Skin in the Game

Dr. Larisa Geskin has two words to describe our relationship with the sun: it’s complicated. 

As a dermatologist and skin cancer specialist, Dr. Geskin has devoted her career to treating patients and promoting awareness about skin cancer prevention and the importance of daily sunscreen usage. Awareness around the benefits of consistent sunscreen usage has grown over the past four decades. However, says Dr. Geskin, people remain skeptical of the protective benefits of sunscreen, leery of potentially harmful chemical ingredients in some sunblock products, or continue to equate the sun only with health benefits versus its damaging effects as a result of over exposure to the sun’s ultraviolet (UV) rays. 

“Sun exposure is a major risk factor for skin cancer, there is no question about it. But patients also hear that there are benefits from sun exposure—mood benefits, health benefits from getting vitamin D, so it’s a tricky message,” says Dr. Geskin, associate professor of dermatology at Columbia University’s Vagelos College of Physicians and Surgeons, and member of the Cancer Genomics and Epigenomics program at the Herbert Irving Comprehensive Cancer Center (HICCC). 

“People should enjoy being outdoors and spending time on the beach and in the sun, but you have to be protected.” 

Skin cancer is the most common form of cancer, with an estimated 9,500 people in the U.S. diagnosed with skin cancer each day. While a small percentage of skin cancers are melanoma, this form of skin cancer is a potentially fatal disease. Today, melanoma is the fifth most common cancer among men and women, and recently there has been an increase in the incidence of melanoma affecting individuals aged 15 to 39 years.

“Melanoma is a preventable cancer but over the last two decades, we’ve seen a dramatic incidence rise in melanoma,” says Dr. Geskin. “We know that sun exposure is a major risk factor for melanoma and skin cancer.  There are two easy ways to protect yourself—daily use of sunscreen and avoiding over exposure to the sun--yet  we are seeing more than 7,000 deaths per year due to melanoma.”

Dr. Geskin, who works with New York State Department of Health and New York State Cancer Consortium as a member of its Skin Cancer Action Team, has made it a priority to spread skin cancer prevention and awareness across all populations, far and wide. 

At Columbia University, she implemented sunscreen dispensers at the Baker Athletics Complex. She also is in the process of launching an educational program for Columbia’s Bright Horizons daycare facilities that will focus on sun safety and protection. 

At the New York State level, Dr. Geskin, with colleagues at the HICCC’s Community Outreach and Engagement Office, went door to door educating senators and assembly members of the dangers of  indoor tanning. Dr. Geskin traveled to Albany to inform state officials about the importance of introducing a bill that prohibits minors to use tanning beds and services. As of August  2018, New York State Public Health Law prohibits children under 18 years of age from using UV radiation devices, making it unlawful for businesses to provide indoor tanning services to this age group, with or without parental consent. Dr. Geskin now is working on raising that age limitation to 21. She has also started work on outreach and educational programming around skin cancer prevention and sun safety in Staten Island with local community partners. 

Her motivation to work on changing policy stems from her patients. “As a dermatologist and oncologist, you really get close to the patient and their families. We learn so much about them. We see them suffer, we see them get better, and we form tight relationships. I want the best for them.”

In a new report, Dr. Geskin and collaborators stressed the benefits of offering sunscreen coverage for low-income families under the New York State Medicaid insurer. For many families, including those covered by Medicaid, sunscreen products are cost prohibitive. Sunscreens can amount to as much as 1.1% to 2.3% of the total income of a Medicaid beneficiary, according to this report, recently published in the Journal of Clinical Pathways.

Dr. Geskin and team analyzed the cost of melanoma treatment under New York State Medicaid and investigated whether coverage of sunscreen for their pediatric beneficiaries could be a cost-effective strategy to reduce the lifetime burden of melanoma. The cost of melanoma treatment is estimated to range from $5,879 per year for local melanoma to $219,536 per year for metastatic melanoma, according to the study. 

“The price of sunscreen may be prohibitive to many lower socioeconomic status families, but a large government health insurer like New York State Medicaid has the ability to make sunscreen accessible to some 2.5 million children,” says Dr. Geskin. “In our report, we found that paying for regular sunscreen coverage in pediatric patients under Medicaid as a solid cancer preventive measure outweighs the cost of treating a melanoma patient.”

The key obstacle the researchers identified in implementing this strategy is the high price of sunscreen at the individual level. However, they noted in the study,  a large government organization like Medicaid has the ability to obtain affordable sunscreen at discount rates using a competitive bidding strategy, whereby manufacturers could provide substantial discounts in return for the exclusive right to provide their product to those insured by Medicaid. Researchers pointed to examples where this has been successfully implemented in the past, including the Supplemental Nutrition Assistance Program (SNAP), Women, Infants and Children (WIC) programs, and Medicare. Using this same strategy, the study suggests Medicaid could drive current market prices down, obtaining and providing high-quality sunscreen at a discounted cost of $60 to $120 per year, per child on average.

“I really do hope that all of our policy-challenging and educational efforts will play a substantial role in changing the melanoma landscape 20 years from now … and that’s how long some of the work we do today will take to effect real change,” says Dr. Geskin. 

“Now that we’ve conducted the Medicaid cost-analysis study for pediatric sunscreen coverage, we’re ready to do the work. I’ll be back at lawmakers' offices, knocking on doors, educating, teaching, and sharing the facts."