Skin Cancer Prevention and Early Diagnosis

Skin cancer is the fastest growing cancer in the UK, and accounts for one third of all new cancers. Incidence rates in England have quadrupled in the last thirty years, and increased by approximately 30% over the last five years. NHS Devon has the fourth highest malignant melanoma incidence rates of all PCTs in England, after Plymouth Teaching, Oxfordshire PCT and Torbay Care Trust.

Skin cancer is caused by overexposure to ultraviolet rays, and around 80% of cases could be prevented through the adoption of safe sun behaviours, from childhood through to adulthood.

Over 95% of skin cancer can be cured if treated early enough. A clear skin cancer pathway already exists within Devon with urgent GP referrals being seen within two weeks by a hospital specialist, and routine referrals being seen within the national 18 week target. Prevention and early diagnosis will reduce hospital episodes and early death. The biggest opportunity to improve early diagnosis is for patients to know the sign and symptoms of skin cancer, to check their skin regularly and for them to see their GP as soon as they notice anything suspicious. Early diagnosis can save lives in Devon.

What are the needs of the population?

Risk factors

Exposure to ultraviolet light through sunlight and sunbeds

The biggest risk factor is the amount of exposure to ultraviolet light over an individual’s lifetime, but intermittent strong exposure has been shown to be more damaging than moderate long-term exposure. A painful sunburn once every two years can triple the risk of skin cancer.

Sunbeds are another source of ultraviolet radiation. Sunbed use under the age of 35 can increase the risk of skin cancer by 75%. Sunbed related burning is relatively common but even for users who never burn, the risk is increased by 59%. Devon as a whole has relatively few sunbeds, but Exeter, Teignbridge and Torbay have 10-15 each (sunbed salon turnover is high so numbers change regularly). On April 8th 2011 legislation was introduced to make it illegal for under 18s to use sunbeds.

Devon has 1501 hours of sunshine per year compared to the national average of 1420.

Skin type

People with fair skin that burns easily, red or blonde hair, lots of freckles, moles, a history of sunburn, a family/personal history of skin cancer or those with immunosuppressive disorders are most at risk. However, people with dark skin can still get skin cancer, and may be at more risk of dying from the disease, as presentation and diagnosis may be delayed.

97% of Devon’s population are of white ethnicity, compared to the national average of 88%.

Age

Skin cancer incidence and mortality increases with age. However, rates of malignant melanoma are disproportionately high in people aged 50 and under, and skin cancer is now the second most common cancer in 15-34 year olds.

11.9% of Devon’s population are aged over 75, compared to the national average of 8.4%.

Number of teenagers and young adults in Devon: 15-19 years – 47,865 and 20-24 years – 43,519 (total: 91,384)

Deprivation

Nationally, there is evidence to suggest that incidence rates of skin cancer are linked to affluence, which would seem to be backed up locally by the fact that Devon’s average score on the Index of Multiple Deprivation is 17.5 compared to the national average of 21.6. However, Plymouth scores at 26.3 and Torbay at 26.2, yet they have the 1st and 2nd highest incidence rates of malignant melanoma in the country, so locally it is difficult to make a causal link between affluence and incidence rates. In addition, nationally deprivation is linked to higher mortality from skin cancer, and sunbed outlets are more likely to be located in deprived areas.

Nationally, an individual is more likely to get skin cancer if they are affluent, but more likely to die from it if they are from a deprived background.

Target groups for information provision based on knowledge, attitude and behaviour, as identified by the South West Public Health Observatory:

Mothers of young children and childcare providers
Parents of school aged children
Teenagers
Outdoor workers
Sports and leisure participants and spectators

To maximise resources Devon is targeting key at risk groups:

Teenagers – emphasis on prevention
Over 50s – emphasis on early diagnosis

Teenagers – behavioural insights

they have the lowest skin protection rate of any age group
knowledge of potential dangers of excessive sun exposure does not always result in sun protection-related behaviours
there is the perception that a tan is ‘sexy’, increasing perceived attractiveness and raising self-esteem
they believe it is ‘worth’ getting sunburnt in order to get a tan and that less protection is needed as a tan progresses

Over 50s – behavioural insights

seeking medical advice for bodily changes is the exception, rather than the norm
individuals diagnosed with cancer often do not realise the seriousness or significance of their bodily changes prior to consultation/diagnosis
fear of a cancer diagnosis can delay help-seeking behaviour
seeking professional help is not straightforward: there are many factors across a number of levels which can influence an individual seeking help, such as attitudes, beliefs and social context

Malignant melanoma

Malignant melanoma is the least common form of skin cancer, but accounts for approximately 75% of deaths. Between 2006 and 2008 there were on average 250 cases of malignant melanoma per year and 40 related deaths in Devon.

Numbers of deaths at local authority level are too small to make any meaningful interpretation but Devon as a whole has a higher rate than England (locally 3.2 per 100,000 direct age-standardised rates compared to 2.6 nationally).

