Just as the Colorado Melanoma Foundation (CMF) was tuning up its Sun Bus for a second summer of large-event visits across Colorado, the coronavirus pandemic brought life to a standstill.
“With the pandemic, we sat back on our heels and thought, ‘How are we going to reinvent ourselves in this new world?’” said Neil Box, PhD, associate professor of dermatology in the CU School of Medicine and assistant professor of epidemiology in the Colorado School of Public Health.
The Colorado Melanoma Foundation's Sun Bus received over 26,000 visitors as it traveled across the state last summer.
Last summer, he said, the vehicle received over 26,000 visitors, provided free skin screening to 850 and referred 96 people with lesions to specialty care. Six of those visitors were subsequently diagnosed with melanoma.
Summer 2020 is another matter, however, and the Sun Bus is, for now, mostly parked.
But the CMF, of which Box is president and co-founder, refuses to sit idle. The organization is rolling out yet more creative ways to deliver sun safety messages across Colorado, where the rate of skin cancer diagnosis exceeds the national average.
Below, listen to the CU Anschutz 360 podcast to learn how Box and the CMF are reinventing community education about sun smart behaviors as well as continuing research into the genetic factors that make some people more susceptible to skin cancer. Also, find out why – despite people spending more time at home amid the pandemic – Box believes it’s likely they are actually getting more sun exposure than before.
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Chris Casey, Host Welcome to CU Anschutz 360, a podcast about the CU Anschutz Medical Campus. We feature faculty, staff and students in their interesting and innovative work. My name is Chris Casey, and I'm an editor in the Office of Communications. And today I'm talking with Neil Box, an Associate Professor of Dermatology in the CU School of Medicine. In addition to his teaching and research into UV exposure, Dr. Box is President and co-founder of the Colorado Melanoma Foundation, which is a leader in providing community education about sun protection and sun safe behaviors. Thanks very much for joining us for this podcast, Neil.
Neil Box Thanks, Chris. Thanks very much. It's a pleasure to be here. Always happy to spread the word and put some of this information out there.
Chris Casey Great. Thank you. So, here we are. And usually in late spring, it's usually in late spring that the Colorado Melanoma Foundation's Sun Bus gets rolling. And I'm wondering, has the coronavirus pandemic put the brakes, so to speak on, on the Bus this year?
Neil Box Well, yeah, Chris, it certainly has. We were going to launch our program actually in March. And literally, around... the shutdown, around March 13, whenever the shutdown really hit, we were actually planning our launch for then. So, we had some big activities planned and some events to plug into. And it's just... that just put the bite on it. And it was kind of over. So, we've had some downtime. The Sun Bus goes to major community events where there are lots and lots of people. So, with the cancellation of all the big community festivals, we've had to sort of sit back on our heels, like everybody else and reinvent ourselves, which we're working on now.
Chris Casey Great. And could you explain a little bit of history with the Sun Bus Neil? Like how did it get started? You mentioned it'll usually go to festivals and such. So, where does it travel? And, and just what exactly is its main purpose?
Neil Box So the Sun Bus got started really when we started the Colorado Melanoma Foundation back in 2013. We started doing some events and raising some money and then we were having some conversations. And I was having one conversation, in particular, with Dr. Karen Nern, who's one of our supporters. Karen started Vail, Aspen and Breckenridge and Glenwood Springs Dermatology.
And so we had an event with her. We raised some money, and then there was a conversation of what should we do with it. And given that we came out of a dermatology background, we were thinking, you know, "what's the most important area for melanoma in dermatology?" And that's really it - I think dermatology owns community prevention and screening as well. So in those areas, we wanted to have a major program that actually could impact the state. And so as we talked it through, Dr. Nern actually realized, "I know we should have a bus."
The idea clicked and that was back in 2015, I believe. And so we started working diligently on raising the funds to launch the program. We raised the seed funds and bought a bus and got it fitted out in the way that it needs to be, and then got some sponsorships together to be able to operate it on an annual basis. And last spring, we put it on the road, and over the summer we were at major community events with over 700,000 people, providing education. We had 26,000 visitors come to the front of the bus and interact with our displays. We gave away 850 free skin cancer screenings, and referred 96 lesions, including six melanomas. And we worked with community derm clinics - we had 27 different providers from 17 different clinics.
Actually, including our own oncologists, Dr. Medina from our own oncology clinic and Dr. Ryan Weight. So they were terrific to work with as well, but largely through community dermatology. And yeah we've been seeing that we've been having an impact in promoting sun safety. We were actually covered by all the major TV stations last summer as well, locally. We helped with the word out there. So I believe we are becoming a feature for making impact locally.
