Trends in melanoma incidence among children: possible influence of sun-protection programs

Factors influencing participants' engagement with an interactive text-message intervention to improve sun protection behaviors: "SunText" randomized controlled trial

There is growing evidence suggesting that text-message-based interventions are effective to promote sun protection behaviors. However, it is still unclear how engagement and adherence with the intervention messages can be optimized through intervention design. This study evaluated the effect of different combinations of personalized and two-way interactive messages on participant engagement with a theory-based skin cancer prevention intervention. In the SunText study conducted in February-July 2019 in Queensland, Australia participants 18-40 years were randomized to four different text message schedules using a Latin square design. This study analyzed if the order and intensity in which the schedules were received were associated with participants' level of engagement, and if this differed by demographic factors. Out of the 389 participants enrolled in the study, 375 completed the intervention period and remained for analysis. The overall intervention engagement rate was 71% and decreased from the beginning to the end of the study (82.2%-61.4%). The group starting with personalized, but not interactive messaging showed the lowest engagement rate. The intervention involving interactive messages three times a week for 4 weeks achieved the highest engagement rate. The intervention with increasing frequency (personalized and interactive three times a week for 2 weeks; then daily for 2 weeks) had lower engagement than intervention with constant or decreasing frequency. Engagement with two-way interactive messages was high across all intervention groups. Results suggest enhanced engagement with constant or decreasing message frequency compared to increasing frequency.

Knowledge and practice of sun protection in schools in South Africa where no national sun protection programme exists

Interventions in primary schools that increase sun-protective behaviours and decrease ultraviolet radiation exposure, sunburn incidence and skin cancer risk can be effective. SunSmart School Accreditation Programmes (SSAP) are recommended. Prior to SSAP implementation in South Africa, we explored the feasibility of obtaining national baseline information and investigated possible associations between strategies regarding sun protection in schools and students' responses to a questionnaire. Principals from randomly selected urban government schools in all nine South African provinces completed a questionnaire and 679 students were surveyed. The mean sun-related knowledge and behaviour scores of students were 4 (range: 1-7) and 3 (range-0-8) out of 9, respectively. The mean school sun protection effort score was 4 out of 14. There were no statistically significant correlations between students' knowledge or behaviour scores and their school score. The World Health Organization recommends an SSAP to address policy, practice and curriculum changes to support sun protection of students. This cross-sectional study demonstrates the feasibility of, and need for, a larger baseline study with longitudinal, multi-variable follow-up which includes other influential factors, such as parent support. Such research could quantify the impact of the SSAP and identify which key factors influence the sun-related knowledge and behaviours of students.

Melanoma Incidence in Children and Adolescents: Decreasing Trends in the United States

OBJECTIVE

To assess trends in the incidence of melanoma in children and adolescents in the US from 2000-2010.

STUDY DESIGN

Using the Surveillance, Epidemiology, and End Results cancer registry data, we calculated age-adjusted incidence rates of melanoma in children and adolescents (age <20 years) from 2000-2010, as well as annual percent changes. We analyzed incidence trends using joinpoint regression models. We further stratified incidence rates and trends by age group, sex, race, and melanoma-specific characteristic (histology, anatomic site, Breslow depth, ulceration status, lymph node involvement, and presence of metastasis).

RESULTS

We included 1185 pediatric patients (age <20 years) diagnosed with melanoma from 2000-2010. In patients age <20 years overall, we found a significant decreasing incidence (11.58% per year) from 2004-2010. Overall, significant decreasing incidence trends were also noted in males, melanoma located on the trunk, melanoma located on the upper extremities, superficial spreading melanoma, and melanoma with good prognostic indicators. When further subdividing the pediatric population by age group, these significant decreasing incidence trends were most notable in adolescents (age 15-19 years), decreasing 11.08% per year from 2003-2010. Furthermore, in 15- to 19-year-olds, decreasing trends were found to be significant in melanoma located on the trunk, superficial spreading melanoma, and melanoma with good prognostic indicators.

CONCLUSIONS

Decreasing trends in melanoma incidence in the pediatric population from 2000-2010 stand in contrast to previous reports of increasing long-term incidence trends. Possible contributors to these decreasing trends include effective public health initiatives, decreased time spent outdoors, and increased sunscreen use.

