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

Trends in Invasive Melanoma Thickness in Norway, 1983-2019

Monitoring melanoma incidence time trends by tumour thickness is essential to understanding the evolution of melanoma occurrence and guiding prevention strategies. To assess long-term incidence trends, tumour thickness was extracted from pathology reports in the Cancer Registry of Norway (1983-2007) and the Norwegian Melanoma Registry (2008-2019), n = 45,635 patients. Across all anatomic sites, T1 (≤ 1 mm) incidence increased most (men annual percentage change [AAPC] = 4.6, 95% confidence interval [95% CI] 4.2-5.0; women AAPC = 3.2, 95% CI 2.8-3.6); the increase was steep until 1989/90, followed by a plateau, and a further steep increase from 2004/05. Increased incidence was also observed for T2 (>1.0-2.0) melanoma (men AAPC = 2.8, 95% CI 2.4-3.2; women AAPC = 1.5, 95% CI 1.1-1.9), and T3 (>2.0-4.0) in men (AAPC = 1.4, 95% CI 0.9-1.9). T4 (>4.0) melanoma followed a similar overall pattern (men AAPC = 1.3, 95% CI 0.9-1.7, head/neck, upper limbs, and trunk; women AAPC = 0.9, 95% CI 0.4-1.4, upper limbs and trunk). Men had the highest T3 and T4 incidence and the sex difference increased with age. Regarding birth cohorts, age-specific incidence increased in all T categories in the oldest age groups, while stabilizing in younger patients born after 1950. Overall, the steep increase in T1 melanoma was not accompanied by a decrease in thick melanoma.

Changes in the incidence of melanoma in Australia, 2006-2021, by age group and ancestry: a modelling study

OBJECTIVES

To estimate the incidence of melanoma in Australia among people with ancestries associated with low, moderate, or high risk of melanoma, by sex and 5-year age group; to establish whether age-specific incidence rates by ancestry risk group have changed over time.

STUDY DESIGN

Modelling study; United States (SEER database) melanoma incidence rates for representative ancestral populations and Australian census data (2006, 2011, 2016, 2021) used to estimate Australian melanoma incidence rates by ancestry-based risk.

SETTING, PARTICIPANTS

Australia, 2006-2021.

MAIN OUTCOME MEASURES

Age-specific invasive melanoma incidence rates, and average annual percentage change (AAPC) in age-specific melanoma rates, by ancestry-based risk group, sex, and 5-year age group.

RESULTS

The proportion of people in Australia who reported high risk (European) ancestry declined from 85.3% in 2006 to 71.1% in 2021. The estimated age-standardised melanoma incidence rate was higher for people with high risk ancestry (2021: males, 82.2 [95% confidence interval {CI}, 80.5-83.8] cases per 100 000 population; females, 58.5 [95% CI, 57.0-59.9] cases per 100 000 population) than for all Australians (males, 67.8 [95% CI, 66.5-69.2] cases per 100 000 population; females, 45.4 [95% CI, 44.3-46.5] cases per 100 000 population). AAPCs were consistently positive for Australians aged 50 years or older, both overall and for people with high risk ancestry, but were statistically significant only for some age groups beyond 65 years. AAPCs were negative for people aged 34 years or younger, but were generally not statistically significant.

CONCLUSIONS

Melanoma incidence has declined in some younger age groups in Australia, including among people with high risk ancestry. Social and behavioural changes over the same period that lead to lower levels of ultraviolet radiation exposure probably contributed to these changes.

Differential time series analysis shows deceleration in melanoma mortality prior to the widespread use of highly effective therapies

BACKGROUND

Although the recent drop in melanoma mortality has been attributed to the introduction of newer therapies, the impact of ongoing public efforts remains unknown.

OBJECTIVE

Characterize and model melanoma mortality trends before the era of molecular and immune therapies (1969-2014) in the U.S. and Australia.

METHODS

Differential time series analysis based on population-ascertained melanoma mortality rates from the U.S. and Australia. Mortality rates were modeled and compared to the trajectories of ten other cancers.

RESULTS

Melanoma mortality rates have been significantly decelerating since the 1970s in both the U.S. (P < .0001) and Australia (P = .0021). Zero acceleration occurred around 2001 (95% CI: 1996, 2008) for the U.S. and 2004 (95% CI: 1999, 2011) for Australia. Male mortality rates decelerated 3x-4x faster than females in both countries. Melanoma mortality followed a similar quadratic function (R2 > 0.9) to 10 other cancers, albeit with a later inflection point (1986 vs 2001) and broader focal width.

LIMITATIONS

Absolute mortality data used without further stratification or considering cancer incidence or covariates.

CONCLUSION

Melanoma deaths have been decelerating for the past 5 decades, reaching an inflection point around 2001, suggesting that mitigating campaigns were already afoot in both the U.S. and Australia before the advent of modern therapies.

Global trends in cutaneous malignant melanoma incidence and mortality

Mortality from cutaneous malignant melanoma (CMM) increased in the past, but trends have been favorable in more recent years in many high-income countries. However, incidence has been increasing in several countries. We provided an up-to-date overview of mortality trends from CMM. We analyzed death certification data from the WHO in selected countries worldwide from 1980 to the most recent available calendar years. We also reported incidence data derived from Cancer Incidence in Five Continents from 1990 to 2012. Separate analyses were performed for young adults aged 20-44 and middle-aged adults aged 45-64 years. Mortality from CMM in all age groups showed a favorable pattern in the majority of the countries considered. Mortality trends declined by 40 to 50% in Australia over the last decades, confirming the importance of prevention measures. Considering young adults aged 20-44, Australia, New Zealand and Northern Europe reported the highest death rates for both sexes (>0.90/100 000 in men and >0.60/100 000 in women) while Japan, the Philippines, and Latin America the lowest ones (<0.50/100 000 and <0.35/100 000 in men and women, respectively). Incidence trends were stable or upward in most countries, with higher rates among women. Our study highlights a global reduction of CMM mortality over the last three decades. The increasing awareness of risk factors, mainly related to UV exposure, along with early diagnosis and progress in treatment for advanced disease played pivotal roles in reducing CMM mortality, particularly in Australia.

Age group-specific changes in keratinocyte cancer treatment rates in Australia, 2012-2021: a retrospective cohort study based on MBS claims data

OBJECTIVES

To examine recent changes in the numbers of Medicare-subsidised keratinocyte cancer excisions, particularly for younger people exposed to primary prevention campaigns since the early 1980s.

STUDY DESIGN

Retrospective cohort study; analysis of administrative data.

SETTING, PARTICIPANTS

Analysis of Medicare Benefits Schedule (MBS) claims data for procedures related to the diagnosis and treatment of keratinocyte cancer in Australia, 2012-2021.

MAIN OUTCOME MEASURES

Age-standardised rates for MBS-subsidised claims for first surgical squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) excisions, Mohs surgery, surgical excisions of benign lesions, skin biopsies, and cryotherapy or serial curettage of premalignant and malignant lesions, overall, and by sex, state/territory, and age group; average annual percentage change in rate for time intervals determined by joinpoint regression.

RESULTS

In men, the age-standardised rate of BCC/SCC excisions increased by 1.9% (95% confidence interval [CI], 1.4-2.4%) per year during 2012-2019 (from 2931 to 3371 per 100 000 men) and then declined by 3.8% (95% CI, 0.5-7.0%) per year during 2019-2021 (to 3152 per 100 000). In women, the age-standardised rate increased by 2.2% (95% CI, 1.7-2.8%) per year during 2012-2019 (from 1798 to 2093 per 100 000 women); the decline to 1967 excisions per 100 000 women in 2021 was not statistically significant. BCC/SCC excision rates declined for men under 55 years of age (by 1.0-3.4% per year) and women under 45 years of age (by 1.7-2.3% per year). Age-standardised biopsy rates increased during 2012-2021 in all age groups (by 2.8-6.9% per year).