Chris Casey Terrific. So, with the cancellation of all the big festivals and outdoor events that the bus typically travels to I'm sure you're having to adapt as you mentioned. So, how will you be getting the word out about sun safety this summer and into July, which I believe is UV safety awareness month?
Neil Box So really when the virus happened we sat back on our heels and we thought how are we gonna reinvent ourselves and get used to this new world. And what we've decided to do is focus on school education because there's very much an opportunity to generate content for classrooms to help augment the existing curriculum that they have. And so, we've decided to focus on middle schools for that. And we're creating a series of videos that complement the human body systems that the kids cover in middle school.
And so, this would be helping build their knowledge around the skin system as an organ and then tying it into sun safety. So it's a good adjunct to help with learning in the middle school curriculum. So, that's going along nicely. We've also decided to start on patient interviews that would be shareable to create a repository of stage specific patient melanoma stories. That's moving as well.
And then we're investigating launching some teledermatology for the remote regions where we can do it. Still have people come to the bus and maybe have a dermatologist online and be able to conduct a teledermatology experience so that we can still be safe with the virus and also provide screening services. We want to start getting out there in socially distant and safe fashion. But start getting out there and making screening more available as well. We are actively working in these three areas now. We're getting very close to the official launch of these programs.
Chris Casey Great. Those sound like very creative adaptations to our current environment. And Colorado seems to rank very high among states with higher rates of skin cancer diagnoses. Could you explain where Colorado ranks and just what are some of the contributing factors there?
Neil Box Yeah. So, there's different types of skin cancers. Let's deal with melanoma first because that's generally considered the most dangerous cancer type - for a skin cancer type. For melanoma, we're actually in the second highest risk group ironically. But we've, in fact, we've been in the highest risk group for death from skin care or from melanoma. And then some of the mountain counties are in the highest risk group nationally as well. So, this is important because we have some of the highest UV exposure levels in Colorado because of altitude. Down in Denver, we're at 25% more UV than at the same latitude to sea level. If you got up to 10,000 feet in the mountains, where we all ski, really between 12 and 10,000 feet that's over 50% more UV.
And then in summer, if you're climbing a fourteener, you're up above 70% UV compared to going to the beach. That's quite a bit more UV than what you would experience in some other places. So, UV is an important local issue. This is really significant for skin cancer in general. Right now, skin cancers like basal and squamous cell carcinoma are associated with your lifetime history of sun exposure. So, it's cumulative. And people living in Colorado will really get more UV than in other places. Generally, non-basal and squamous cell carcinomas are dealt within local dermatology clinics. And we don't actually collect data on those through local cancer registries.
So, we can assume here that Colorado has some of the highest rates of other skin cancers than melanoma in the country. And so really getting the word out about sun safety is critically important to try to come to terms with all of melanoma and basal and squamous cell carcinoma.
Chris Casey And as you alluded there, melanoma is the most aggressive type of skin cancer. And I believe it has a five-year survival rate for a stage three diagnosis at about 50%. How do you help people balance the risk of the disease against their desire to spend time out in Colorado's great outdoors?
Neil Box Well, we believe that, and the evidence is there, that all sun safety, like all efforts that you've made to actually avoid sun exposure are helpful and will lower your risk of skin cancers and melanoma. On the other hand, we've got a balance that - you're absolutely right. We don't want people to be cave dwellers and not enjoy the great environment that we're blessed to live in. So, balancing those two factors is really important. And the way we recommend to do that is to follow the American Academy of Dermatology's recommendations, which are to wherever possible if you're out in the sun trying, and if you have the opportunity, to spend time in the shade. And then where you can't be in the shade, wear a hat, wear sun safe clothing, cover up in whatever way you can, wear sunscreen on the exposed parts of your body, wear sunglasses.
If your kids are out swimming, get them to wear a swim-shirt. The surfers call them a 'rashy' or a 'rash guard.' Those are terrific for helping to reduce the amount of UV exposure. So, we recommend to do those things as well. So all in all, I think that the guide that you can use is don't get a sunburn, don't accumulate that much, do whatever you can with those covering up strategies to avoid getting a sunburn, but please enjoy the great weather we have here in Colorado.
Chris Casey And maybe you could quantify for our audience just a bit as to how many people on average will get melanoma each year in Colorado, and what's the mortality rate of those?
Neil Box So, nationally, first of all, there'll be just over 100,000 new cases of melanoma appearing in the country. And about 1,900 of those will come from Colorado. We are a pretty small state population wise compared to some of the others. But in terms of death - about 7,500 people will die from these nationally, and about 130 of those will come from Colorado. Because of advances, we've found with immunotherapies and their effectiveness over recent years those numbers have actually come down for the death rates, which is really terrific, but the numbers of new cancers have continued to climb. So, a prevention is lagging the treatment efforts. We have to do more in the prevention level.