443 paediatric cases of malignant melanoma registered with the German Central Malignant Melanoma Registry between 1983 and 2011

BACKGROUND

Malignant melanoma is a very rare paediatric tumour. This study was performed in order to understand clinical features and prognosis of malignant melanoma in children and adolescents.

METHODS

443 patients ⩽ 18 years of age with malignant melanoma were prospectively registered with the German Central Malignant Melanoma Registry between 1983 and 2011. Cases were collected from 58 participating centres. 276 paediatric cases with a follow-up >3 months were evaluated for survival probabilities and prognostic factors by Kaplan-Meier method.

RESULTS

Age of diagnosis ranged from 3 months to 18 years (median age 16 years). The male to female ratio was 0.8 (202 male, 240 female). Most melanoma were located at the trunk (n = 195) and the lower extremity (n = 114). Patients with >3 months of follow-up (median 55 months) showed an overall survival (OS) of 94.8% in 5 years. Survival according to tumour stage was 98.5% for stage I (n = 190), 91.1% for stage II (n = 39) and 53.0% for stage III/IV tumours (n = 11). Worse outcome was seen in patients with nodular melanoma (OS 77.9%, n = 42) compared to superficial spread histotype (OS 100%, n = 138) or other histotype (OS 96.9%, n = 88) (p < 0.0001), in case of thicker tumours (Clark level IV or V, OS 87.1%, n = 84) compared to thinner tumours (Clark level I, II, III, OS 99.1%, n = 164) (p = 0.0008) and in case of ulceration (OS 65.6%, n = 17) compared to no ulceration (OS 99.2%, n = 182).

CONCLUSION

Patient and tumour characteristics in paediatric melanoma patients show no evident differences to adult melanoma cases. The same clinical approach as in adults should be used.

The consequences for human health of stratospheric ozone depletion in association with other environmental factors

Ozone depletion, climate and human health.

Towards skin cancer prevention and early detection: evolution of skin cancer awareness campaigns in Australia

Since the 1980s, Australia's mass-media campaigns promoting skin cancer awareness, namely skin cancer-preventative behaviors and early detection, have targeted the general community as well as high-risk groups, including outdoor workers, schoolchildren and youths. During that time, campaigns have evolved in tone and method of delivery. Their messages are today accompanied by policies, supportive environments such as shade and access to quality sun-protection products governed by national standards. Early detection of skin cancer has been the other aim of these campaigns, and recent downturns in incidence rates, especially in the young, and the shift to mostly thin melanomas at diagnosis in Australia, may partly reflect some campaign success. However, sustained efforts are required for long-lasting skin cancer control.

Melanoma incidence trends and survival in adolescents and young adults in Queensland, Australia

Cutaneous melanoma is a relatively common cancer in adolescents and young adults in Australia, but detailed information about occurrence patterns and prognosis is limited. We evaluated incidence trends from 1982 to 2010 and recent survival rates in those aged 15-24 years in the state of Queensland. In situ and invasive melanoma cases were identified from the Queensland Cancer Registry. Incidence rates were age-standardised to the 2000 World population and trends calculated using joinpoint regression. Five-year relative survival was estimated by the period method and Poisson models were used to produce adjusted mortality hazard ratios. Average annual incidence rates for the 5-year period 2006-2010 were 6.3 per 100,000 [95% confidence interval (CI) 5.4, 7.2] for in situ and 10.1 per 100,000 (95% CI 9.0, 11.3) for invasive melanoma. Since the mid-1990s, incidence rates for in situ melanomas have been stabilizing while invasive melanoma has decreased in both sexes, mainly owing to declining rates of thin tumours (≤1 mm) (-5.4% per year, 95% CI -8.3%, -2.4%). Incidence rates of melanomas >1 mm in thickness have remained relatively unchanged since 1991 however. In the period 2006-2010, relative 5-year survival of 15-24 year olds with invasive melanoma was 95.7% (95% CI 92.9%, 97.5%). The subgroup with tumours >1 mm was nearly six times more likely to die within 5 years than those with thin tumours (adjusted hazard ratio = 5.53, 95% CI 1.72, 17.80). Incidence of thin melanoma in young people in Queensland is declining, suggesting benefits of primary prevention efforts are being realised.