CONCLUSIONS

Rates of MBS-subsidised treatment for keratinocyte cancers increased during 2012-2019, but BCC/SCC treatment rates declined among younger Australians, who have probably been exposed to less sunlight than earlier generations because of public health interventions and population-wide lifestyle changes related to technology use.

Incidence and survival rates of primary cutaneous malignancies in Korea, 1999-2019: A nationwide population-based study

Primary cutaneous malignancies are among the most commonly diagnosed types of cancer worldwide. We aimed to examine the incidence and 5-year survival rates of all types of primary cutaneous malignancies in the Korean population. Data from the Korean Nationwide Cancer Registry from 1999 to 2019 were analyzed. The crude incidence rates, age-standardized incidence rates, and 5-year relative survival rates of each type of skin cancer were calculated. A total of 89 965 patients were diagnosed with primary cutaneous malignancies, which was a 7-fold increase from 1999 to 2019. The age-standardized incidence rates increased 3.4-fold in basal cell carcinoma (3.7/100 000 person-years), 2.0-fold in squamous cell carcinoma (1.6/100 000 person-years), 12.0-fold in Bowen disease (1.2/100 000 person-years), and 1.8-fold in malignant melanoma (0.7/10 000 person-years) in 2019. Average annual percentage changes in age-standardized incidence rates were statistically significant in basal cell carcinoma (15.8%), Bowen disease (5.8%), squamous cell carcinoma (5.1%), malignant melanoma (1.2%), melanoma in situ (1.1%), dermatofibrosarcoma protuberans (1.2%), mycosis fungoides (0.5%), primary cutaneous CD30+ T-cell proliferations (0.5%), adnexal and skin appendage carcinoma (0.4%), extramammary Paget's disease (0.2%), and Merkel cell carcinoma (0.2%). The 5-year relative survival rates were the highest in basal cell carcinoma (103.3%), followed by dermatofibrosarcoma protuberans (99.7%) and mycosis fungoides (96.6%), and lowest in angiosarcoma (24.7%). The 5-year relative survival rates steadily increased in extramammary Paget's disease (23.6%), cutaneous B-cell lymphoma (21.3%), mycosis fungoides (20.2%), extranodal NK/T-cell lymphoma, nasal type (18.1%), and malignant melanoma (16.1%) from 1996-2000 to 2015-2019. Most primary cutaneous malignancies have increased in incidence and survival rates in the Korean population, but to varying extents depending on the type of skin cancer.

Relationship between climate change and skin cancer and implications for prevention and management: a scoping review

OBJECTIVES

This study aimed to explore the published research on the relationship between climate change and skin cancer and the implications for prevention, management and further research.

STUDY DESIGN

Scoping review.

METHODS

This scoping review following JBI methodology reviewed English articles identified in searches of MEDLINE, Embase, CINAHL, Web of Science and Scopus on 14 April 2023. The screening of articles was completed by two independent reviewers. Data were extracted by a single reviewer and checked by another. A causal pathway diagram was iteratively developed throughout the review and was used to categorise the findings.

RESULTS

The search identified 1376 papers, of which 45 were included in the final review. Nine papers reported primary research, and 36 papers were reviews, perspectives, commentaries, editorials, or essays. The papers examined climate change influencing behaviours related to ultraviolet exposure (30 papers), ambient temperature (21 papers) and air pollution (five papers) as possible risk factors; occupational, rural, and contextual factors affecting skin cancer (11 papers); and prevention and access to health care in the context of climate change (seven papers). Most papers were published in journals in subject areas other than health.

CONCLUSIONS

This review identified ultraviolet radiation, occupation, rising temperature, individual behaviour and air pollution as possible influences on skin cancer rates. Furthermore, it highlights the complexity and uncertainties in the relationship between climate change and skin cancer and the need for further research on this relationship, including primary epidemiological research and reviews that follow recognised review guidelines and include assessment of health services and social determinants in the causal pathways of this relationship.

Assessing the quality of care for skin malignant melanoma on a global, regional, and national scale: a systematic analysis of the global burden of disease study from 1990 to 2019

Malignant melanoma (MM) is a highly aggressive form of skin cancer with increasing global incidence rates, particularly in developed countries. Variations in the prevalence and quality of care provided to patients with melanoma exist across different regions and across different sex and age. Assessing the global burden of melanoma and evaluating the quality of care can provide valuable insights for developing targeted interventions in certain underperforming regions and improving patient outcomes. This study aimed to systematically analyze the Global Burden of Disease Study from 1990 to 2019 to assess the quality of care for skin malignant melanoma on a global scale. We conducted a comprehensive literature review and extracted data on melanoma incidence, mortality, and disability-adjusted life years (DALYs) from the Global Burden of Disease Study. We incorporated these variables using principal component analysis (PCA) to form an informative single variable of quality of care index (QCI) and analyzed its spatial-temporal variations as well as disparities across age, sex and socio-demographic index (SDI). The overall Quality of Care Index (QCI) for melanoma improved from 82.81 in 1990 to 91.29 in 2019. The QCI score showed a positive correlation with socioeconomic status across regions. Australia ranked highest in QCI (99.96), while Central African Republic, and Kiribati had the lowest scores. China and Saudi Arabia showed significant QCI improvement, while the QCI of the Democratic People's Republic of Korea, Zimbabwe, and Guam decreased from 1990 to 2019. The highest QCI scores were observed in the age groups of 20-39 years old (93.40-94.65). Gender disparities narrowed globally in these three decades, but lower Socio-demographic Index (SDI) regions showed increased gender inequities. Our findings highlighted the spatial-temporal variations in the quality of care of MM as well as its disparities across different SDI levels, age groups and sex. These findings offer valuable insights and guidance for implementing focused interventions and resource allocation to enhance the quality of care and overall outcomes for MM worldwide, especially for underperforming regions.

To be or not to be: Arts-based approaches in public health messaging for dementia awareness and prevention

OBJECTIVES

Multiple modifiable risk factors exist across the lifespan to reduce dementia prevalence, and public understanding of these factors is increasing. Yet dementia is frequently misunderstood and stigmatised, and dementia prevention is not generally recognised as a health priority. Current limitations of public health campaigns for dementia prevention must be addressed and innovative alternatives developed to improve public comprehension and implementation of preventative action across all stages of life.

METHODS

In searching various databases and public information on dementia prevention, restraints were found in current health messaging which did not reflect the complexity of this health issue and address diversity of its impact across cultures and ages. In consultation with researchers and public health organisations, we outline four case studies in Australia where innovative arts-based approaches have been adopted and discuss the potential for arts-based approaches to address these gaps.

RESULTS

Arts-based approaches have the unique capacity to shift perceptions on ageing and dementia, overcome language and literacy barriers, represent health concerns across cultures, and actively involve individuals, communities and healthcare professionals in the process of dementia prevention. Future campaigns can engage a variety of communities and environments with art mediums suited to their preferences, capacities and efficacy.

CONCLUSIONS

Recommendations include example mediums, environments and people to engage. Future research is required to understand the impact of, and to improve, the long-term adoption of innovative arts-based approaches in dementia prevention practices.

WH, Salopek TG, Rahme E, Peláez S, Litvinov IV. Assessing Skin Cancer Risk Factors, Sun Safety Behaviors and Melanoma Concern in Atlantic Canada: A Comprehensive Survey Study

BACKGROUND

The incidence of cutaneous melanoma (CM) is increasing at an alarming rate in Canada and elsewhere around the world. Significant regional differences in CM incidence have been identified in Atlantic provinces. The goal of this study is to compare ultraviolet exposure, sun protective behaviours, level of worry and baseline CM knowledge in provinces with a high versus low incidence of CM as well, as between various demographic groups.

METHODS

A cross-sectional survey study was conducted in Atlantic provinces between July 2020 and August 2022. All participants aged ≥ 16 years with a completed survey were eligible. Survey responses were summarized using frequency counts, percentages, and means. Two-sided Z-tests for equality of proportions and logistic regression models were used to compare the survey results between geographic and demographic groups.