Chris Casey Do you have any ideas as to why it's difficult to get the sun smart message out to people?
Neil Box Well, it's really creating a culture of sun safety. At our community events with the Sun Bus last summer, we were out in the middle of the Colorado summer, which has some of the highest UV exposure levels in the country, and look - count the number of people wearing a hat at mid-day. And it's actually very few. Very few people. We haven't created that culture of say, for example, it's a very simple part of it, hat use. We haven't created a culture of hat use. That's a smart thing to do. You know, these messages are just not getting out there enough. We're not getting enough reminders out there. We're not engaging with different industries and schools and all of our stakeholders locally to actually encourage them to take on these private strategies that can help us address the importance of sun safety. So, we really need to pick that up another notch, and that's what our Sun Bus program is designed to try to stimulate.
Chris Casey Also, it seems like there's always relative confusion about what's the best SPF level of sunscreen to use. Do you have any recommendations as to the SPF level, maybe, particularly here in Colorado, and then how often folks should be reapplying the sunblock?
Neil Box Well, yeah, these are good reminders always. SPF is a measure actually, interestingly of UVB exposure where UVB is the shorter wave of UV - high energy wavelength as UV. And they actually caused the burning. So, it's "B for burning." And SPF or sun protection factor of 30 or above screens out 97% of UV rays. SPF 50: it's 98%. If you had [SPF] 100, it will be 99%. So, it sounds like a big increase in terms of SPF factor level, but it doesn't give much. It's only another 1% increase between [SPF] 30 and 50, and 50 and 100. So, the dermatologists have developed the recommendations to use SPF 30 or above. And we certainly hold to that recommendation.
And then in terms of how often should you reapply? Well, follow the directions and reapply every two hours. There's two different types of sunscreens. Some of the old style UV absorbing sunscreens that are very effective at building UVB ray, they need to be applied every two hours because they break down with UV. But then the, um, UV reflecting sunscreens, which have zinc and titanium in them, they sit on the surface of your skin and can be rubbed off. And so you'd want to reapply those every two hours as well.
Chris Casey Okay, great. People may be inclined to try to get a base tan from, say, a tanning bed to get started on the summer outdoor season, thinking this is a "protective tan." What are your thoughts on tanning beds?
Neil Box Well, that's very interesting. Just before the virus hit, we were engaged with an effort to try to get the state of Colorado to ban tanning beds for ages 18 and under. Tanning beds are a class one carcinogen as categorized by the World Health Organization in the same category as tobacco. Now everybody has a tobacco ban for children, but we don't have that [for tanning beds]. Colorado is one of the last states to have a ban for children with tanning beds. A single tanning bed usage can increase your risk of melanoma. Now tanning beds use UVA. So UVA, we use a little mnemonic there of 'A for aging' because the UVA rays penetrate deeper into your skin and cause damage to your dermis and they promote solar elastosis - or leathery skin - and pigmentary changes like pigmented blotches on your skin as you get older, but they also have an action spectrum where they promote melanoma.
So, a single tanning bed use can elevate your risk of getting melanoma in the future. You know, definitely follow with the World Health Organization and the scientific data in recommending that people do not use tanning beds under any circumstances. And in fact: the idea of a base tan or a protective tan is a leftover from an era past, which is really unsubstantiated. And it doesn't confer a lot of value. A tanning effect is damage. You don't really want to get a tan. A tan is just a biomarker for skin damage into DNA damage or mutations that seem lighting in your skin. So, we do not recommend that.
Chris Casey I'm curious: just how did you get interested in melanoma research in the first place?
Neil Box I did my graduate school in Brisbane, Australia at the University of Queensland. And so Queensland is the melanoma capital of the universe, I suppose, in terms of rates of melanoma. We've got a lot of people with pasty white skin living close to the Equator and spending a lot of time on the beach. And so they've had a, a real local problem with historically melanoma rates three times that of the US. They had invested in some really great researchers that have performed some of the seminal work on understanding prevention in all skin cancer and melanoma. So, I had the privilege of working with some of those people at the University of Queensland. And so that really stimulated my interest. I actually didn't realize how good those people were until I left (laughs) and, and came to work in other places. It was a real privilege in my career to be able to train the people I trained with.
Chris Casey And that kind of brings me to the next question, which is: do you have any melanoma research programs currently underway? And if so, what is the focus? And does the Sun Bus play any role in helping you and your research team to gather information?