Sun exposure, sunbeds and sunscreens and melanoma. What are the controversies?

The association between various measures of sun exposure and melanoma risk is quite complex to dissect as many case-control studies of melanoma included different subtypes of melanomas which are likely to be biologically different, so interpretation of the data is difficult. Screening bias in countries with high levels of sun exposure is also an issue. Now that progress is being made in the genetic subclassification of melanoma tumours, it is apparent that melanomas have different somatic changes according to body sites/histological subtypes and that UV exposure may be relevant for some but not all types of melanomas. Melanoma behaviour also points to non-sun-related risk factors, and complex gene-environment interactions are likely. As UV exposure is the only environmental factor ever linked to melanoma, it is still prudent to avoid excessive sun exposure and sunburn especially in poor tanners. However, the impact of strict sun avoidance, which should not be recommended, may take years to be apparent as vitamin D deficiency is a now a common health issue in Caucasian populations, with a significant impact on health in general.

Current principles of sunscreen use in children

PURPOSE OF REVIEW

Physicians need to be prepared to counsel patients on why and how to protect themselves from damaging ultraviolet (UV) radiation, including the proper use of sunscreens. In this article, we review the interplay between UV radiation, sunscreens and the skin, highlighting current controversies and recommendations surrounding sunscreen use.

RECENT FINDINGS

An important concept is that excessive UV exposure has long-term damaging effects on the skin beyond the immediate sunburn. Recent discoveries of the role of UVA radiation in skin cancer development have set high standards for broad-spectrum coverage to be met by sunscreens. Current evidence does not support an association between sunscreen use and melanoma, systemic toxicity or vitamin D deficiency. Although sunscreen application is the most common modality for sun protection, many people do not use it correctly. Regular sunscreen use during childhood and adolescence can significantly reduce lifetime incidence of skin cancer; therefore, targeting children in pediatric offices regarding unprotected UV exposure may be a practical approach.

SUMMARY

Sunscreens continue to be a major method of photoprotection among the public, offering numerous benefits that clearly outweigh potential risks; however, optimizing the use of sunscreens, especially among children and adolescents, remains a major challenge.

[Melanoma in children: diagnosis and treatment specificities]

Skin melanoma is an extremely rare disease at pediatric age and its incidence increases with age. Links with predisposition syndrome exists (giant congenital naevus, xeroderma pigmentosum). Diagnosis is often difficult and distinction between benign or malignant lesion is sometime impossible (Spitzoid naevus, melanocytic neoplasms) leading to the diagnosis of "melanocytic tumor of uncertain malignant potential" (MELTUMP). Atypical features (amelanotic or raised lesions, atypical histotype) are frequent leading to delay in treatment. Diagnosis and treatment require expertise for pathologists and dermatologists pediatricians. Invasive melanomas are of poor prognosis despite recent progress in adult treatment. Early and rigorous treatment of suspect skin lesions is necessary.

Childhood exposure to ultraviolet radiation and harmful skin effects: epidemiological evidence

We review the general amount and patterns of exposure to solar ultraviolet (UV) radiation that children and teenagers experience and the spectrum of UV-related skin damage that can occur as a result. Data about the amount of solar UV received by children and teenagers are relatively few but suggest that around 40-50% of total UV to age 60 occurs before age 20. Among white children, those with the palest complexions suffer the most damage. Comparisons of prevalence and incidence of outcomes in children and teenagers sharing common ancestry, but living at different latitudes, show that prevalence rates of photoaging and melanocytic naevi are higher in Australian compared with British children, and similarly for melanoma. Genetic risk for the majority of the melanomas in teens is a function of genes controlling naevus propensity and pigmentation in the skin. High numbers of naevi and freckles, red hair, blue eyes, inability to tan, as well as a family history are the primary determinants of melanoma among adolescents. Beyond the signs of skin damage seen in children are the latent effects observed later in adulthood. Childhood is believed to be a susceptible window for long-term harmful effects of UV, as evidenced by clear differences in skin cancer risk between child and adult migrants from high to low latitudes. Effective UV radiation protection from childhood is necessary to control both immediate and long-term harmful effects on children's skin.