RESULTS

In total, 7861 participants were included (28.0% men; mean age 61.3 years; response rate 28%). Our results (gender- and age-adjusted odds ratio, 95% confidence interval) show that high-incidence provinces for CM (Prince Edward Island and Nova Scotia) had significantly more sunburns (OR 2.00, 1.72-2.31), total sun exposure (OR 2.05, 1.68-2.50), recreational sun exposure (OR 1.95, 1.61-2.35) and tans (OR 1.77, 1.53-2.05) than individuals in low-incidence provinces (Newfoundland and Labrador). However, individuals in high-incidence provinces displayed more protective behaviors: there were less tanning bed users (OR 0.82, 0.71-0.95), they checked their skin more frequently for new moles (OR 1.26, 1.06-1.51) and practiced more sun protection overall. Additional analyses are presented based on education, income, sexual orientation and gender.

DISCUSSION

These findings suggest that future efforts aimed at reducing the CM burden in Atlantic Canada should be tailored for target geographic and/or demographic groups.

LIMITATIONS

the study participants are not representative of the population in Atlantic Canada due to recruitment strategies.

Significant improvement in melanoma survival over the last decade: A Hungarian nationwide study between 2011 and 2019

BACKGROUND

Recent real-world studies have reported significant improvements in the survival of malignant melanoma in the past few years, mainly as a result of modern therapies. However, long-term survival data from Central Eastern European countries such as Hungary are currently lacking.

METHODS

This nationwide, retrospective study examined melanoma survival in Hungary between 2011-2019 using the databases of the National Health Insurance Fund (NHIF) and Central Statistical Office (CSO) of Hungary. Crude overall survival and age-standardized 5-year net survival as well as the association between age, sex and survival were calculated.

RESULTS

Between 2011 and 2019, 22,948 newly diagnosed malignant melanoma cases were recorded in the NHIF database (47.89% male, mean age: 60.75 years (SD: ±16.39)). Five-year overall survival was 75.40% (women: 80.78%; men: 69.52%). Patients diagnosed between 2017-2019 had a 20% lower risk of mortality compared to patients diagnosed between 2011-2012 (HR 0.80, 95% CI 0.73-0.89; p < 0.0001). Age-standardized 5-year net survival rates in 2011-2014 and 2015-2019 were 90.6% and 95.8%, respectively (women: 93.1% and 98.4%, men: 87.8% and 92.7%, respectively). The highest age-standardized 5-year net survival rates were found in the 0-39 age cohort (94.6% in the 2015-2019 period).

CONCLUSION

Hungary has similar melanoma survival rates to Western European countries. Based on net survival, the risk of dying of melanoma within 5 years was cut by more than half (55%) during the study period, which coincides with the successful implementation of awareness campaigns and the wide availability of modern therapies.

Twenty years of melanoma in Victoria, Queensland, and South Australia (1997 - 2016)

BACKGROUND

Given the high incidence of melanoma in Australia alongside high mortality with later stage disease, we investigated the populations and locations most at risk, to optimise public health activities in areas where intervention is most needed. This study examines trends and identifies significant prognostic factors and potential disparities in incidence, mortality and survival between population groups in Victoria, Queensland and South Australia.

METHODS

The analysis includes data from the population-based cancer registries of the three states over a twenty-year period (1997-2016). Age-standardized and age-specific incidence rates were calculated, and long-term trends analysed using Joinpoint Regression. Five-year relative survival estimates for the study population were calculated using the cohort method and multivariable flexible parametric survival models were applied for each jurisdiction to calculate adjusted excess mortality hazard ratios for the key characteristics.

RESULTS

There were more males with melanoma than females in all the three states. Over 60% of the cases occurred in the 40-74 years age group. Most melanomas had a Breslow thickness less than or equal to 1.0 mm. For males, Victoria and Queensland had a statistically significant increasing trend whereas in South Australia there was a decreasing trend. For females, the incidence rate trend was stable in Victoria but significantly decreasing in South Australia. In Queensland there was an increasing and statistically significant trend from 2006 to 2016. Across all three states there was a reducing incidence rate in the youngest cohort, stabilizing incidence in the 40-59-year-old age group, and increasing in the oldest cohorts. Five-year relative survival decreased with increasing age and with Breslow thickness across all three jurisdictions. Males had between 43%- 46% excess mortality compared to females in all the three states. There was higher risk with increasing age and Breslow thickness, with the largest risk among the 75 + age group and those with a Breslow thickness of > 4 mm.

CONCLUSION

It is the first time that data from these three registries has been analysed together in a uniform way, covering more than half of the Australian population. This study compares the epidemiology of melanoma across three states and provides a better understanding of trends and factors affecting outcome for Australians with melanoma. While there has been some improvement in aspects of incidence and mortality, this has not been evenly achieved across Australia.

Trends in keratinocyte skin cancer incidence, mortality and burden of disease in 33 countries between 1990 and 2017

BACKGROUND

Keratinocyte cancers (KCs) are the most common type of cancer in the White population worldwide, with associated high healthcare costs. Understanding the epidemiological trends for KCs, namely basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (SCCs), is required to assess burden of disease, project future trends and identify strategies for addressing this pressing global health issue.

OBJECTIVES

To report trends in BCC and SCC incidence, and SCC mortality and disability-adjusted life-years (DALYs).

METHODS

An observational study of the Global Burden of Disease (GBD) database between 1990 and 2017 was performed. European Union countries and other selected high-income countries, including the UK and the USA, classified as having high-quality mortality data, were included. Annual age-standardized incidence rates (ASIRs), age-standardized death rates (ASDRs) and DALYs for each country were obtained from the GBD database. Trends were described using joinpoint regression analysis.

RESULTS

Overall, 33 countries were included. For both BCC and SCC in 2015-2017, the highest ASIRs were observed in the USA and Australia. Males had higher ASIRs than females at the end of the observation period in all countries for SCC, and in all countries but two for BCC. In contrast, the highest ASDRs for SCC were observed in Australia and Latvia for males, and in Romania and Croatia for females. The highest DALYs for SCC for both sexes were seen in Australia and Romania. Over the observation period, there were more countries demonstrating decreasing trends in mortality than in incidence, and disparities were observed between which countries had comparatively high mortality rates and which had high incidence rates. Overall reductions in SCC DALYs were observed in 24 of 33 countries for males, and 25 countries for females.

CONCLUSIONS

Over the past 27 years, although trends in SCC incidence have risen in most countries, there is evidence that mortality rates have been decreasing. Burden of disease as assessed using DALYs has decreased in the majority of countries. Future work will explore potential explanatory factors for the observed disparity in trends in SCC incidence and mortality.

Mortality Trends Due to Skin Melanoma in Poland in the Years 2000-2020

The aim of this article is to assess mortality trends due to skin melanoma in Poland between the years 2000 and 2020, taking into account gender and place of residence (urban, rural). The subject of the analyses was data on 25,061 deaths that occurred between 2000 and 2020 due to skin melanoma (C43 according to ICD-10). Mortality rates due to this cancer, both crude (CDR) and standardised (SDR), were calculated. Trends on the calculated rates were analysed using the annual percentage change (APC) and average annual percentage change (AAPC), obtained from joinpoint regression models. Over the study period, the standardised death rate (SDR) due to skin melanoma in Poland increased from 3.60 to 4.03 per 100,000 population (AAPC = 1.1; p < 0.05), for urban residents it increased from 3.56 to 3.91 (APC = 1.2; p < 0.05) and for rural residents it increased from 3.00 to 4.24 (APC = 2.2; p < 0.05). A higher growth rate in terms of the SDR value between the years 2000 and 2020 was recorded in men compared to women and in rural when compared to urban residents. In Poland, mortality due to skin melanoma is on the rise. The early diagnosis of this cancer should become common practice in the Polish population.

The impact of skin cancer prevention efforts in New South Wales, Australia: Generational trends in melanoma incidence and mortality

BACKGROUND

In Australia, skin cancer awareness campaigns have focused on raising the awareness and consequences of skin cancer and highlighting the importance of utilising sun protection.

