UV-Related Melanoma Cancer and Its Association with the Human Development Index (HDI): GLOBOCAN Sources and Methods

AUTHORS

Maryam Seraji 1 , Zaher Khazaei ORCID 2 , Victoria Momenabadi 3 , Reza Beiranvand 4 , Ahmad Naghibzadeh-Tahami 5 , Elham Nejadsadeghi 6 , Maryam Zahmatkeshan 7 , Leili Moayed 8 , Elham Goodarzi 9 , *

1 Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

2 Department of Epidemiology, School of Public Health, Ilam University of Medical Sciences, Ilam, Iran

3 Department of Public Health, Bam University of Medical Sciences, Bam, Iran

4 Department of Public Health, School of Medicine, Dezful University of Medical Sciences, Dezful, Iran

5 Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran

6 Behbahan University of Medical Sciences, Behbahan,Iran

7 Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran

8 Iranian Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Iran

9 Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran

How to Cite: Seraji M , Khazaei Z, Momenabadi V, Beiranvand R, Naghibzadeh-Tahami A, et al. UV-Related Melanoma Cancer and Its Association with the Human Development Index (HDI): GLOBOCAN Sources and Methods, Iran Red Crescent Med J. 2020 ; 22(7):e103605. doi: 10.5812/ircmj.103605.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 22 (7); e103605
Published Online: August 9, 2020
Article Type: Research Article
Received: April 12, 2020
Revised: July 4, 2020
Accepted: July 10, 2020
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Abstract

Background: Exposure to radiation is a major risk factor for skin cancer so that 65 to 90% of skin cancers can be attributed to the exposure with sunlight.

Objectives: The current study aimed to investigate the association between the human development index and the incidence of UV-related melanoma.

Methods: This is an ecological study. Data on the incidence of UV-induced melanoma were extracted from the GLOBOCAN estimates (GLOBOCAN 2012), and data on the human development index were extracted from the World Health Organization (WHO) database. Data analysis was conducted by Stata software (Ver. 14). The descriptive analysis involved mean and standard deviation. The correlation method was used to evaluate the association between the population attributable fraction (PAF) of melanoma for ultraviolet (UV) and the HDI components. A P value < 0.005 was considered as statistically significant.

Results: The results revealed a significant positive association between UV-attributable melanoma cancer and HDI in women (r = 0.401, P < 0.0001), men (r = 0.488, P < 0.0001), and both sexes (r = 0.455, P < 0.0001). In Americas (r = 0.452, P < 0.05) and Europe (r = 0.740, P < 0.05), a significant positive correlation was observed between UV-induced melanoma and HDI, but this association was not significant in Asia (P > 0.05). In Africa, a negative correlation was observed, though it was not statistically significant (r = -0.301, P > 0.05). The results of the analysis of variance (ANOVA) showed a significant statistical relationship between the incidence of UV-related melanoma and the levels of development (F = 25.1, P < 0.0001) so that the higher the score of HDI, the higher the incidence of this cancer.

Conclusions: Since there is a positive correlation between UV-related melanoma and HDI, further attention should be paid to this risk factor, especially in countries with a high HDI to reduce the UV-induced melanoma cancer.

Copyright © 2020, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Background

According to the predictions, cancer would be the major burden of diseases, so that it is expected that the incidence of various types of cancer increases by 15 million by 2020 (1-3). Skin cancer is one of the most prevalent cancers in the world (4), that its incidence has been on the rise in recent decades due to the consequences of climate changes, such as ozone depletion and altered individual and social habits. Skin cancer has two main types: Melanoma skin cancer (MSC) and non-melanoma skin cancer (NMSC) subgroups (4-6).

Malignant melanoma accounts for 1% of all skin tumors and 60% of all deaths due to skin cancer. The incidence of melanoma has been growing worldwide over the past four decades (7). According to the US Academy of Dermatology, melanoma is particularly common in Australia, New Zealand, Asia, Africa, and Latin America. In the United States, Europe, and Australia skin cancer constitutes 25, 20, and 45% of all new cases of cancer each year, respectively (8).