Neil Box Well, yes. We're sort of taking baby steps towards initiating the research back on campus and the lab. But it will be a little bit longer before we can get the Sun Bus back in operation regarding research. But we do have a research component to it, where we're collecting information from our community about attitudes and behaviors for sun safety, and also trying to work on developing new measures or validating new measures of sun damage on your skin. So, we can incorporate that into melanoma case control studies. So, we do have a pretty nice research aspect to the Sun Bus that has its kind of a community science type feel to it, which I really like. As the, as major events start to open up, we'll be able to reinitiate those studies.
Chris Casey Great. And the Sun Bus is a distinctly Colorado creation, a first in the nation kind of effort. Do you have long-term plans to try to take it or the concept of it nationwide?
Neil Box Well, yes. We want it to be going in Colorado first. And we have been engaging in discussions with our team of sponsors about delivering design concept in some other geographic areas as well. Again, we've put those conversations on a hold while we will wait for this virus. But I think there is a broader interest in what we're doing and trying to use the public education, you know, those aspects. The great public reach that we get through Sun Bus program partners fits very well with marketing efforts for the sun safety industry. And so, we've pulled a team of those players together, and we're hoping to fund some of this commercially at a broader scale. But those conversations have been ongoing, but we're just kind of waiting for this virus as the events open up, and we'll be able to get back in operation. So we are kind of continuing those discussions as we speak.
Chris Casey And speaking of the virus, do you think there's a possible silver lining to the pandemic in that perhaps it has kept people indoors longer as people are self-quarantining and potentially reducing their risk then to skin cancer?
Neil Box Well, actually, I think it might be the other way around. I think with people being home in quarantine, I've seen a lot of people are taking walks, in the middle of the day, that might otherwise have been in an office working at work. So, I wouldn't be surprised if people are actually getting more sun exposures. I think the aim for this message is that while people having a break from their work from home and getting outside and doing the gardening or going for a walk or a bike ride, or what have you, that they don't forget to be sun safe. It's really necessary.
Chris Casey And you being from Australia, talk about a rough year for a country. First the massive wildfires and now the coronavirus pandemic. I'm just curious how: you probably have family, friends, colleagues, et cetera in Australia. How are folks fairing with all the adversity they've faced?
Neil Box Well, certainly those bush fires were really...I mean, talking about wildfires, right? What a wild experience for everybody involved. That was incredible. But, the coronavirus, I think, Australia fared incredibly well for the coronavirus. They did have an initial influx of cases, but they got onto it very quickly. The prime minister, Scott Morrison, recruited all the state premiers on the coronavirus task force group. And they got the necessary expertise under their belt and then unified the country in how they were going to approach it. And so they really got a lead on it and shut it down very quickly. Queensland, where I'm from, early on, didn't have, you know, really many cases at all, and then the cases that they did have, with the social distancing that they engaged in, they hit it early, they hit it hard, and they just did not see that escape in sort of a massive spread that you saw in the United States. So I think that the unity in the healthcare system, that they had really helped them to address that nationwide. And now they're looking at reopening. They are in the middle of reopening things and getting back on track.
You know, the government's been great about trying to offset a lot of the losses that the people have experienced and get the economy up and working again. So, I think the whole world is kind of in that phase, but as far as deaths and case numbers, Australia was pretty low down there. And I think it's largely because they announced the unified and effective response to the virus.
Chris Casey Great. Glad to hear that aspect of things has gone relatively smoothly then. And so, back here in Colorado, as people head into the summer months, Neil, do you have any final thoughts?
Neil Box If I could just leave people with one though, I would say, whatever you do: don't get a sunburn.
Chris Casey (laughs) Okay. Good advice at any time of year, for certain. Okay. Dr. Neil Box, thank you very much for joining us for this podcast and sharing all the very important sun safety messages with us.
Thank you, Chris. It was a pleasure, always happy to do it.
[Music - Acknowledgments and Credits]
CU Anschutz 360 is produced by the University of Colorado Anschutz Medical Campus. Story editing and production by Chris Casey, mix and tech production by Matt Hastings, digital design by Sarah Adams and Jenny Merchant. A special thanks to the rest of the Office of Communications team for support and edits. We'd also like to thank our guest this week, Dr. Neil Box. You can read more on the Sun Bus and the other latest stories and breakthroughs on our campus at news.cuanschutz.edu. This is CU Anschutz 360.
Disclaimer: Transcripts are generated using a combination of speech recognition software and human transcribers. It may contain minor differences from the audio, including some edits for clarity in print. Please check the recording and with the Communications team before quoting in print.