METHODS

Trends in melanoma incidence and mortality have been explored elsewhere in Australia and this study sought to examine the trends in NSW. Anonymised incidence and mortality data for in situ and invasive melanoma from 1988 to 2014 were obtained from the NSW Cancer Registry. Trends of melanoma incidence and mortality were analysed using segmented regression to allow for changes over time. Birth cohort patterns were assessed using age-period-cohort models.

RESULTS

Over the period, incidence of in situ melanoma increased in all age groups although the rates were lowest in those under 40 years of age. Incidence of invasive melanoma was either stable or decreased in people under 60, while it increased in those aged 60 and above, particularly in men. Age-period-cohort analysis revealed decreasing age-specific incidence of invasive melanoma under 40 years of age. Melanoma mortality over the period was stable or decreased in all groups except in men aged 60 or over. Overall, mortality rates generally declined or remained stable particularly in recent years.

CONCLUSION

It is encouraging that rates of invasive melanoma are declining in the younger age cohorts - which could be attributed to both primary prevention efforts with individuals protecting their skin as well as early detection through self assessment and clinician performed skin checks. In addition, whilst it is important to monitor the increasing rates of in situ melanoma, the increase is likely due to early detection and treatment of melanoma that could have progressed to invasive melanoma and therefore detection whilst still in situ is an improved outcome. Overall, the results demonstrate the need to continue to improve the understanding of and compliance with primary skin cancer prevention measures in order to reduce population UVR exposure and overall melanoma incidence.

Incidence of in Situ vs Invasive Melanoma: Testing the "Obligate Precursor" Hypothesis

Background

Melanoma incidence has been rising in populations with predominantly European ancestry (White), speculated to be partly driven by heightened detection of indolent tumors. If in situ melanomas are destined to evolve to invasive cancers, detecting and removing them should deplete the pool of invasive lesions, and people with in situ melanoma should, on average, be younger than those with invasive melanoma.

Methods

We analyzed long-term incidence trends (1982-2018) for in situ and invasive melanomas in 3 predominantly White populations with high, medium, and low melanoma rates: Queensland (Australia), United States White, and Scotland. We calculated the incidence rate ratio (IRR) of in situ to invasive melanomas and estimated the contributions of age, period, and cohort effects. We compared age at diagnosis of in situ vs invasive melanomas overall and stratified by sex and anatomic site.

Results

In all 3 populations, the in situ to invasive incidence rate ratio increased statistically significantly from less than 0.3 in 1982 to 1.95 (95% confidence interval [CI] = 1.88 to 2.02) in Queensland, 0.93 (95% CI = 0.90 to 0.96) in the US White population, and 0.58 (95% CI = 0.54 to 0.63) in Scotland in 2018. The mean age at diagnosis of in situ melanomas was the same or higher than invasive melanomas for almost all time periods among men and women and on all body sites except the lower limbs.

Conclusions

The increasing ratio of in situ to invasive melanoma incidence over time, together with the high (and increasing) mean age at diagnosis of in situ melanomas, is consistent with more indolent lesions coming to clinical attention than in previous eras.

Using the Prediction Model Risk of Bias Assessment Tool (PROBAST) to Evaluate Melanoma Prediction Studies

Simple Summary

The rising incidence of cutaneous melanoma over recent decades, combined with a general interest in cancer risk prediction, has led to a high number of published melanoma risk prediction models. The aim of our work was to assess the validity of these models in order to discuss the current state of knowledge about how to predict incident cutaneous melanoma. To assess the risk of bias, we used a standardized procedure based on PROBAST (Prediction model Risk Of Bias ASsessment Tool). Only one of the 42 studies identified was rated as having a low risk of bias. However, it was encouraging to observe a recent reduction of problematic statistical methods used in the analyses. Nevertheless, the evidence base of high-quality studies that can be used to draw conclusions on the prediction of incident cutaneous melanoma is currently much weaker than the high number of studies on this topic would suggest.

Abstract

Rising incidences of cutaneous melanoma have fueled the development of statistical models that predict individual melanoma risk. Our aim was to assess the validity of published prediction models for incident cutaneous melanoma using a standardized procedure based on PROBAST (Prediction model Risk Of Bias ASsessment Tool). We included studies that were identified by a recent systematic review and updated the literature search to ensure that our PROBAST rating included all relevant studies. Six reviewers assessed the risk of bias (ROB) for each study using the published “PROBAST Assessment Form” that consists of four domains and an overall ROB rating. We further examined a temporal effect regarding changes in overall and domain-specific ROB rating distributions. Altogether, 42 studies were assessed, of which the vast majority (n = 34; 81%) was rated as having high ROB. Only one study was judged as having low ROB. The main reasons for high ROB ratings were the use of hospital controls in case-control studies and the omission of any validation of prediction models. However, our temporal analysis results showed a significant reduction in the number of studies with high ROB for the domain “analysis”. Nevertheless, the evidence base of high-quality studies that can be used to draw conclusions on the prediction of incident cutaneous melanoma is currently much weaker than the high number of studies on this topic would suggest.

Analysis of Geographic and Environmental Factors and Their Association with Cutaneous Melanoma Incidence in Canada

BACKGROUND

Over 90% of skin cancers including cutaneous melanoma (CM) are related directly to sun exposure. Despite extensive knowledge on ultraviolet radiation's (UVR) detrimental impact, many still fail to implement sun protection/sun avoidance. Human behavior, attitudes, and cultural norms of individuals and communities heavily depend on the surrounding climate/environment. In many instances, the climate shapes the culture/norms of the society. Canada has vast geographic/environmental differences.

METHODS

In the current ecological study, we sought to examine the relationship between various geographic and environmental factors and the distribution of CM incidence by Forward Sortation Area (FSA) postal code across Canada. CM incidence data were extracted from the Canadian Cancer Registry, while environmental data were extracted from the Canadian Urban Environmental Health Research Consortium (greenspace, as measured by the normalized difference vegetation index; annual highest temperature; absolute number and average length of yearly heat events; annual total precipitation [rain and snow]; absolute number and average length of events with precipitation [rain and snow]; and summer UVR index). The above geographic/environmental data by FSA were correlated with the respective CM incidence employing negative binomial regression model.

RESULTS

Our analysis highlights that increases in annual average temperature, summer UVR, and greenspace were associated with higher expected incidence of CM cases, while higher number of annual heat events together with highest annual temperature and higher average number of annual rain events were associated with a decrease in CM incidence rate. This study also highlights regional variation in environmental CM risk factors in Canada.

CONCLUSIONS

This national population-based study presents clinically relevant conclusions on weather/geographic variations associated with CM incidence in Canada and will help refine targeted CM prevention campaigns by understanding unique weather/geographic variations in high-risk regions.

Global Burden of Cutaneous Melanoma in 2020 and Projections to 2040

Importance

Despite many cases being preventable, cutaneous melanoma remains the most serious skin cancer worldwide. Understanding the scale and profile of the disease is vital to concentrate and reinforce global prevention efforts.

Objective

To examine global patterns of cutaneous melanoma in 2020 and to provide projected estimates of cases and deaths by 2040.

Design, Setting, and Participants

This population-based study used the GLOBOCAN 2020 database for global epidemiological assessment of new cases and deaths due to invasive melanoma.

Main Outcomes and Measures

Age-standardized incidence and mortality rates were calculated per 100 000 person-years by country, world region, and 4-tier level of human development. Estimated numbers of cases and deaths were calculated for the year 2040.

