UV Exposure and the Risk of Keratinocyte Carcinoma in Skin of Color: A Systematic Review.

Importance: Ultraviolet radiation exposure is an important modifiable risk factor for keratinocyte carcinoma (KC) in fair-skinned non-Hispanic White populations; however, the evidence for this relationship in darker-skinned populations is less certain. Objective: To assess and synthesize the published data concerning the association between UV exposure and the risk of KC in individuals with skin of color. Evidence Review: PubMed, Cochrane, and Web of Science databases were searched from database origin through January 2022. Studies deemed eligible included UV exposure as a risk factor for KC in individuals with skin of color, defined as any race other than non-Hispanic White, Fitzpatrick skin types IV to VI, or tanning ability of rarely or never burns. The UV index, irradiance, latitude, history of phototherapy, history of sunburn, or occupational exposure were used as measures of exposure. The Oxford Centre for Evidence-Based Medicine guidelines were used to assess evidence quality. Findings: A total of 72 716 articles appeared in the search. After duplicate removal, 29 393 database records were screened, 454 full-text articles were assessed, a forward and reverse citation search was performed, and 12 articles, with clinical data spanning the years 1990 to 2019, met inclusion criteria. More than 32 970 KCs in individuals with skin of color were included. Eight studies found no association between UV exposure and KC, while 4 studies showed a positive association. Study types included 1 ecological study, 9 cohort studies, and 2 case-control studies. The quality of the studies was rated from moderate to low (2b to 4). Conclusions and Relevance: Results of this systematic review show that the evidence assessing the association of UV exposure with KC is of moderate to low quality. The studies that found no association were among patients receiving phototherapy. Studies assessing nonphototherapy-related UV exposure, such as geographic location or occupation, found small positive associations in primarily East Asian individuals. There were no studies performed in the US, no studies among Black individuals, and only 1 study among a Hispanic population. Further research is required to better assess whether these associations exist across populations of patients with darker skin types.

Response: "The Signal and the Noise"-a response to Clayton et al. (2021).

The purpose of this response is to clarify points about the steps we took in a systematic review of the literature and to reaffirm our findings.

Review: Puberty blockers for transgender and gender diverse youth-a critical review of the literature.

BACKGROUND: Increasingly, early adolescents who are transgender or gender diverse (TGD) are seeking gender-affirming healthcare services. Pediatric healthcare providers supported by professional guidelines are treating many of these children with gonadotropin-releasing hormone agonists (GnRHa), which reversibly block pubertal development, giving the child and their family more time in which to explore the possibility of medical transition. METHODS: We conducted a critical review of the literature to answer a series of questions about criteria for using puberty-blocking medications, the specific drugs used, the risks and adverse consequences and/or the positive outcomes associated with their use. We searched four databases: LGBT Life, PsycINFO, PubMed, and Web of Science. From an initial sample of 211 articles, we systematically reviewed 9 research studies that met inclusion/exclusion criteria. RESULTS: Studies reviewed had samples ranging from 1 to 192 (N = 543). The majority (71%) of participants in these studies required a diagnosis of gender dysphoria to qualify for puberty suppression and were administered medication during Tanner stages 2 through 4. Positive outcomes were decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life. Adverse factors associated with use were changes in body composition, slow growth, decreased height velocity, decreased bone turnover, cost of drugs, and lack of insurance coverage. One study met all quality criteria and was judged 'excellent', five studies met the majority of quality criteria resulting in 'good' ratings, whereas three studies were judged fair and had serious risks of bias. CONCLUSION: Given the potentially life-saving benefits of these medications for TGD youth, it is critical that rigorous longitudinal and mixed methods research be conducted that includes stakeholders and members of the gender diverse community with representative samples.

UV Exposure and the Risk of Cutaneous Melanoma in Skin of Color: A Systematic Review.

Importance: While current evidence supports UV exposure as an important risk factor for cutaneous melanoma in fair-skinned populations, the evidence for this association in skin of color is less certain. Objective: To critically assess and synthesize the published data regarding the association between UV exposure and the risk of cutaneous melanoma in skin of color. Evidence Review: A search was conducted including PubMed, Cochrane, and Web of Science databases from database origin to June 3, 2020. Only peer-reviewed original studies were screened in full text. Eligible studies analyzed UV exposure as a risk factor for cutaneous melanoma in people with skin of color, which was defined broadly as any race/ethnicity other than non-Hispanic White, Fitzpatrick skin types IV through VI, or tanning ability of rarely or never burns. Measures of UV exposure included UV index, irradiance, latitude, history of phototherapy, and history of sunburn. Evidence quality was assessed using criteria from the Oxford Centre for Evidence-Based Medicine. Findings: After duplicate removal, 11 059 database records were screened, 548 full-text articles were assessed, and 13 met inclusion criteria. Study types included 7 ecological studies, 5 cohort studies, and 1 case-control study. All studies used race and/or ethnicity to categorize the participants, and more than 7700 melanomas in skin of color were included. Of the 13 studies that met inclusion criteria, 11 found no association between UV exposure and melanoma in skin of color, 1 study showed a small positive relationship in Black males, and 1 showed a weak association in Hispanic males. All studies were of moderate to low quality (Oxford Centre ratings 2b to 4). Conclusions and Relevance: In this systematic review, the evidence suggests that UV exposure may not be an important risk factor for melanoma development in people with skin of color. Current recommendations promoting UV protection for melanoma prevention in skin of color are not supported by most current studies. However, evidence is of moderate to low quality, and further research is required to fully elucidate this association.