Each year the U.S. spends over eight billion dollars treating skin disorders and cancers. Skin cancer is the most common cancer in the US, affecting around one in five Americans.¹ Melanoma, the deadliest form of skin cancer has been on the rise for the last forty years even though we know one of the major causes is excessive ultraviolet radiation (UV) exposure.^{2, 3} Our best method for measuring excessive UV exposure is sunburns.

Sunburns are preventable and there are some effective treatments to limit your UV exposure. You can use sun-protective behaviors such as wearing protective clothing (rash guards, long sleeves), use sunscreen, and seek out or create shade to avoid peak UV times during the day.²  These protective measures are important for active people because physical activity is related to a 28% increased risk of melanoma, primarily through sunburns rather than exercise directly.⁴

Tips to stay safe:

• Wear sun protective clothing and hats like rash guards, long sleeves and sun glasses with UV protective lens
• Use Sunscreen
• Seek out or create shade to avoid peak UV time with a shade umbrella or sunrise and sunset photo

How are sport and physical activity related to skin cancer?

You may be aware that skin cancer risk is increased from indoor tanning (which is unfortunately far too common in popular gym chains).⁵ However, you may not know that skin cancer risk from sunburns is similar to the cancer risk from indoor tanning. Unlike indoor tanning, sunburns are far more common among teens (57%) and adults (35%) and strongly related to participation in physical activity.^{2, 3, 6} Many physical activities take place outside during peak UV exposure times.

We hadn’t known if sunburns were more common for people who participate physical activity, but in a recent survey among adults sunburned in the last 12 months, 33% reported engaging in swimming or spending time near the water and 14% were sunburned while participating in leisure time physical activity.⁷ Other national data show that approximately half of adults (52%) reporting sunburn in the last year were sunburned specifically while swimming or while participating in non-swimming sports.⁸ More than half of adult golfers (58%) who play golf reported a painful sunburn in the past year.⁹ In addition, 12% reported being sunburned while watching a sporting event. Moreover, only a small percentage of those sunburned were seeking a tan.⁷ Unfortunately, among those sunburned while swimming, about 13% reported not using any sun protection, and among those sunburned doing non-swimming physical activity, almost 25% reported no sun protection or sun avoidance (e.g., seeking shade).⁷ Estimates from adult golfers are similar.⁹

Research suggests that sunburns are highly tied to physical activity and the large majority of people sunburned unintentionally were participating in sports or physical activity. A large majority of people sunburned were using sun-protection measures ineffectively and a small number of people sunburned reported using no protection while participating in physical activity.

Can sunburn and sun protection play a role in sports and athletic performance?

Sunburn and sun protection are important considerations for exercise performance and sports occurring in the sun, especially in hot and humid environments. Sunburn affects thermoregulation and the dissipation of excessive heat that can profoundly affect performance. It is a risk factor for heat related illness in athletes. Sweating, while vital for thermoregulation, also increases photosensitivity to sun i.e., reduces the amount of UV exposure (ultraviolet radiation) before sunburn will occur.¹⁰

Yet, sometimes, athletes must train under hot, humid and frequently high-UV (ultraviolet radiation) conditions to acclimate for competition, or they simply can’t control the schedules and locations for events and practices. So, what can athletes and recreational exercisers due when they can’t avoid the sun?

Applying sunscreen significantly reduces UV dose and can prevent sunburn.^{10, 11} Sunscreen may also improve microvascular blood flow to the skin, which normally is impeded with UV exposure, and plays an important role in thermoregulation and overall skin health and aging.^{11, 12}  While athletes report some barriers with sunscreen use (e.g., makes hands slippery or gets in eyes), these can be avoided when applied before going outside so it can be absorbed into the skin, choosing a sunscreen with the “feel” you like, and combining sunscreen use with clothing, hat/visor and sun glasses. Many sunglasses designed for sports are UV-rated and completely block UV radiation. Exercise apparel is also increasingly incorporating use of breathable but tightly woven materials with other sun protective features (e.g., UPF rating) that lessen the body surface area requiring sunscreen, which saves time and improves ease of application and reapplication. Some dermatologists recommend higher SPF sunscreen for athletes because of sweat effects on photosensitivity and the common finding that most people only apply about half the recommended amount of sunscreen. The CDC currently recommends broadband sunscreen with SPF of 15 or greater with reapplication every 80 minutes. Athletes may need to apply more frequently if toweling off.

Considering that sun protection can impact sports performance, overall health and skin cancer rates, there are strategies to use in sports and recreational physical activity. As ACSM members, we can engage as parents, coaches, advisors, sports/recreational governing bodies, and organizations in promoting sun protection. Given the limited number of sun protection programs for different physical activity contexts, we also need to understand what physically active children and adults will accept in the way of supports for sun protection if we hope to maximize uptake of these behaviors.

Exercise Science and Skin Cancer Prevention Research was a topic at the National Cancer Institute (NCI) meeting to engage exercise science and physical activity investigators into the conversation about individual and organizational demands and the ethos of the sports and physical activity context.¹³ We have an opportunity to play an important research role, particularly for youth who are especially sensitive to excess sun exposure.


Frank Perna, Ed.D., Ph.D.

David Conroy, Ph.D., FACSM, is a Professor the The Pennsylvania State University and an Adjunct Professor at Northwestern University Feinberg School of Medicine

References

1. Guy, G.P., Jr., et al., Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med, 2015. 48(2): p. 183-187.

2. Holman, D.M., et al., Sunburn prevalence among US adults, National Health Interview Survey 2005, 2010, and 2015. J Am Acad Dermatol, 2019. 80(3): p. 817-820.

3. National Cancer Institute, N., DHHS, Cancer Trends Progress Report Bethesda, MD, July 2021, https://progressreport.cancer.gov. July 2021.

4. Moore, S.C., et al., Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med, 2016. 176(6): p. 816-25.

5. Pagoto, S.L., et al., Assessment of Tanning Beds in 3 Popular Gym Chains. JAMA Netw Open, 2019. 2(12): p. e1918058.

6. Siegel, R.L., et al., Cancer Statistics, 2021. CA Cancer J Clin, 2021. 71(1): p. 7-33.

7. Holman, D.M., et al., The Context of Sunburn Among U.S. Adults: Common Activities and Sun Protection Behaviors. Am J Prev Med, 2021. 60(5): p. e213-e220.

8. National Cancer Institute, NIH., DHHS, HINTS 5, Cycle 3 (2019) dataset, updated April 2021. 2021. https://hints.cancer.gov/data/download-data.aspx

9. Weikert, A.E., et al., Golfers’ Interest in Multilevel Sun-Protection Strategies. International Journal of Environmental Research and Public Health, 2021. 18(14): p. 7253.

10. Wendt, D., L.J. van Loon, and W.D. Lichtenbelt, Thermoregulation during exercise in the heat: strategies for maintaining health and performance. Sports Med, 2007. 37(8): p. 669-82.

11. Kenney, W.L., et al., Temperature regulation during exercise in the heat: Insights for the aging athlete. J Sci Med Sport, 2020.

12. Wolf, S.T., et al., Sunscreen or simulated sweat minimizes the impact of acute ultraviolet radiation on cutaneous microvascular function in healthy humans. Exp Physiol, 2019. 104(7): p. 1136-1146.

13. Perna, F.M., Sun Safety in the Physical Activity Context: Opportunities and Challenges, in Dispatches from Implementation Science at NCI NCI, Editor. 2018 https://cancercontrol.cancer.gov/is/blog/dispatches-from-is-at-nci-blog-november-2018