Results

A worldwide total of 325 000 new melanoma cases (174 000 males, 151 000 females) and 57 000 deaths (32 000 males, 25 000 females) was estimated for 2020. Large geographic variations existed across countries and world regions, with the highest incidence rates among males (42 per 100 000 person-years) and females (31 per 100 000 person-years) observed in Australia/New Zealand, followed by Western Europe (19 per 100 000 person-years for males and females), North America (18 per 100 000 person-years for males, 14 per 100 000 person-years for females), and Northern Europe (17 per 100 000 person-years for males, 18 per 100 000 person-years for females). Melanoma continued to be rare in most African and Asian countries, with incidence rates commonly less than 1 per 100 000 person-years. Mortality rates peaked at 5 per 100 000 person-years in New Zealand, and geographic variations were less pronounced than for incidence. Melanoma was more frequent among males than females in most world regions. If 2020 rates continue, the burden from melanoma is estimated to increase to 510 000 new cases (a roughly 50% increase) and to 96 000 deaths (a 68% increase) by 2040.

Conclusions and Relevance

This epidemiological assessment suggests that melanoma remains an important challenge to cancer control and public health globally, especially in fair-skinned populations of European descent.

The dynamic behaviour of sunscreens under in-service conditions

Discussion continues over various aspects of sunscreen science: regulation, test methods, sun protection factor (SPF), labelling claims, potentially harmful components, among others. In this paper the UV transmission properties of a number of commercial sunscreens have been determined at constant sunscreen film thickness under different local UV Index conditions. The data demonstrate difficulties facing the public and the sunscreen industry as a whole, even though SPF values and other data stated on the sunscreen packaging are assumed to be correct according to standard testing methods. This work has shown that at realistic application rates the critical factors are the intensity of the incident solar radiation and the accumulated erythema UV dose transmitted over time. In one example, on 'Extreme' UV Index days, an SPF 30 sunscreen under test transmitted one minimal erythema dose (MED) of UV in only 35 min. In another example, although it should not, in theory, transmit one MED until several hours of exposure, this level was reached in 1 h by an SPF 50 sunscreen under these typical Australian summer conditions (UV Index 12) in Wollongong, NSW (34.4°S). Such properties could have severe consequnces if these sunscreens were used by individuals with Fitzpatrick Skin Type 1, organ transplant recipients or other immuno-compromised individuals.

Population-Based Study Detailing Cutaneous Melanoma Incidence and Mortality Trends in Canada

Background

Cutaneous melanoma (CM) is one of the most fatal types of skin cancer. Alarmingly, increases in incidence and mortality were noted globally for this malignancy, despite increase in understanding of melanoma pathogenesis and enhanced prevention efforts.

Methods

Data was extracted for CM patients for provinces and territories (except Quebec) using two independent, population-based registries. Analysis was performed using both clinical and pathological characteristics: tumor morphologic classification, age, sex, anatomic site affected and place of residence. Mortality trends were assessed over a 7-year period. Results were compared to prior findings for 1992-2010.

Results

During 2011-2017 39,610 patients were diagnosed with CM, with 5,890 reported deaths. National crude CM incidence was 20.75 (age-standardized incidence: 14.12) cases per 100,000 individuals per year. Females accounted for 45.8% of cases and 37.1% of deaths. While CM incidence rates continue to increase in both sexes, since 2013 the CM mortality is declining. We observed important differences across the provinces/territories, where Nova Scotia, Prince Edward Island, southern Ontario/British Columbia and certain coastal communities of New Brunswick demonstrated higher CM incidence and mortality rates. The observed incidence and mortality trends for 2011-2017 validate and extend earlier observations from 1992 to 2010 for CM.

Conclusion

This population-based study highlights that while melanoma's incidence is increasing in Canada, mortality rates are for the first time decreasing since 2013. We detail regional distribution of this cancer highlighting communities in southern/coastal areas, as being most at risk as well as the latest trends of melanoma incidence by age, sex and anatomic site. In males, melanoma is more common on the head/trunk, while in females on the extremities. Notably, Acral Lentiginous Melanoma was the only CM subtype that was more common in females, which primarily affects hands and feet.

Self-reported skin cancer-related behaviours in rural Victoria: results from repeat cross-sectional studies in 2001-2003 and 2016-2018

OBJECTIVE

To assess whether self-reported use of sun-protective measures and skin examination have changed between 2001 and 2018 in a rural setting.

METHODS

Repeat cross-sectional survey of randomly selected households in four rural Victorian towns. People aged 16 years and older were eligible to participate. Logistic regression was used to identify demographic factors associated with sun-protective measures and skin examination.

RESULTS

Overall, 5,328 participated in 2001-2003 and 2,680 in 2016-2018. Among participants who go out in the sun, the mean number of reported sun-protective measures (2.6±1.3 vs. 2.6±1.6, p=0.867) and the proportion of participants reporting usually/always using sun protection (65.1% vs. 63.9%, p=0.307) were unchanged between the two surveys. However, an increased proportion of participants reported avoiding the sun when outdoors in the more recent survey (from 18.8% to 34.3%, p<0.001). Avoiding the sun was associated with being older, female, of European origin and having post-secondary school education. Skin examination rates increased between the two surveys (32.7% to 40.8%, p<0.001). Skin examinations were associated with older age groups, European origin and post-secondary school education and being male.

CONCLUSIONS

Given the small changes in sun protection over time, updated skin cancer campaigns are needed to encourage increased sun-protective behaviours and skin examinations among rural residents. Implications for public health: Results suggest that updated health promotion campaigns targeted to rural areas are warranted.

Slip versus Slop: A Head-to-Head Comparison of UV-Protective Clothing to Sunscreen

Simple Summary

Photoprotection reduces invasive melanoma incidence and mortality, but not all sun protection modalities are created equal. Dermatologists have long debated the pros and cons of photoprotective clothing and sunscreen, but few studies compare the effectiveness of these two modalities head-to-head. This study uses both in vitro and in vivo techniques to compare the ultraviolet radiation (UVR) protective capacity of four modern textiles and two commercially available, broad-spectrum sunscreens.

Abstract

Ultraviolet radiation (UVR) exposure is the most important modifiable risk factor for skin cancer development. Although sunscreen and sun-protective clothing are essential tools to minimize UVR exposure, few studies have compared the two modalities head-to-head. This study evaluates the UV-protective capacity of four modern, sun-protective textiles and two broad-spectrum, organic sunscreens (SPF 30 and 50). Sun Protection Factor (SPF), Ultraviolet Protection Factor (UPF), Critical Wavelength (CW), and % UVA- and % UVB-blocking were measured for each fabric. UPF, CW, % UVA- and % UVB-blocking were measured for each sunscreen at 2 mg/cm² (recommended areal density) and 1 mg/cm² (simulating real-world consumer application). The four textiles provided superior UVR protection when compared to the two sunscreens tested. All fabrics blocked erythemogenic UVR better than the sunscreens, as measured by SPF, UPF, and % UVB-blocking. Each fabric was superior to the sunscreens in blocking full-spectrum UVR, as measured by CW and % UVA-blocking. Our data demonstrate the limitations of sunscreen and UV-protective clothing labeling and suggest the combination of SPF or UPF with % UVA-blocking may provide more suitable measures for broad-spectrum protection. While sunscreen remains an important photoprotective modality (especially for sites where clothing is impractical), these data suggest that clothing should be considered the cornerstone of UV protection.

Difference in Sun Exposure Habits Between Individuals with High and Low Risk of Skin Cancer

Background

Skin cancer incidence is rapidly increasing. The main risk factor, sun exposure, can be modified. Informational campaigns can be effective in raising skin cancer awareness and target the high-risk population. Still, sun exposure habits in people at high risk of skin cancer are not well-known.

Objective

To investigate if and how sun exposure habits differ between low-risk and high-risk individuals.

Methods

During the Swedish Euromelanoma campaign of 2018, questionnaires were collected containing information regarding sun exposure habits and risk factors for skin cancer. Data on 4,141 participants was used to investigate the association between risk factors and sun exposure habits.

Results

A fair skin type and a previous history of skin cancer were significantly associated with enhanced sun protective behavior. Family history of skin cancer, childhood sunburns and the presence of large/atypical nevi had no effect on sun exposure habits. Going on sunny holidays were particularly unaffected by being at high risk of skin cancer.

