When Amelia Webb walks down the aisle in 21 days' time, her radiant appearance will be partly due to a healthy tan. But her glowing skin won't be the result of a warm spring break in the sun: it will have come from a fake tan spraying session.
'The idea of lying in the sun in order to go brown fills me with absolute horror,' she said. ' In fact, even the phrase "going brown" makes me feel queasy.'
These days the 29-year-old publishing executive is a little more careful of her skin. Webb is a survivor of melanoma, the most dangerous form of skin cancer and the disease which is now rising at a rapid rate across the UK. She is one of a growing number of young women and men who find themselves facing a disease that has a terrible prognosis
Yet she was not an avid sun-worshipper, nor is she particularly pale-skinned. 'I would have my two weeks in the sun, like everyone else, and I would also have the occasional sunbed,' said Webb. 'But I wasn't obsessive about it. I liked a healthy tan, but I tried not to burn.
Like so many young women, she put off going to the doctor for a while, although she thought the mole just below her collarbone, on her chest, looked a bit bigger. 'It started to become a bit itchy, and that is when I worried,' she said. 'I finally dragged myself off to the doctor and they didn't think there was anything wrong with it, but decided it should be excised [cut out] just for safety.'
To her distress it turned out to be malignant melanoma, and Webb was very lucky because it hadn't spread. 'But I keep thinking about what might have happened had I left it another few months, or gone on another Greek holiday. It was a very big shock for me and my family.'
Webb is one of the 9,000 people a year in the UK who end up with a diagnosis of melanoma, a form of skin cancer which was barely heard of 20 years ago. The disease now claims 1,800 lives a year, and is growing at a faster rate than breast or prostate cancer. Cases of what used to be called the 'cancer noire' have risen by almost half in a decade and quadrupled since the Seventies. Our love of the sun and a bronzed tan are creating a new epidemic of disease.
Around the world the situation is little better. Some 160,000 new cases of melanoma are diagnosed worldwide each year, and it is more frequent in men and in white-skinned people, particularly those in hot countries. Currently one in five North Americans and one in two Australians will develop some form of skin cancer in their lifetime.
It was the renowned British surgeon John Hunter who is reported to have been first to operate on a melanoma, in 1787. Unsure of precisely what he had found, the anatomist described the growth as a 'cancerous fungous excrescence'. The excised tumour, still preserved in a cabinet in the Hunterian Museum of the Royal College of Surgeons in London, was not identified until nearly 200 years later as an example of metastatic melanoma, a form of the cancer that had spread.
The disease is caused by the uncontrolled, sometimes frenzied, growth of pigment cells known as melanocytes which are found predominantly in skin. It is not the only form of skin cancer, nor the most common, but it is responsible for the most deaths. Those who survive the cancer have usually spotted it at a relatively early stage, and the crucial factor for doctors is the thickness of the mole, or tumour, itself. If the malignancy is diagnosed when it is still less than 1.5mm in thickness, then the chance of being alive five years after diagnosis is more than 90 per cent for both men and women, but for those whose tumours are thicker than 3.5mm, that chance falls to 52 per cent for women, and 42 per cent for men. This is because the thicker tumours have embedded themselves into the skin, and malignant cells have had a chance to spread.
Cancerous cells can break off from the tumour and move through the lymph nodes, or they can move into other organs such as the lungs or the brain, by which time it is impossible to treat. Someone such as Amelia Webb, whose tumour was just 0.4mm thick, had a good chance of recovery because the doctors were able to excise it, and then cut around some of the surviving tissue to make sure it hadn't spread.
'When they first removed it, they were not even sure it was a malignancy,' she said. 'But the tests showed it was, and then they had to take further tissue for safety.'
New research has also shown that an individual's survival depends on where on the body the skin cancer first appears. A highly significant study of 51,704 previous melanoma cases in the US, published last week, found that melanomas occurring on the scalp or neck led to death at nearly twice the rate of melanomas on other parts of the body.
It had always been suspected that scalp and neck skin cancers had a worse prognosis because they are often diagnosed later than other forms of the disease. The new study took this delay in diagnosis into account and still showed a clear difference in survival rates.
Dr Nancy Thomas, associate professor of dermatology of the University of North Carolina School of Medicine, has advised doctors to take extra care when examining patients for signs of skin cancer. 'Only 6 per cent of melanoma patients present with the disease on the scalp or neck, but those patients account for 10 per cent of melanoma deaths. That's why we need to take extra time to look at the scalp during full-skin examinations,' she said.
For many years, doctors used to disregard the moles and bumps of patients that seemed to turn a strange shape. Now, the NHS has a two-week target for referring suspected skin cancers to hospital consultants. For Dr Tom Lucke, a consultant dermatologist working in Truro, Cornwall, his weekly clinic brings some sad cases, because the truth is that by the time the cancer has metastasised, or spread, there is very little anyone can do about it. Despite all the research, there is no really effective drug which can be given after surgery that would help to mop up the cancer cells.
'We see three times the national rate of melanomas here in Cornwall, and it's a major problem, almost an epidemic,' said Lucke. 'A lot of our cases are caused by the sun exposure people had in their twenties and thirties, which then turns up to give them problems later in life.' But when Lucke goes down to his local beach, he watches young people surfing, sailing and fishing without seeing much evidence that they have understood the importance of covering up, or staying out of the midday sun.
'I don't know that the messages about safe sun levels are really getting through. The truth is that, if we pick it up early, then it is possible to make a complete recovery. But once it has spread and invaded other organs, then it isn't treatable. The outlook is grim, and palliative care becomes the only option.'
