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Original Investigation |

The Risk of Melanoma in Airline Pilots and Cabin Crew:  A Meta-analysis ONLINE FIRST

Martina Sanlorenzo, MD1,2; Mackenzie R. Wehner, MPhil1,3; Eleni Linos, MD, DrPH1; John Kornak, PhD4; Wolfgang Kainz, PhD5; Christian Posch, MD1,6; Igor Vujic, MD1,6; Katia Johnston, BS1; Deborah Gho, BS1; Gabriela Monico, BS1; James T. McGrath, EE1; Simona Osella-Abate, PhD2; Pietro Quaglino, MD2; James E. Cleaver, PhD1; Susana Ortiz-Urda, MD, PhD1
[+] Author Affiliations
1Mount Zion Cancer Research Center, Department of Dermatology, University of California, San Francisco
2Section of Dermatology, Department of Medical Sciences, University of Turin, Turin, Italy
3School of Medicine, Stanford University, Stanford, California
4Department of Epidemiology and Biostatistics, University of California, San Francisco
5Center for Devices and Radiological Health, Division of Physics, US Food and Drug Administration, Silver Spring, Maryland
6Department of Dermatology,The Rudolfstiftung Hospital, Vienna, Austria
JAMA Dermatol. Published online September 03, 2014. doi:10.1001/jamadermatol.2014.1077
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Importance  Airline pilots and cabin crew are occupationally exposed to higher levels of cosmic and UV radiation than the general population, but their risk of developing melanoma is not yet established.

Objective  To assess the risk of melanoma in pilots and airline crew.

Data Sources  PubMed (1966 to October 30, 2013), Web of Science (1898 to January 27, 2014), and Scopus (1823 to January 27, 2014).

Study Selection  All studies were included that reported a standardized incidence ratio (SIR), standardized mortality ratio (SMR), or data on expected and observed cases of melanoma or death caused by melanoma that could be used to calculate an SIR or SMR in any flight-based occupation.

Data Extraction and Synthesis  Primary random-effect meta-analyses were used to summarize SIR and SMR for melanoma in any flight-based occupation. Heterogeneity was assessed using the χ2 test and I2 statistic. To assess the potential bias of small studies, we used funnel plots, the Begg rank correlation test, and the Egger weighted linear regression test.

Main Outcomes and Measures  Summary SIR and SMR of melanoma in pilots and cabin crew.

Results  Of the 3527 citations retrieved, 19 studies were included, with more than 266 431 participants. The overall summary SIR of participants in any flight-based occupation was 2.21 (95% CI, 1.76-2.77; P < .001; 14 records). The summary SIR for pilots was 2.22 (95% CI, 1.67-2.93; P = .001; 12 records). The summary SIR for cabin crew was 2.09 (95% CI, 1.67-2.62; P = .45; 2 records). The overall summary SMR of participants in any flight-based occupation was 1.42 (95% CI, 0.89-2.26; P = .002; 6 records). The summary SMR for pilots was 1.83 (95% CI, 1.27-2.63, P = .33; 4 records). The summary SMR for cabin crew was 0.90 (95% CI, 0.80-1.01; P = .97; 2 records).

Conclusions and Relevance  Pilots and cabin crew have approximately twice the incidence of melanoma compared with the general population. Further research on mechanisms and optimal occupational protection is needed.

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Figures

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Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-analyses Flowchart of Article Search and Study Selection

Nineteen studies met inclusion criteria and were included in the meta-analysis.

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Figure 2.
Standardized Incidence Ratio and Standardized Mortality Ratio of Melanoma in the Studies Included in the Meta-analysis

The overall summary standardized incidence ratio (SIR) of participants in any flight-based occupations was 2.21 (95% CI, 1.76-2.77; P < .001; 14 records). The overall summary standardized mortality ratio (SMR) of participants in any flight-based occupation was 1.42 (95% CI, 0.89-2.26; P = .002; 6 records). ES indicates effect size. Weight, %, indicates the degree to which the study contributed to the final results.