Conclusion

Individuals at high risk of developing skin cancer showed suboptimal sun exposure habits and harmful traveling behaviors. We suggest that future skin cancer campaigns inform on accurate sun protection behavior during sunny holidays and associated risk factors. Risk factors such as childhood sunburns, numerous common and large/atypical nevi, as well as family history of skin cancer seem to be less recognized by the population.

Changing epidemiology and age-specific incidence of cutaneous malignant melanoma in England: An analysis of the national cancer registration data by age, gender and anatomical site, 1981-2018

Background

The incidence of cutaneous malignant melanoma, which is mostly attributable (86%) to UV radiation exposure, has been steadily increasing over the past four decades in predominantly fair-skinned populations. Although public health campaigns are increasing sun-protective behaviour in England, their effect on melanoma incidence is largely unknown. We conducted a retrospective population-based cohort study to examine whether there have been changes in the epidemiology of melanoma in England during the past four decades.

Methods

Individual level data for patients diagnosed with melanoma in England during 1981–2018 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by three age categories (0–34, 35–64, 65+ years), gender and anatomical site during the seven five-year time periods (1981–85 to 2011–15) and the recent three-year period (2016–18). The percentage change in incidence was calculated as change in the average incidence rate from the first (1981–85) to the last time period (2016–18). The Average Annual Percentage Change (AAPC) was estimated using the slope of the linear trend line fitted to the incidence rates by year of diagnosis.

Findings

During the 38-year period (1981–2018), a total of 265,302 cases of melanoma (45.7% males, 54.3% females) were registered in England. The average annual number of cases increased from 837/year in 1981–85 to 6963/year in 2016–18 in males (+732%), and from 1609/year in 1981–85 to 6952/year in 2016–18 in females (+332%). In the young age-group (0–34 years), the average annual incidence rates initially increased from 1981–85 to 2001–05 and then stabilised during the recent period (2006–18). In the middle age group (35–64 years), the rates increased by +332% (AAPC, 10.4%) in males (from 5.6/100,000 in 1981–85 to 24.2/100,000 in 2016–18) and +185% (AAPC, 5.7%) in females (from 10.2/100,000 in 1981–85 to 29.1/100,000 in 2016–18); and in the old age-group (65+ years) the rates increased by +842% (AAPC, 25.7%) in males (from 9.6/100,000 in 1981–85 to 90.4/100,000 in 2016–18) and +381% (AAPC, 11.2%) in females (from 12.5/100,000 in 1981–85 to 60.1/100,000 in 2016–18). The largest increase in incidence in both males and females was observed for melanoma of the trunk (+817%, AAPC, 24.8% in males and +613%, AAPC, 18.3% in females), followed by melanoma of upper limb (+750%, AAPC, 22.9% in males and 518%, AAPC, 15.5% in females).

Interpretation

It appears that the incidence of melanoma among young people in England has stabilised (or levelled off) in recent decades, whereas it continues to increase substantially in older population. These findings suggest that public health campaigns targeted at children/adolescents/parents may be favourably influencing melanoma incidence. The steeper increase in incidence in males is consistent with their relatively greater sun exposure and poor sun-protective behaviour. All the available evidence suggests that the enormous increase in the melanoma of the trunk and upper limb, since the 1980s, is most likely due to increasing trend in intermittent high intensity recreational UV radiation exposure (e.g. sunbathing, holidaying in places with strong sunlight, indoor tanning).

Funding

This work was supported by Brighton and Sussex Medical School (BSMS).

Trends of cutaneous basal cell carcinoma, squamous cell carcinoma, and melanoma among the Chinese, Malays, and Indians in Singapore from 1968-2016

BACKGROUND

Previous analysis showed that the incidence rates of skin cancer in Singapore increased from 1968 to 2006, especially among older Chinese, and particularly for basal cell carcinoma (BCC).

OBJECTIVE

We updated the skin cancer incidence rates and time trends among the Chinese, Malays, and Indians in Singapore.

METHODS

We analyzed the skin cancer incidence from the nationwide Singapore Cancer Registry from 1968 to 2016.

RESULTS

Among 12,692 cases diagnosed from 1968 to 2016, there were 8367 (65.9%) cases of BCC, 3598 (28.3%) of squamous cell carcinoma (SCC), and 727 (5.8%) of melanoma. The mean ages at skin cancer diagnosis were 72.7 years for SCC, 66.9 years for BCC, and 59.8 years for melanoma. Sun-exposed areas accounted for 81.3% of BCCs, 61.6% of SCCs, and 26.7% of melanomas. The age-standardized incidence rate of cutaneous BCC was highest in the Chinese and increased by 2.5 fold over the study period, followed by a lower rate and slower increase in the Malays, and the lowest rate among the Indians. The SCC and melanoma incidences remained low in all 3 ethnicities during this study period. The Chinese had the highest relative risk for developing any skin cancer (P < .0001) compared with those of the Malays and Indians. Most cases of skin cancer were diagnosed at age ≥60, with men showing a higher incidence of SCC compared with that of women.

CONCLUSION

Incidence rates of BCC have increased in Singapore, especially among the Chinese, in the past 5 decades. The SCC and melanoma incidence rates remained low and stable.

Trend Shifts in Age-Specific Incidence for In Situ and Invasive Cutaneous Melanoma in Sweden

BACKGROUND

The incidence of invasive cutaneous melanoma (CM) is increasing in Sweden. The aim was to present age- and sex-specific trends of the age-standardised incidence and the average annual percentage change (AAPC) for in situ and invasive CM.

METHODS

Joinpoint regression models were used to analyse data from the Swedish Cancer Register and the Swedish Melanoma Registry 1997-2018 (N = 35,350 in situ CM; 59,932 CM).

RESULTS

The AAPC of CM for women was 4.5 (4.1-5.0; p < 0.001) for the period 1997-2018. For men, the APCC was 4.2 (3.0-5.4; p < 0.001), with a significantly higher annual percentage change (APC) for the period 2000-2018 (5.0; 4.6-5.4; p < 0.001) compared to 1997-1999. An increasing annual incidence of CM ≤ 0.6 mm and 0.7 mm Breslow tumour thickness was found for men with a significant incidence shift for the period 2006-2015, respectively. Similarly for women, with a significantly higher APC for CM ≤ 0.6 mm from 2005. The incidence of intermediate thick CM (2.1-4.0 mm) has not increased since 2011. The incidence of CM > 4.0 mm has been increasing among both sexes, with a significantly lower APC among women from 2005.

CONCLUSIONS

The incidence of in situ and low-risk CM ≤ 1.0 mm in tumour thickness has been rising among both sexes since the 2000s.

Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries

This article provides an update on the global cancer burden using the GLOBOCAN 2020 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer. Worldwide, an estimated 19.3 million new cancer cases (18.1 million excluding nonmelanoma skin cancer) and almost 10.0 million cancer deaths (9.9 million excluding nonmelanoma skin cancer) occurred in 2020. Female breast cancer has surpassed lung cancer as the most commonly diagnosed cancer, with an estimated 2.3 million new cases (11.7%), followed by lung (11.4%), colorectal (10.0 %), prostate (7.3%), and stomach (5.6%) cancers. Lung cancer remained the leading cause of cancer death, with an estimated 1.8 million deaths (18%), followed by colorectal (9.4%), liver (8.3%), stomach (7.7%), and female breast (6.9%) cancers. Overall incidence was from 2-fold to 3-fold higher in transitioned versus transitioning countries for both sexes, whereas mortality varied <2-fold for men and little for women. Death rates for female breast and cervical cancers, however, were considerably higher in transitioning versus transitioned countries (15.0 vs 12.8 per 100,000 and 12.4 vs 5.2 per 100,000, respectively). The global cancer burden is expected to be 28.4 million cases in 2040, a 47% rise from 2020, with a larger increase in transitioning (64% to 95%) versus transitioned (32% to 56%) countries due to demographic changes, although this may be further exacerbated by increasing risk factors associated with globalization and a growing economy. Efforts to build a sustainable infrastructure for the dissemination of cancer prevention measures and provision of cancer care in transitioning countries is critical for global cancer control.