Environmental studies have shown that the incidence of melanoma is associated with geographical variations all around the world. Besides, these studies reported that the melanoma incidence is higher in low-latitude regions near the equator and higher-altitude areas (9). Ultraviolet (UV) radiation is a risk factor for approximately 65% of melanoma and 90% non-melanoma skin cancers, and sunburn doubles the risk of melanoma. Therefore, environmental changes that increase UV radiation transmission have a direct impact on human health. Hence, a history of sunburn and extensive sun exposure is directly related to the relative risk of melanoma during life (10, 11).

One of the most important factors associated with cancer is the human development index (HDI), which reflects the social and economic status of individuals in different countries (12, 13). HDI is a globally-verified indicator that demonstrates the level of economic and social well-being of communities. Comprising three dimensions of health, education, and income, this index shows the quality of life (14). Melanoma cancer is more common in people with high socioeconomic status, but its mortality rate is higher in individuals from lower socioeconomic status (15).

2. Objectives

The current study aimed to investigate the association between HDI and the incidence of UV-related melanoma.

3. Methods

3.1. Cancer incidence and HDI Grouping

National estimates of the new cases of cutaneous melanoma, herein referred to as melanoma, were obtained from GLOBOCAN 2012. In this study, only countries/territories with at least 10 melanoma cases (in both sexes) were included (n = 153 countries/territories), which accounted for 96% of the estimated global melanoma burden.

The results are classified by several factors, including HDI, which is a composite indicator of life expectancy, education, and gross domestic product (GDP) per person. 153 countries/territories that had inclusion criteria were assigned to four categories according to their 2012 UN-defined HDI groups: very high, high, medium, and low HDI (UNDP 2013 Human Development Report).

3.2. Exposure Assessment

It is difficult to quantify the intensity of UV radiation exposure in the population. Given that all populations to somehow are exposed to the sunlight, the traditional approach to quantifying population attributable fractions (PAF) (i.e., using population prevalence of exposure and the corresponding relative risks of cancer) was not applicable. Hence, we compared the observed melanoma incidence rates with those of a minimally exposed reference population (1). By doing so, differences in the number of new cases could be attributed to corresponding differences in UV radiation exposure between the reference and study populations.

PAFs were calculated as the difference between the estimated number of new cases in 2012 (by country/territory in 5-year age groups (ages ≥ 30 years) and sex) and the expected number of cases based on incidence rates of the reference population (1).

The following formula was used to calculate country/territory-, age, and sex-specific PAFs:

PAF = (Ip - Iu)/Ip

Where Ip is the incidence of melanoma in the study population in 2012 and Iu is its incidence in the reference population. The number of cancer cases attributable to UV radiation exposure was also expressed as the percentage of the total number of all new cancer cases in 2012, except for non-melanoma skin cancers.

The variance estimate of PAF obtained from the delta method was used to achieve 95% uncertainty estimates.

3.3. Human Development Index

HDI, which ranges from zero to one, exhibits the extent of the progress in achieving the highest value (HDI = 1), which allows comparisons across countries. In other words, HDI is a summary measure that combines the mean achievements of a country/territory in three dimensions of human development, including long and healthy life, education, and decent living. As a geometric mean of normalized indices for each of these dimensions, HDI measures the degree of progress and success in each dimension. Life expectancy is measured by life expectancy at birth, education by mean years of schooling (elementary, secondary, and higher education), and standards of living by gross national income (GNI) per capita (16, 17).

3.4. Statistical Analysis

Data were analyzed using Stata software (Ver. 14). The descriptive analysis included mean and standard deviation. The correlation method was used to evaluate the association between PAF of melanoma for UV and HDI components. A P value of P < 0.05 was considered as statistically significant.

4. Results

The highest proportion of UV-related cancers was among those aged 30-49-years in South-Central Asia, followed by those aged 50-69-year olds in East Asia and those aged 70-year olds in the Australia and New Zealand (Table 1).