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Figure 3.
Standardized Incidence Ratio and Standardized Mortality Ratio of Melanoma in the Studies Included in the Meta-analysis Stratified by Sex

For men, the overall summary standardized incidence ratio (SIR) was 2.38 (95% CI, 1.75-3.23; P = .001; 12 records) (A), and the overall summary standardized mortality ratio (SMR) was 1.87 (95% CI, 1.32-2.65; P = .39; 5 records) (B). For women, the overall summary SIR was 1.93 (95% CI, 1.50-2.48; P = .41; 2 records) (C), and the overall summary SMR was 0.61 (95% CI, 0.13-2.85; P = .51; 2 records) (D). Weight, %, indicates the degree to which the study contributed to the final results.

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Figure 4.
Funnel Plots With Pseudo–95% CIs for the Standardized Incidence Ratio (SIR) and Standardized Mortality Ratio (SMR) of Melanoma

Funnel plots to check the existence of publication bias. SE indicates standard error.

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Airline pilots and cabin crew at risk for melanoma
Posted on September 10, 2014
Claude Bachmeyer, Christofer Rein
Department of Internal Medicine, Tenon Hospital (AP-HP), Paris, France
Conflict of Interest: None Declared
We read with great interest this meta-analysis on the risk of melanoma in airline pilots and cabin crew. The authors conclude that the incidence of melanoma is twice among the pilots and cabin crew compared with the general population. However this result suggests an association rather than causal effects of UV radiation as an occupational exposure. The authors acknowledge limitations to their study including retrospective data, exposure heterogeneity, no control of skin phototype. We can add that unfortunately the primary sites of the lesions are not indicated in this meta-analysis (but perhaps it is noted in some studies). It is well-known that there is a relationship between melanoma and patterns of sun exposure according to age and site. For instance melanomas developing on the trunk seem to be associated with chronic or regular sun exposure, and those developing on the trunk are associated with intermittent sun exposure.1Indeed the anatomic site of melanoma has been evaluated in numerous studies. We can mention the results of some of them recently published. In a series on invasive cutaneous melanoma including 124,055 cases in England, melanoma developed on the lower limbs (33%), the upper limbs (18%), the trunk (25%), and the head and neck (16%) with higher rates on female lower limbs and male trunk.2 In an American study on 361,394 adolescents and young adults (ages 15-39 years) with invasive melanoma of the skin, lesions were localized on lower limbs (14.6% and 31.4% respectively in men and women), the upper limbs (18.2% and 21.6%), the trunk (46.7% and 36.8%), and the head and neck (16.0% and 8%).3 Finally, another study from Queensland, Australia, with 41,715 patients diagnosed with invasive melanoma, indicated that the site of the lesion were the lower limbs (21%), the upper limbs (23%), the trunk (33%), and the head and neck (16%).4 If we consider that exposure to UV and cosmic radiation is increased in high altitude resulting in an occupational risk, lesions should develop mainly on sun-exposed sites, since the uniforms of the airplane staff consist of dresses (and traditional dresses) and trousers, short-sleeves shirt, and jackets. Only the face, but also upper and lower limbs (to a lesser degree) are sun-exposed during the working hours of the aircraft crew. The development of melanoma on other anatomic sites could be due to the fact that air pilots and cabin crew travelling in sunny countries took “benefit” of the wonderful weather at these places or because they go to a tanning salon regularly. In conclusion, a prospective randomized study evaluating the anatomic site of melanoma in aircraft crew with a control group and taking into account all sources of UV exposure would be important in order to confirm their occupational risk for melanoma and therefore to propose optimal occupational protection. References1. Whiteman DC, Stickley M, Watt P, Hughes MC, Davis MB, Green AC. Anatomic site, sun exposure, and risk of cutaneous melanoma. J Clin Oncol 2006;24(19):3172-7.2. Wallingford SC, Alston RD, Birch JM, Green AC. Increases in invasive melanoma in England, 1979-2006, by anatomical site. Br J Dermatol 2011;165(4):859-64. 3. Weir HK, Marrett LD, Cokkinides V, et al. Melanoma in adolescents and young adults (ages 15-39 years): United States, 1999-2006. J Am Acad Dermatol 2011;65(5 Suppl 1):S38-49. 4. Youl PH, Youlden DR, Baade PD. Changes in the site distribution of common melanoma subtypes in Queensland, Australia over time: implications for public health campaigns. Br J Dermatol 2013;168(1):136-44.
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