Older Adults Who Spend More Time Outdoors in Summer and Have Higher Dietary Vitamin D Than Younger Adults Can Present at Least as High Vitamin D Status: A Pilot Study

Vitamin D₃ can be produced by exposing skin to UVB radiation or sourced through dietary products. It is often stated that vitamin D status declines in older adults, yet little is known about differences in current-day lifestyle and dietary behaviours influencing vitamin D outcomes in younger (18–40 years old) and older adults (65–89 years old). Our objectives were to perform a pilot study to compare sun exposure behaviours, i.e., time spent outdoors, holiday behaviour and use of sunscreen/clothing, and dietary vitamin D intake, in young and older adults in the UK, together with assessment of their vitamin D status. A total of 13 young and 11 older volunteers completed a four-page questionnaire to assess sun exposure and photoprotective behaviour and an eleven-page one-week vitamin D diet diary, alongside their plasma 25(OH)D measurement. It was found that the older group tended to spend more time outdoors during the working week in summer, to take more summer and winter holidays each year, take longer winter holidays and have similar sunscreen use when compared to younger adults. Older adults had a significantly higher daily dietary intake of vitamin D (4.0 μg) than young adults (2.4 μg). Mean winter 25(OH)D concentration was higher in older (56.9 nmol/L) than in young adults (43.2 nmol/L), but there was no statistical difference between the groups. Contrary to common assumptions, in this study, older adults had sun exposure and dietary behaviours conferring a vitamin D status at least as good as that of younger adults.

Reviewing the impact of 11 national Be Clear on Cancer public awareness campaigns, England, 2012 to 2016: A synthesis of published evaluation results

The Be Clear on Cancer (BCoC) campaigns have run in England since 2010. They aim to raise awareness of possible cancer symptoms, encouraging people to consult a general practice with these symptoms. Our study provides an overview of the impact of 11 national campaigns, for bowel, lung, bladder and kidney, breast and oesophago-gastric cancers. We synthesised existing results for each campaign covering seven clinical metrics across the patient pathway from primary care attendances to one-year net survival. For each metric, "before" and "after" periods were compared to assess change potentially related to the campaign. Results show that primary care attendances for campaign-related symptoms increased for 9 of 10 campaigns and relevant urgent referrals for suspected cancer increased above general trends for 9 of 11 campaigns. Diagnostic tests increased for 6 of 11 campaigns. For 7 of 11 campaigns, there were increases in cancer diagnoses resulting from an urgent referral for suspected cancer. There were sustained periods where more cancers were diagnosed than expected for 8 of 10 campaigns, with higher than expected proportions diagnosed at an early stage for sustained periods for 4 of 10 campaigns. There was no impact on survival. In summary, there is evidence that the BCoC campaigns impact help-seeking by patients and referral patterns by general practitioners, with some impact on diagnosis (incidence and stage). There was no clear evidence of impact on survival.

Changing Trends in Melanoma Incidence and Decreasing Melanoma Mortality in Hungary Between 2011 and 2019: A Nationwide Epidemiological Study

Background

The incidence of malignant melanoma has continually increased during the past few decades, however, certain reports suggest a recent change in trends. The aim of our study was to examine the epidemiology of melanoma in Hungary.

Methods

This nationwide, retrospective, longitudinal study included melanoma patients diagnosed between 1 January 2009 and 31 December 2019 using the databases of the National Health Insurance Fund (NHIF) and Central Statistical Office (CSO) of Hungary. Age-standardized incidence and cause-specific mortality rates were calculated.

Results

We identified 2,426 and 2,414 new melanoma cases in 2011 and in 2019. Age-standardized incidence rates were higher in males and varied between 28.28 and 34.57/100,000 person-years (PYs), and between 22.63 and 26.72/100,000 PYs in females. We found 16.14 and 18.82% increases in male and female incidence rates from 2011 to 2015 (p=0.067 and p<0.001, respectively), and 12.77 and 11.35% decreases from 2015 to 2019 (p=0.062 and p=0.004, respectively). The change of incidence trends (2011–2015 vs. 2015–2019) was significant in females (p=0.002) and in the total melanoma population (p=0.011), but not in the male population (p=0.063). A 16.55% (95% CI: −27.07 to −4.59; p=0.013) decrease in mortality rates was found in the overall melanoma population.

Conclusions

We observed a significant trend change in melanoma incidence in the female and total melanoma population, and a significant decrease in mortality in the total melanoma population. These changes may be attributed to intensive melanoma awareness campaigns as well as to the increase in screening and access to modern therapies.

Early detection of melanoma in specialised primary care practice in Australia

BACKGROUND

Primary care skin cancer clinics facilitate early treatment of melanoma in Australia. We investigated the clinical and histopathological features of melanomas diagnosed and treated in an established clinic in Brisbane.

METHODS

Retrospective audit of medical records of patients diagnosed with in situ or invasive primary cutaneous melanoma in a primary care clinic specializing in skin cancer, 2000-2017. Demographic and clinical data were standardly extracted by a medically-trained investigator. We used descriptive analyses to assess characteristics of patients and melanomas, and examine surgical management according to tumour thickness.

RESULTS

Of 380 patients (median age 57 years; 57 % male) newly diagnosed with 497 histologically-confirmed primary cutaneous melanomas, 369 were in situ and 128 invasive. Of the 369 in situ melanomas, 143 (39 %) were on the trunk and 87 (24 %) on the head and neck; 247 (67 %) were diagnosed by shave biopsy; and 141 (38 %) referred for wide local excision (WLE). Of the 128 invasive melanomas, only 21 (16 %) had thickness ≥ 0.8 mm and these occurred more often on head and neck than thin invasive melanomas (p = 0.02). The majority of invasive melanomas were diagnosed by excision biopsy, and WLE was carried out in a median of 3 days (melanomas ≥ 0.8 mm) and 2 days (<0.8 mm). The doctor detected the majority of in situ (83 %) and thin invasive (73 %) melanomas during surveillance, compared with 48 % of thicker invasive melanomas ≥ 0.8 mm (p < 0.001).

CONCLUSION

In Australia, specialised primary care practice plays a major role in detection and treatment of early primary melanoma.

Sun-protective clothing and shade use in public outdoor leisure settings from 1992 to 2019: Results from cross-sectional observational surveys in Melbourne, Australia

Skin cancer presents a significant public health burden in Australia. The present study aimed to supplement population-based estimates of sun protection behaviour by examining setting-specific trends in directly observed sun protection in public outdoor leisure settings. Repeated cross-sectional observational surveys of adolescents and adults were conducted on summer weekends between 11 am and 3 pm from 1992 to 2002, 2006 to 2012, and 2018 to 2019 (N = 44,979) at pools/beaches and parks/gardens within 25 km of the centre of Melbourne, Victoria. The primary outcome was a binary index representing individuals having above or below the median level of body surface covered by hat, shirt, and leg garments in each setting type. The prevalence of above-median body coverage increased between 1992 and 2002 in both settings. At pools/beaches, a slight decline in above-median body coverage between 2006 and 2019 in males and females (adjusted odds ratio, AOR = 0.96 [0.94, 0.97]; 0.94 [0.93, 0.95]) appeared to be driven by a decline in leg coverage, while arm coverage, hat, sunglasses, and shade use remained stable. At parks/gardens, a decline in above-median body coverage between 2006 and 2019 (AOR = 0.90 [0.89, 0.91]; 0.94 [0.93, 0.95]) was accompanied by small declines across other protective behaviours that varied between males and females. Patterns in protective behaviours observed in outdoor leisure settings may reflect the changing composition of individuals choosing to remain outdoors during peak UV times and highlight the importance of continued promotion and monitoring of the use of multiple measures to protect against UV damage in Australia.

Testing Wearable UV Sensors to Improve Sun Protection in Young Adults at an Outdoor Festival: Field Study

Background

Australia and New Zealand have the highest skin cancer incidence rates worldwide, and sun exposure is the main risk factor for developing skin cancer. Sun exposure during childhood and adolescence is a critical factor in developing skin cancer later in life.

