Rise in Skin Cancer Rate for Veterans

November 6, 2024

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U.S. military members experience unique challenges both during and after their tour of duty. Unfortunately, these can be associated with greater morbidity across different diseases. A recent systematic review was published online in JAMA Dermatology on September 4, 2024, titled “Skin Cancer and Other Dermatologic Conditions Among US Veterans.” The study compared the prevalence and odds of skin cancer and dermatologic conditions among veterans versus non-veterans.

The observational analysis examined 61,307 participants, including 54,554 nonveterans and 6,753 veterans, to compare the prevalence and odds of dermatologic conditions such as skin cancers, psoriasis, eczema, and dermatitis. The findings indicate that veterans have a higher likelihood of having a history of skin cancer, with 9% of veterans reporting skin cancer compared to just 2.9% of nonveterans.

Data from the National Health and Nutrition Examination Survey (NHANES)* confirmed veterans exhibited higher rates of melanoma and poorer survival rates due to later-stage diagnoses. Veterans were also 1.61 times more likely to be diagnosed with psoriasis than their nonveteran counterparts. Collectively, these results underscore the need for targeted healthcare interventions to address the underlying causes of worsened skin health in military veterans to improve prevention, diagnosis and treatment options.

*Nonveteran and veteran NHANES data was analyzed from August 2023 to April 2024 by Shawheen J. Rezaei, MPhil, an M.D. student at Standford University School of Medicine and his colleagues Jiyeong Kim , PhD, MPH, and Sonia Onyeka, MBBS, Susan M. Swetter, M.D., Martin A. Weinstock, M.D., PhD, MPhil, Steven M. Asch, M.D., MPH, and Eleni Linos, M.D., MPH, DrPH.

“This is an interesting cross-sectional study of the increased skin cancer rates among American military veterans,” says Michael Steppie, M.D., President and Medical Director of Associates in Dermatology. “Indeed, we have treated many veterans over the past 35 years at Associates in Dermatology for their dermatological needs, including all forms of skin cancer. Hopefully, this will lead to an increased awareness of the military’s need for sufficient sun protection education and routine skin examinations both during and after active duty.”

Today, the Veterans Administration reports that 11.4% of U.S. veterans are diagnosed with cancer, which is a higher rate than non-military service populations at ten percent. According to VA data, the frequently diagnosed malignancies for former members of the military includes prostate, lung, colorectal, melanoma, and bladder cancers. Men and women who served should consider genetic testing, especially smokers or those stationed near the equator.

Early Skin Cancer Risk Studies

An early study on skin cancer in the military was published in the Journal of the American Academy of Dermatology in June 2018. This was a systematic review of melanoma and non-melanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel. Published studies on the subject of skin cancers in military personnel was needed to help improve preventive education, screening efforts, diagnoses, and treatments for the nation’s military populations.

This systematic review of published studies was conducted by Kelsie Riemenschneider, M.D., Jesse Liu, BSE and Jennifer G. Powers, M.D., and focused on the occurrence of melanoma and non-melanoma skin cancer in military personnel. The nine studies described skin cancer occurrence rates among U.S. active duty and veteran military populations.

Four of the nine studies specifically were specific to melanoma skin cancer occurrences. The review findings revealed:

• Increased risk for melanoma associated with military service and prisoners of war.
• Increased risk for non-melanoma and melanoma among WWII veterans that served in tropical environments.

Most of the studies that were reviewed suggested reasons as to why U.S. military and veteran personnel had higher rates of skin cancer:

• Increased sun exposure during their military service.
• Insufficient sun protection while serving on active duty.
• Two of the nine studies determined an increased risk for deadly melanoma with the highest rates among service members who served in the branch of the United States Air Force.

This review that was conducted prior to the COVID-19 pandemic identified an abundance of evidence for an increased risk for non-melanoma and melanoma skin cancer development among both active duty and veteran populations. Since the articles and studies had variable results, the authors suggested that a random controlled trial would be beneficial to better understand the need to develop interventions to mitigate skin cancer risk for members of the U.S. military and veteran populations.

Importance of early treatment for melanoma...

When compared with nonveteran populations, military veterans were more likely to have been diagnosed with skin cancer at some point in their lives, had a higher mean age of skin cancer diagnosis, and much more likely to have been diagnosed with melanoma. Recognizing skin changes through routine self-examinations is the best way to detect skin cancers early, and both veterans and active service members should consider annual exams with a board-certified dermatologist.

“Melanoma is the deadliest form of skin cancer,” says Dr. Steppie Orlando Mohs cancer surgeon. “But it is highly treatable when detected early and has a five-year survival rate of 99%. One problem is melanoma can quickly spread to the lymph nodes and is often diagnosed in later stages for patients with darker skin tones.”

