 48 %) said that they generally use sunscreen on sunny days . According to their answers to the questionnaire , only 54 % ( 44 / 81 ) of pilots had previously undergone a medical skin check by a dermatologist and 78 % ( 64 / 82 ) mentioned regular self-examination . Furthermore , 74 % ( 56 / 76 ) of participants stated that they were interested in further information about
1 https :// www . medicaljournals . se / acta / content / abstract / 10.2340 / 00015555-2547
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2017 Acta Dermato-Venereologica . doi : 10.2340 / 00015555-2547 Acta Derm Venereol 2017 ; 97 : 393 – 394