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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