Objective

This study aims to test the effectiveness of wearable UV sensors to increase sun protection habits (SPH) and prevent sunburn in adolescents.

Methods

During the weeklong school leavers outdoor festival (November 2019) at the Gold Coast, Australia, registered attendees aged 15-19 years were recruited into the field study. Participants were provided with a wearable UV sensor and free sunscreen. The primary outcome was sun exposure practices using the SPH index. Secondary outcomes were self-reported sunburns, sunscreen use, and satisfaction with the wearable UV sensor.

Results

A total of 663 participants were enrolled in the study, and complete data were available for 188 participants (188/663, 28.4% response rate). Participants provided with a wearable UV sensor significantly improved their use of sunglasses (P=.004) and sunscreen use both on the face (P<.001) and on other parts of the body (P=.005). However, the use of long-sleeve shirts (P<.001) and the use of a hat (P<.001) decreased. During the study period, 31.4% (59/188) of the participants reported receiving one or more sunburns. Satisfaction with the wearable UV sensor was high, with 73.4% (138/188) of participants reporting the UV sensor was helpful to remind them to use sun protection.

Conclusions

Devices that target health behaviors when outdoors, such as wearable UV sensors, may improve use of sunscreen and sunglasses in adolescents.

Incidence and mortality for cutaneous squamous cell carcinoma: comparison across three continents

BACKGROUND

Population-based incidence and mortality studies of cutaneous squamous cell carcinoma (SCC) have been few owing to the commonness of the disease, and rare deaths making accurate mortality statistics difficult.

OBJECTIVES

Our aim was to summarize SCC incidence and mortality in populations across three continents, exemplified by Australia, the United States (US) and Germany.

METHODS

We estimated age-specific and age-standardized (Australian Standard 2001 Population) incidence and mortality rates per 100 000 person-years.

RESULTS

Squamous cell carcinoma incidence is plateauing or falling in Australia, stable in the United States (2013-2015) and rising in Germany (2007-2015). Current incidence estimates in men and women are 341 and 209, 497 and 296, and 54 and 26, respectively, for the three countries. Incidence increases strongly with age in all countries. Mortality of non-melanoma skin cancer appears to be increasing in Germany and stable in Australia (unavailable for the US population).

CONCLUSIONS

Squamous cell carcinoma is an important health issue, particularly among older men, with incidence exceeding most other cancers. More precise and uniform population-based studies of incidence and mortality are needed to better quantify the impact of SCC on healthcare systems worldwide and to gauge the effect of new treatments such as anti-PD1 therapy on mortality.

Melanoma Screening Days During the Coronavirus Disease 2019 (COVID-19) Pandemic: Strategies to Adopt

Melanoma is one of the most common cancers, with an increasing incidence worldwide. Disease stage represents the most important prognosis factor; therefore, early diagnosis is essential for melanoma patients' survival rates. Following the outbreak in China, the coronavirus disease 2019 (COVID-19) pandemic has spread all over the world and the majority of dermatological visits have been postponed. These measures could cause a delay in melanoma diagnosis and management leading to an increase of morbidity, mortality and healthcare costs. Herein we propose an alternative model of skin cancer screening and the organization of screening campaigns in order to detect malignant lesions early during this emergency period.

Awareness about proper use of sunscreen in people of color: A Jordanian-based survey

INTRODUCTION

The use of sunscreen is an important preventive measure against skin cancer and treatment for other skin conditions. There is evidence pointing to lack awareness and misconceptions regarding use of Sunscreen. This is especially evident in populations with skin of color (POC).

METHODS

This is a cross-sectional study of 2000 individuals. A structured questionnaire was designed to collect data on general knowledge and use of sunscreen as well as reasons for stopping use of sunscreen.

RESULTS

The results of this study indicate a clear deficiency in the use and knowledge about sunscreen among Jordanians. Females are using sunscreen more than males. However, the use of sunscreen is inadequate in many aspects including timing of application, frequency of use, and amount used among other things. There is an obvious lack of knowledge about sunscreen as shown by lack of awareness about benefits of use in various times of the year, use in children, use for all skin types, and several misconceptions among other knowledge gaps. Main reasons for stopping sunscreen include side effects, cost, and being not suitable for skin. Awareness about sunscreen can be improved by proper counseling by healthcare professionals and utilization of various media platforms.

CONCLUSIONS

The use of sunscreen is inadequate in this population of color (POC). Lack of proper counseling, failure to read use instructions can contibute to inadequate use of sunscreen. Risks and benefits of sunscreen should be explained by medical professionals. The media should be more utilized to disseminate such knowledge.

Trends in malignant melanoma mortality in 31 countries from 1985 to 2015

BACKGROUND

Malignant melanoma (MM) causes the highest absolute number of deaths among skin cancers. An up-to-date analysis of international MM mortality trends is required for assessing the burden of disease, and may support the assessment of the effectiveness of new diagnostic, therapeutic and preventative strategies.

OBJECTIVES

To report MM mortality trends between 1985 and 2015 using the World Health Organization (WHO) Mortality Database.

MATERIALS AND METHODS

We used country-level MM mortality data from the WHO Mortality Database for all countries with high usability death registration data. Mortality trends were described using Joinpoint regression modelling.

RESULTS

Thirty-one countries met the inclusion criteria. All countries, except the Czech Republic, demonstrated increased age-standardized death rates (ASDRs) in males over the observation period. More countries exhibited decreased or stable MM mortality in females. The median mortality rate for 2013-2015 was 2·57 deaths per 100 000 for males and 1·55 per 100 000 for females. Australia and Norway had the highest ASDRs for males (5·72 per 100 000 and 4·55 per 100 000, respectively). Norway and Slovenia had the highest ASDRs for females (3·02 per 100 000 and 2·58 per 100 000, respectively). MM mortality was greater for males than females in all countries, with sex disparity increasing across the period. Disparity in mortality between older and younger cohorts in several countries was also found.

CONCLUSIONS

An overall increase in MM mortality over the past 30 years was observed. However, there was notable variation in mortality trends between countries, as well as between males and females, and between different age groups.

A decade of sun protection in Australian early-childhood services: analysis of cross-sectional and repeated-measures data

Limiting ultraviolet radiation exposure during early childhood can significantly reduce the risk of developing skin cancer, making early childhood a critical time for sun protection strategies. This study aimed to measure sun protection practices utilized in Australian early-childhood services over the past decade and evaluate the impact of Cancer Council Australia's SunSmart Early-Childhood Program. Results are presented from cross-sectional and repeated-measures survey data, completed by directors or other staff at randomly sampled early-childhood services in 2008, 2013 and 2018 (N�=�3243). Most sun protection practices were used by a significantly greater proportion of services in 2018 relative to earlier years, such as requiring the use of sunscreen (98.4%), and sun-protective hats (99.7%) and clothing (88.8%). However, only a small and declining proportion of services (16.3%-22.4%) required the use of specific items of sun-protective clothing. SunSmart program members reported enacting significantly more sun protection practices compared to non-members, while new members showed an increase in the use of those practices relative to services whose status did not change (d�=�0.48). The results demonstrate improvements in sun protection in Australian early-childhood settings, and highlight the benefits and limitations of the SunSmart program.

Public Health and Online Misinformation: Challenges and Recommendations

The internet has become a popular resource to learn about health and to investigate one's own health condition. However, given the large amount of inaccurate information online, people can easily become misinformed. Individuals have always obtained information from outside the formal health care system, so how has the internet changed people's engagement with health information? This review explores how individuals interact with health misinformation online, whether it be through search, user-generated content, or mobile apps. We discuss whether personal access to information is helping or hindering health outcomes and how the perceived trustworthiness of the institutions communicating health has changed over time. To conclude, we propose several constructive strategies for improving the online information ecosystem. Misinformation concerning health has particularly severe consequences with regard to people's quality of life and even their risk of mortality; therefore, understanding it within today's modern context is an extremely important task.