According to the AAD, melanoma is the most serious form of skin cancer and is characterized by the uncontrolled growth of pigment-producing cells, which can appear suddenly or develop within an existing mole. Experiencing excessive UV exposure from the sun or tanning beds increases the risk of melanoma diagnosis as well as an increased risk for basal cell or squamous cell carcinoma as well.

ABCDE Skin Assessment Tool

If you notice a mole on your skin, you should follow the ABCDE rule, which outlines the warning signs of melanoma. This is the most common tool used to examine new and existing skin lesions, spots and moles using a full-length mirror to look at both sides as well as the front and back of your body. You should also use a hand mirror to examine your scalp, neck, back areas, and buttocks. Here’s some helpful warnings signs for the most dangerous skin cancers:

1. Asymmetry: Normal moles tend to be symmetrical or similar in shape all the way around. If a mole is asymmetrical, it could be a sign of melanoma and needs to be examined by a dermatologist.
2. Border: Harmless moles will have regular edges. Melanoma often has an irregular border that can be notched, ragged or blurred with pigmentation that spreads. Have any of these checked by a dermatologist.
3. Color: Melanoma will often have more pronounced coloring, such as red, black, dark brown, or flesh-colored. Unique color of a mole can be a good indicator it needs to be checked by a dermatologist.
4. Diameter: The size of the mole matters. If a mole is larger than the eraser end of a pencil (about 6 mm or ¼ inch) or changes rapidly in size, it should be examined by a dermatologist.
5. Evolving: Moles and birthmarks do change over time and need to be checked routinely. Any changes in color, size, shape, or elevation should be examined by a dermatologist.

The Skin Cancer Foundation warns that only 20-30% of melanomas are found in existing moles while 70-80% occur on normal-looking skin, so annual checkups with a dermatologist can be life-saving. Malignant melanoma begins in cells known as melanocytes. Although less common that basal cell carcinoma or squamous cell carcinoma, it is much more dangerous due to its ability to rapidly spread to other organs at an early stage.

Types of Melanoma Cancer

“Using the ABCDE tool is important,” adds Dr. Steppie. “But understanding that melanomas can present in many different locations, shapes, sizes, and colors can be life-saving knowledge for early detection. Although darker-skinned people naturally have better protection from sun damage, skin cancer can happen to anyone and regardless of their skin tone.” Discussed below are the four main types of melanoma and what you should know:

• Superficial Spreading Melanoma – This type of melanoma can appear as new skin lesion or in an existing mole. Although it can be found anywhere, it tends to grow on the surface before penetrating more deeply and is highly treatable when detected early. Colors include shades of tan, brown, black, red, pink, blue, white or skin-toned (amelanotic). Monitor skin changes regularly and be on the lookout for moles that are “ugly ducklings.”
• Acral Lentiginous Melanoma – This is the most common type of melanoma found in people of color and it often appears in hard-to-spot places, such as subungual and on the palms of the hands or soles of the feet. The tragic death of Bob Marley at age 36 was due the spread of toe-nail melanoma he had thought was due to a soccer injury. His refusal to surgically remove the toe resulted in the spread of the cancer and an early death for the musician.
• Lentigo Maligna Melanoma – This is a type of cancer that develops in older people (also called Hutchinson melanotic freckle). Similar to the superficial spreading-type of melanoma, a tumor typically arises on UV-damaged skin due to sun exposure to the face, ears, arms or upper torso. It often looks like a dark stain that is flat or slightly-raised with uneven borders. The color is usually blue-black but can vary from tan to brown to dark brown.
• Nodular Melanoma – This is the most aggressive type of melanoma and accounts for 10 to 15 percent of all melanoma cases. Its tumor grows deeper in the skin and more rapidly that other types. It is frequently a bump on the skin of the torso, legs, arms, or scalp (in older men). A handy UK mnemonic used to identify nodular melanoma is EFG Rule, which stands for Elevated, Firm to the Touch, and Growing Progressively.

Your body’s largest organ deserves equal attention, protection, and care. Although sun-damaged spots most often are benign, they can be dangerous to your health if malignant. At times lesions manifest slowly, so it can take years before an abnormality is noticed. Any rapid growth or suspicious changes to your skin is cause for immediate concern. Fortunately, most skin cancers can be prevented with proper sun protection and diagnosed early with routine skin examinations.

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US veterans face an increased risk of developing various skin conditions compared to nonveterans. Since early detection can be crucial for the successful treatment of certain types of skin cancer like melanoma, make your appointment online or call 800-877-7546 to schedule an exam with a dermatologist at one of our sixteen Central Florida offices in Orlando, Altamonte Springs, Apopka, Celebration, Clermont, Davenport, Dr. Philips, Hunter's Creek, Kissimmee, Mount Dora, Ocoee, Poinciana, Sanford, or St. Cloud.