As a member of the British Association of Dermatologists, Lucke would like to see some more sensible messages getting out to the public. 'The group with the worst prognosis is middle-aged and older men, and their cancers are likely to be on their backs, which of course they don't check. So we need to start asking women to check their husbands' backs for suspicious moles. It's simple and it works.'
Although more women than men get melanoma, more men die from it because they do not seek help quickly enough. Dr Ian Banks, president of the Men's Health Forum, who is also a GP, said: 'Men go to see a doctor later rather than sooner, and many men are dying unnecessarily because of that.' He pointed out that men get burnt more often because they don't wear sun cream. 'They also get sunburnt through their shirts when they are at football matches because the replica shirts are so thin.'
According to official estimates, a 10 per cent decrease in the ozone layer would create an additional 300,000 non-melanoma, and 4,500 melanoma skin cancers could be expected worldwide each year.
In Britain the effects of climate change are also wide-ranging, and alarming. A report recently published by the Health Protection Agency warned of a 'high' risk by 2012 of a severe heatwave leading to 3,000 immediate deaths, followed by a further 6,350 fatalities from conditions such as heart failure and cancers. But it also pointed out that skin cancer rates could triple over the next 20 to 30 years, as the increased exposure to sunlight takes its toll and as we fail to adapt to a shifting world.
Much of the damage to our skin may be happening before we are even aware of it. It seems to be children who are the most vulnerable, as they are at a higher risk of suffering damage from exposure to ultra-violet radiation than adults. Their skin is thinner and more sensitive, and even a short time outdoors can result in a red and sore burn. Long-term population studies have shown that episodes of sunburn in childhood also set the stage for high rates of melanoma later in life. As about 80 per cent of a person's lifetime exposure to UV is received before the age of 18, covering up children is crucially important for parents.
Should families and others not be aware now of the dangers of the sun, given that we have had more than a decade of campaigns warning about sunburn? Professor Lesley Rhodes, a photo-dermatologist who works at the University of Manchester hospital trust, said: 'I don't think it is ignorance. I think that there is still a large number of people who ignore the evidence. The information is out there, but perhaps it isn't convincing enough to make them change their behaviour. Perhaps we have to get more sophisticated in our approach and use different images. We could explain, for example, that too much sun ages the skin even faster than smoking does.'
Rhodes, whose work is funded by Cancer Research UK, is also worried about sunbeds, which are also increasingly being targeted as dangerous. More than 100 deaths from skin cancer every year in Britain are thought to be linked to the use of the machines, which came into the high streets during the Eighties as a deep tan became extremely fashionable, like the mahogany hue of George Michael in his Wham! days.
The accepted health advice in Britain is that the under-16s and fair-skinned adults who burn easily should never use a sunbed. The proposals from the Health and Safety Executive, produced last week, came as experts estimated that 170,000 children in the UK have used a sunbed. In Scotland, which has high rates of melanoma, a new law to ban under-18s from using sunbeds is set to be passed by the Holyrood parliament.
'Sunbeds need to be far better controlled, and run by people who know what they are doing,' said Rhodes. 'If we are going to start defeating this disease, it is really about altering our behaviour.' If the first priority is to change our attitude to the sun, then the second surely has to be encouraging people to spot the first signs of the cancer.
This summer, the BBC Gardener's World Live show in Birmingham will host an unusual kind of medical event. It will be the UK's largest ever 'free mole check', with a team of consultant dermatologists offering visitors a quick examination of any suspicious moles, bumps or freckles.
The same kind of 'radical action' will take place at Glastonbury as well as at the music festival T4 on the Beach at Weston-super-Mare, and even the more upmarket Badminton horse trials.
The approach marks a radically different approach to diagnosing the condition. Today melanomas are diagnosed only after they become visible on the skin. In the future, however, physicians will hopefully be able detect melanomas based on a patient's genotype, not just on his or her skin colour.
If doctors could identify people with high-risk genotypes, they might then also be able to determine which of a person's moles have the greatest chance of becoming cancerous.
It was Coco Chanel who first started the fashion of being tanned. In the Twenties, she came back from a holiday on the Duke of Westminster's yacht in the South of France with a deep tan, prompting the country's fashionable women to throw away their parasols and do the same. A tan had always been a clear definer of class, but from that point on, it started to separate the paler servants from a healthier leisured class - an exact reversal of how a tan had been interpreted for hundreds of years previously. The question is now whether society can adapt again, to start to see the permatanned as undesirable, unhealthy, and most important of all, unhip.
Denise Van Outen, a role model for lots of girls, has been one of those who warned recently about the risks of sunbeds. Her face was blemished with brown spots as a result of using them as a teenager.
Van Outen, who started out on the Big Breakfast Show and won acclaim in the musical Chicago, said: 'I used a sunbed when I was 18 because I did not know the risks, but I'm paying for it now. It's my big regret.' Her 'tanorexia', as the obsession has been nicknamed, left her with pigmentation scars on her face and marks on her cheeks and brow. She now wears heavy make-up to cover the damage done by the tanning-booth sessions.
'Girls are still using sunbeds, they are still risking skin cancer for a tan. But they should know that tans fade and it's not worth the risk.'
Amelia Webb: One woman's story
'A mole I'd had all my life, under my collar bone, turned out to be a melanoma when I was 26. I was lucky: doctors caught it. The disease has completely changed my attitude to the sun. If I see someone who is really tanned, I think how unhealthy they look, whereas before I was like everyone, wanting a glow. People say the sun here isn't strong enough to cause cancer. That's rubbish.'