Table 1. Relative Proportions (by Age Group) of Cancer Cases Attributable to UV Radiation Exposure in Men and Women of All Ages (30+ years) Separated by Region in 2012 (source: GLOBOCAN 2012)
RegionAge Group, yTotal
30 - 4950 - 6970+
NumberRelative, %NumberRelative, %NumberRelative, %
Western Europe758025.01310043.01000033.030700
Sub-Saharan Africa43316.0163059.070025.02760
Southern Europe492035.0597042.0327023.014200
South-East Asia2741.03959.000.0067
South-Central Asia13942.015948.03410.0333
South America and Caribbean162026.0244039.0221035.06280
Northern Europe473024.0836042.0678034.019900
North America1210019.03010046.02260035.064900
Middle East and Northern Africa47328.078746.044326.01710
Eastern Europe316024.0706053.0307023.013300
East Asia3130.07168.022.0104
Australia and New Zealand265019.0623045.0499036.013900

UV-induced melanoma cancers separated by men and women and for both sex are shown in Table 2. As shown in the table, the highest incidence of UV-related melanoma cancers in both sexes in Asia belongs to in Israel (88.2%) and Timor-Leste (87%), the United States (90.5%) and Canada (85.4%) in Americas, Norway (92.5%) and Switzerland (92%) in Europe, and South Africa (72.4%) and Uganda (72%) in Africa (Table 2 and Figure 1).

Table 2. Fraction of Melanoma Attributable to UV Radiation Exposure Among Men and Women of All Ages (30+ Years) by Country in 2012 (source: GLOBOCAN 2012)
CountryFraction of Melanoma Attributable to Ultraviolet (UV)
MaleFemaleBoth
Asia---
Kuwait-0.00.0
Jordan0.00.013.2
United Arab Emirates5.450.072.4
Saudi Arabia0.00.06.2
Israel92.483.314.0
Qatar---
Bahrain--2.97
West Bank and Gaza Strip95.270.7-
Syrian Arab Republic0.00.040.9
Lebanon30.211.118.1
Iraq0.00.015.6
Turkey59.921.0-
Kazakhstan73.70.0-
Oman--49.3
Uzbekistan19.635.745.1
Georgia64.226.945.6
Azerbaijan44.827.3-
Iran4.660.0-
Armenia58.638.99.56
Turkmenistan52.913.217.0
Kyrgyzstan34.50.029.8
Mongolia--37.4
Malaysia1.510.022.3
Yemen38.126.737.2
Darussalam Brunei--53.7
Singapore3.820.027.6
Republic of Korea19.20.044.8
Japan1.750.038.6
Tajikistan46.10.8162.35
China0.530.0-
Maldives--55.1
Thailand0.00.072.0
Philippines0.420.06.28
Bhutan--50.1
Democratic People’s Republic of Korea0.00.035.2
Pakistan7.580.0-
Sri Lanka0.00.022.8
Indonesia7.890.013.6
India0.00.041.8
Lao People’s Democratic Republic1.850.0-
Nepal0.00.067.4
Myanmar0.00.044.9
Timor-Leste91.378.448.9
Afghanistan22.40.04.45
Cambodia7.340.06.57
Viet Nam0.00.027.1
Bangladesh0.00.027.6
Europe29.5
Czech Republic92.984.031.1
Malta79.269.13.46
Spain81.571.553.5
Cyprus71.553.818.7
Luxembourg90.982.3
Germany90.181.638.4
Ireland92.287.590.5
Hungary86.368.452.8
Slovenia93.387.385.4
Poland77.258.032.3
United Kingdom92.086.7-
Portugal78.170.4-
Serbia86.866.221.2
Lithuania81.365.1
Belgium86.984.119.0
Slovakia91.281.145.4
Finland92.883.066.5
Bosnia and Herzegovina65.824.144.7
Austria88.577.949.4
Iceland88.084.6-
Croatia88.379.321.6
Switzerland94.489.41.31
Italy86.976.737.2
Greece57.614.341.1
Bulgaria72.040.355.7
Montenegro83.250.062.1
Latvia82.170.425.0
France88.079.428.6
Russian Federation73.459.00.0
Netherlands93.489.915.1
The former Yugoslav Republic of Macedonia81.863.04.6
Norway94.890.349.2
Albania39.418.1-
Sweden93.889.428.6
Belarus72.557.4-
Africa---
Egypt0.00.0-
Libya15.811.90.0
South Africa83.461.63.12
Tunisia13.30.00.0
Morocco21.612.488.2
Mauritius---
Algeria5.370.0-
Swaziland--77.9
Gabon52.629.20.0
Cameroon32.86.3419.4
Mauritania19.112.70.0
Djibouti--40.3
Cabo Verde--53.8
Zimbabwe43.751.2-
Botswana59.535.09.68
Namibia60.833.153.7
Equatorial Guinea--35.4
Lesotho--2.59
Nigeria14.90.047.5
Ghana3.8927.333.9
Cote d’Ivoire48.77.9420.0
Benin0.045.6-
Sierra Leone2.8431.30.87
Senegal33.939.332.8
Guinea9.6761.6-
South Sudan36.321.81.86
United Republic of Tanzania46.943.810.4
Liberia23.245.10.73
Sudan5.190.027.3
Comoros--0.53
Congo60.051.8-
Uganda81.361.70.0
Somalia14.73.680.23
Mozambique75.845.6-
Angola45.128.80.0
America86.8
Puerto Rico58.814.986.0
United States of America94.384.889.7
Argentina72.129.077.5
Canada90.479.390.2
Mexico56.21.166.9
Bahamas--89.3
Belize--73.7
Chile34.412.178.3
Barbados72.0
Venezuela (Bolivarian Republic of)34.00.085.3
Trinidad and Tobago65.215.786.1
Uruguay78.853.488.5
Costa Rica63.023.545.4
Panama63.631.083.3
Suriname--86.1
Nicaragua33.07.9583.4
El Salvador0.02.0492.0
Paraguay46.629.181.7
Ecuador48.935.338.4
Brazil71.738.056.8
Colombia77.044.969.2
Peru46.91.275.0
Guatemala41.710.783.5
Dominican Republic0.00.064.2
Honduras25.53.6891.5
Cuba8.990.072.8
Bolivia (Plurinational State of)54.546.392.6
Guyana--30.2
Jamaica57.70.091.7
Haiti--63.0
Onia55.8
Australia97.579.8
New Zealand97.591.2
61.5
45.7
Figure 1. Global map presenting PAF of melanoma cases attributable to UV radiation exposure worldwide among men and women of all ages (30+ years) by country in 2012 (source: GLOBOCAN 2012).

