(22-31 years) when the disease might appear. No specific Gulf War exposures were assessed, although risk by occupational group was calculated.

There was some evidence of an association of testicular cancer with Gulf War deployment in a pilot cancer-registry-based study. Levine et al. (2005) matched a stratified random sample of 621,902 Gulf War deployed active-duty, reserve, and National Guard veterans and 746,248 nondeployed veterans with the central cancer registries of New Jersey and the District of Columbia. From 1991 to 1999, 17 deployed and 11 nondeployed veterans were identified with testicular cancer for a proportional incidence rate of 2.33 (95% CI 0.95-5.70) adjusted for state of residence, deployment status, race, and age. The greatest proportions of testicular cancer were in deployed men in the age groups of 25-29 and 30-34 years (standardized incidence ratio 1.42) and in nondeployed men in age groups of 30-34 and 35-39 years (standardized incidence ratio 0.94). The number of excess cases peaked 4-5 years after deployment, as opposed to the findings in the Knoke et al. study, which found the excess in the first few months after the soldiers returned home.

Gray et al. (1996) analyzed hospital records from DoD facilities for the last 5 months of 1991 and all of 1992 and 1993. In 1991, hospitalizations for malignant neoplasm of the testis were slightly higher in deployed men (rate ratio 2.12, 95% CI 1.11-4.02), but no difference was seen in 1992 or 1993.

Skin Cancer

There are two types of skin cancer: melanoma, which forms in the skin cells that make pigment and is less common, and the more common nonmelanoma skin cancer, which typically begins in cells that do not make pigments—basal cells (small round cells in the base of the outer layer of skin) or squamous cells (flat cells that form the surface of the skin). The annual age-adjusted incidence of melanoma of the skin is about 18.5 per 100,000 people. Skin cancer was assessed separately by the committee because of the potential for military personnel to be exposed to ultraviolet radiation and environmental toxicants and because several of the studies considered by the committee provided an analysis of skin cancer as distinct from other cancers.

The committee identified only one primary study that assessed the prevalence of skin cancer in Vietnam veterans: CDC (1988b) looked for skin cancer as part of the VES. The prevalence of skin cancer on dermatologic examination was 0.6% in Vietnam-theater veterans and 0.7% in Vietnam-era veterans for a nonsignificant OR of 0.8 (95% CI 0.4-1.7) adjusted for age at enlistment, race, year of enlistment, enlistment status, score on general technical test, and primary military occupation.

One primary study that assessed the risk of skin cancer in Gulf War veterans was identified. As of 2002, when Australian Gulf War veterans were compared with their nondeployed counterparts, they had no increase in prevalence of probable or possible skin cancers diagnosed after 1991 (Kelsall et al. 2004a). The entire Australian cohort of 1871 veterans who were deployed to Southeast Asia was compared with nondeployed veterans frequency matched for service type, sex, and age. Participants completed a self-report questionnaire about medical conditions that had been diagnosed or treated by a medical doctor and about when the conditions had been diagnosed. Participants also underwent a comprehensive health assessment by specially trained health professionals who were blinded to the deployment status of the participants and asked further questions about the diagnoses and determined whether the self-reports were unlikely, possible, or probable according to pre-established criteria. The participation rate was 80.5% for Gulf War veterans and 50.5% for the control group. This study



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