Incidence of Malignant Melanoma (Direct Age-Standardised Rate per 100,000), 2006-08

Non-melanoma skin cancer

Non-melanoma skin cancers consist of basal cell carcinoma and squamous cell carcinoma. They are less likely to result in death than malignant melanoma but affect the lives of many more people. Between 2004 and 2006 there were on average 2065 cases of non-melanoma skin cancers per year and 9 related deaths. It should be noted that unlike data on other cancers, registration data for non-melanoma is incomplete, and the number of cases reported both locally and nationally is likely to be an underestimate.

Incidence of skin cancers other than malignant melanoma (direct age-standardised rate per 100,000), 2006-08.JPG

Incidence of Skin Cancer Other Than Malignant Melanoma (Direct Age-Standardised Rate per 100,000), 2006-08

Numbers of deaths from non-melanoma skin cancers at local authority level are too small to make any meaningful interpretation.

Costs of skin cancer

The consequences of skin cancer are serious and often underestimated; even if the diagnosis does not lead to death, it is likely to require life-changing and disfiguring surgery. Nationally, skin cancer typically accounts for 30% of a consultant dermatologist’s workload and one-third of all plastic surgery on the NHS. The mean cost to the NHS of diagnosing and treating skin cancer is estimated to range from £2179 per registration of malignant melanoma to £1149 per registration of non-melanomas http://guidance.nice.org.uk/PH32.

Risk Pyramid

Risk pyramids illustrate the number of events per annum across Devon. This is intended to illustrate both the scale of the issue, and the distribution of different health-related outcomes and behaviours.

Risk Pyramid for Skin Cancer (based on 2008 data)

For further information refer to the Devon Skin Cancer Prevention Strategy.

What works?

NICE guidance on ‘Skin cancer prevention: information, resources and environmental changes’ was released in January 2011. Six recommendations are included in the draft guidance: Recommendations 1 and 2 cover national and local information provision to raise awareness and increase knowledge; Recommendation 3 highlights the importance of message development; Recommendation 4 focuses on the content of information; Recommendation 5 focuses on key segments – children, young people and outdoor workers by developing workforce policies (utilising Recommendations 1 and 2) and Recommendation 6 covers structures to provide shade as part of the initial design of new buildings.

Awareness raising is identified as an important first step in the process of behaviour change, but it does not guarantee behaviour change. Any awareness raising or information provision must be targeted and tailored to the target audience, and informed by insight about that population segment. Interventions should cover a range of methods encompassing support, education, design and control.

In 2010 the Peninsula Cancer Network worked collaboratively with Forster, a social marketing company, to engage stakeholders across the network and the resulting report informed the development of the local strategy. http://www.swpho.nhs.uk/skincancerhub/resource/item.aspx?RID=51735

Teenagers

Changing perceptions towards the attractiveness of a tan is extremely difficult and outside the scope of the strategy. The focus will be on encouraging teenagers to ‘know the skin they’re in’, to avoid burning, and to seek safe alternatives such as using fake tan. Interventions and messages should appeal to appearance rather than just health concerns.

Over 50s

Early diagnosis has been identified as a important part of improving cancer survival rates in the UK and bringing them up to the European average (Improving outcomes: a strategy for cancer http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123371). There is currently no national screening programme for skin cancer as it is not considered cost-effective. Early diagnosis must therefore be achieved by patients checking their skin regularly for signs of changes, and visiting their GP without delay if they notice anything. The five-year survival rate for melanoma if treated at Stage I is 97%, compared to 90% for breast cancer and 42% for lung cancer (How to improve cancer survival, The Kings Fund, 2011). http://www.kingsfund.org.uk/publications/cancer_survival.html

What is currently being done in Devon?

NHS Devon has coordinated a partnership approach to working in Devon, resulting in the production of the Devon Skin Cancer Prevention Strategy 2011-14. A steering group, accountable to the Health and Wellbeing Board, is responsible for planning and delivering the action plan.

Teenagers – behavioural goals

teenagers avoid burning by adopting safe sun habits
teenagers who want to tan choose safer alternatives such as using fake tan
teenagers recognise and act according to their individual skin type
under 18s cease to use sunbeds under new legislation

Over 50s – behavioural goal

over 50s check their skin regularly and seek appropriate medical advice and treatment if they notice any abnormal changes

Strategic approach

adopt a partnership approach to ensure skin cancer prevention is embedded in local policy and practice
identify opportunities to raise awareness at key trigger points using insights and key messages
use a mix of interventions which cover “Educate, Design, Support, Control” as recommended by the National Social Marketing Centre

For further information on current and planned activities in Devon refer to the Devon Skin Cancer Prevention Strategy.

Recommendations for commissioning

Commission an intervention targeting teenagers based on social marketing insights and evidence base
Commission a targeted early diagnosis awareness raising programme through local community stakeholders such as community pharmacies
Commission the ongoing coordination across partners of consistent awareness raising, messages and quality assurance