According to the results, the higher the incidence of UV-induced melanoma cancers in men and women of all age groups, the higher the HDI (Figure 2).

Figure 2. Bar charts show the distribution of UV-related melanoma in terms of HDI components for a: Male and b: Female in 2012 (source: GLOBOCAN 2012).

According to the results, there is a significant positive correlation between UV-induced melanoma and HDI in women (r = 0.401, P < 0.0001), men (r = 0.488, P < 0.0001), and for both sex (r = 0.455, P < 0.0001) (Figure 3).

Figure 3. The correlation between HDI and the fraction of melanoma attributable to ultraviolet (UV) worldwide in 2012.

Concerning the relationship between HDI and UV-related melanoma in each continent, the results suggested a positive and significant correlation between the ratio of UV-related melanoma and HDI in the Americas (r = 0.452, P < 0.05) and Europe (r = 0.740, P < 0.05), though this relationship was not significant in Asia (P > 0.05). In Africa, a negative correlation was found, which was not statistically significant (r = 0.301, P > 0.05) (

Figure 4. Correlation between HDI and the fraction of melanoma attributable to ultraviolet (UV) in each continent in 2012.

According to the results of the analysis of variance (ANOVA) the highest mean of UV-related melanoma was for women (60.4 ± 32.3), men (73.8 ± 29.5), and both sexes (68.0 ± 29.8) in regions with very high human development, while the lowest mean was for women (15.0 ± 20.3), men (26.1 ± 25.1), and both sexes (20.21 ± 22.1) in regions with a medium human development (Table 3).

Table 3. Mean Fraction of Melanoma Attributable to UV in Different HDI Regions in 2012a, b
HDI ComponentsFraction of Melanoma Attributable to Ultraviolet (UV)
FemaleBothMale
Very high human development60.4 ± 32.368.0 ± 29.873.8 ± 29.5
High human development20.4 ± 21.432.58 ± 24.642.9 ± 29.8
Medium human development15.0 ± 20.320.21 ± 22.126.1 ± 25.1
Low human development26.0 ± 21.729.4 ± 19.330.0 ± 22.6
F-test23.725.121.61
P value< 0.0001< 0.0001< 0.0001

aValues are expressed as mean ± SD.

bStatistical method: analysis of variance (ANOVA).

5. Discussion

In 2012, there were nearly 168,000 cases of UV-related cancers worldwide. Studies estimated that each year there occur 23,000,000 new cases and 55,000 deaths due to melanoma globally (18). Various studies have shown that exposure to radiation is a major risk factor for skin cancer so that 65% to 90% of skin cancers are caused by exposure to UV radiation. Hence, skin protection is of paramount importance in this regard (19). It has been shown that 86% of all melanoma cases are induced by sun exposure, so increased exposure to sunlight raises the risk of melanoma up to two-fold (20).

According to the results of the current study, the highest incidence of UV-related melanoma in both sexes was in Israel (88.2%) in Asia, the United States (90.5%) in Americas, (92.5%) Norway in Europe, and South Africa (72.4%) in Africa. In Americas (r = 0.452, P < 0.05) and Europe (r = 0.740, P < 0.05), there was a significant positive association between UV-related melanoma ratio and HDI, but it was not significant in Asia (P > 0.05). In Africa, there was a negative correlation, which was not statistically significant (r = -0.301, P > 0.05).

One reason for variations in melanoma incidence worldwide is the disparity in UV exposure in different regions of the world. In the Southern Hemisphere, due to higher exposure with UV radiation, the incidence of this cancer is higher. Although the rate of melanoma is higher among Caucasians, people known as non-white are also at risk for melanoma. Lack of awareness may also increase the risk (21).

Sun is the major source of UV radiation, and the degree of exposure to this radiation depends on latitude and location, time of day and year, cloud cover, air pollution, and ozone depletion in the stratosphere (22). Therefore, outdoor activities and exposure to sunlight can be considered as the major causes of melanoma proliferation over the past 5 decades (23).

The highest incidence of melanoma in New Zealand, Australia, and Europe has been registered in the elderly, with UV being a major cause of the disease in these countries (24, 25). Other reasons include genetics, lifestyles, the habit of living in open areas, and tanning by sunlight. Epidemiological studies revealed that UV is a risk factor for melanoma in genetically vulnerable populations. The presence of cancer markers is associated with a significant rise in the risk of melanoma. New Zealand’s population is at an increased risk of melanoma due to these cancer markers. In recent decades, the population distribution in New Zealand has changed dramatically, which may lead to a lower incidence of the disease in the future (26).

Given that middle-aged and older men are more prone to sun cancer than younger men and women, they are more susceptible to skin cancer. In a study conducted in Colombia, 62 and 19% of all melanoma cases in men in women were related to UVR exposure, respectively (27).

Avoiding UVR, especially during childhood and adolescence, which is a sensitive age for UV carcinogenesis, and UVR protection using appropriate garment and cover can reduce the risk of cancer at the old ages (28, 29). The incidence of skin cancer rises significantly with age, which is probably due to long-term exposure to environmental carcinogens and cancer development (30). Studies have shown that protecting individuals against the harmful effects of UVR during outdoor activities can lead to a dramatic drop in melanoma (31).

5.1. Conclusions

Melanoma is one of the most common cancers in the world, and UV radiation is its major risk factor. Since our study exhibited a positive correlation between the ratio of UV-related melanoma and HDI, further attention should be paid to this risk factor, particularly in countries with high HDI scores. Accordingly, restricting the level of exposure to UV radiation can effectively reduce UV-related melanoma cancer.

Footnotes

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