Applying the Australian Experience in Skin Cancer Control

1
Applying the Australian Experience in Skin Cancer
Control

• Craig Sinclair
• Director Cancer Education Unit,
• The Cancer Council Victoria
• Chair, National Skin Cancer Committee
• The Cancer Council Australia
• Head, WHO Collaborative Centre for the Promotion
  of Sun Protection

2
Presentation Overview

• Where have we come from
• How did we face the challenge
• What have we learnt as applicable to Ireland
• What are the key emerging issues

3
1982
4
Behaviour change
5
Melanoma incidence and mortality trends Australia
1982-2000
Source Cancer Epidemiology Centre 2004
6
Comparative world age-standardised rates for
malignant melanoma
7
The Human Financial Costs of Skin Cancer in
Australia

• In 2002, 374,000 Australians had a skin cancer
  removed. Pop 20m (NCCI, 2003)
• Most expensive burden on the health system of
  all cancers.
• Direct cost of treatment... 9.70 per
  head p.a

• Cost of prevention campaigns... 0.14 per
  head p.a
• Carter R, Marks R, Hill D

8
How did we face the challenge
9
Slip!Slop!Slap!

• Started with the Anti-Cancer Council of Victoria
  in 1980
• Budget was approximately 50K
• SunSmart commenced in 1988 as a community-wide
  intervention

10
SCHOOLS
COMMUNITY

• Local Government
• General Practitioners
• Community HealthCentres
• Recreation Settings
• Workplaces(OHS)

• Pre-School
• Child Care Centres
• Primary Schools
• Secondary Schools
• Tertiary

MEDIA

• Unpaid public relations
• Paid advertising

RESEARCH
11
SunSmarts Strategic Framework

• To build a solid funding base
• To build community capacity
• Transfer of knowledge through research
• Provision of support resources
• Facilitation of key partnerships across sectors
• Skills training
• To advocate for environmental change
• To lead and share knowledge

12
The Cancer Council Victorias Model for Program
Delivery
Centre for Behavioural Research in Cancer
Cancer Epidemiology Unit
SunSmart Quit PapScreen Victoria
13
Schools
14
Schematic diagram of changes in sun protection
with age
50 yrs
n
30-49 yrs
20-29 yrs
n
14-19 yrs
n
n
Schofield et al 1993 (NSW)
Dixon et al 1997 (Vic)

Broadstock et al 1996 (Vic)
n
Hill et al 1993 (Vic)
3
-
4
5

-

1
1
1
2

-

1
7
1
4

p
l
u
s
a
g
e
/
y
r
s
15
SunSmart Schools
A SunSmart School must have

• an approved sun protection policy
• no hat, play in the shade practice
• sun protection taught at every level
• sufficient shade in the school

16
Impact on our schools

• 2004 - 79 of all Victorian primary schools
  are SunSmart Schools

17
Impact on our beaches
18
Community
19
Impact on Local Government Authorities

• By 2001
• 45 - sun protection policy in their Public
  Health Plans, compared to 37 in 1998
• 76 - sun protection policy for outdoor staff,
  compared to 29 1990

20
VIC swimming pools

• In 2001 53 of LGA outdoor swimming pools have
  shade over wading pools compared to
• 43 in 1998 and
• 20 in 1993
• Revised baseline due to 96 LGA restructure

21
Legislative Changes

• Federal Court Decision that allows outdoor
  workers to claim for sun protective gear lt85pa
• Definition of outdoor workers redefined to
  include many white collar workers
• Sunscreens tax exempt
• Restrictions applied to sunbeds operators

22
Media

23
Paid television advertising

• 1982 - Slip! Slop! Slap!
• 1990 - Leave Your Hat On
• 1997 - How to Remove a Skin Cancer
• 2000 - Timebomb
• 2004 - Tattoo

24
(No Transcript)
25
Preference to not want to tan
26
Why are we seeing stronger pro-tan beliefs?

• Limited investment in media campaign
• Significant growth in sunbed operators
• Changing fashion trends

27
Decline in summer weekend sunburn - Victoria
1.0
Baseline year
Odds ratio adjusted for UVR temperature month
sex age skin type
SunSmart years
28
Basal cell carcinoma - changes in Australian
incidence 1985-1995

Percent change in BCC rates 1985-1995
29
What we did learn?
30
Health Promotion
Education
Advocacy
Social and cultural norms
Political processes
Knowledge, attitudes, intentions of individuals
Environmental and legislative change
Health behaviour change
Health Gain
Figure 1. A schematic diagram of the main
routes of influence of a comprehensive health
promotion program
31
Summary of the Evidence for Schools Programs

• In order to best influence children's behaviour,
  school-based strategies need to take into account
  the broader physical and social environment
  because while schools provide a good foundation,
  they are limited in scope.
• therefore ...

32
Summary of the Evidence for Schools Programs

• Community-wide interventions of the adult
  population, in conjunction with school based
  policy, curriculum and practice implementation,
  should be the initial primary strategy.
• Buller and Borland (Health Educ Behav. 1999
  26(3)317-343)

33
Summary of Evidence - sport

• At the sporting club level, progress made in
  implementing strategies for minimising the
  effects of exposure to UV in sunlight would
  likely not have occurred without community support

..
34
Our success can be mostly attributed to.

• Montague, Borland Sinclair (2001)
• broad multi-faceted intervention program
• history of mass media underpinning program
• having access to adequate consistent resources
• growing out of a strong home base
• integration of research and evaluation into
  program planning

35
The Emerging Issues

• Balancing the risks and benefits of sun exposure
• Growth in the number of Sunbeds

36
Vitamin D and its link to other known conditions

• Likely beneficial for reducing the risk of
  osteoporosis
• Some studies have shown beneficial effects of sun
  exposure related to non Hodgkin lymphoma and
  multiple sclerosis.
• NHL possible link, however only limited studies
  and the biological pathways are unclear.
• MS again possible, however the biological
  pathways are unclear and it is not known how much
  sun exposure is necessary.

37
How can the message be complementary?

• Vitamin D deficiency is largely confined to
  months when the sun protection message should not
  be relevant
• In some studies, gtobesity levels gt risk of
  deficiency
• When UVI is in the moderate to extreme range, sun
  protection will not reduce Vitamin D levels.

38
How can the message be complementary?

• Ensure the sun protection message is relevant to
  when the UVI is gt3
• Greater reliance on the UV Index to guide
  behaviour
• Refrain from messages that relate to stay
  indoors
• Acknowledge both known benefits and detrimental
  effects of sun exposure

39
Global Solar UV Index
40
UV index
Belfast 54o
41
Sunbed issues

• Some sunbeds emit levels x5 the strength of the
  midday sun UVI 60
• Output levels vary considerably (study in the UK
  found up to a 60 fold difference). Autier
• Where there are regulations, could result in
  false sense of security, particularly in relation
  to outputs
• Enforcement/compliance checking generally poor

42
Sunbed issues

• Self regulation appears to not work
• Fail to measure skin types
• Fail to control age access
• Fail to notify clients of risks
• Unsupervised sunbeds continue to grow

43
WHO Guidelines www.who.int/uv

• Provides Guidance for governments to
• Restrict age lt18
• Warning notices
• Client consent forms
• Skin type 1 exclusion
• Operator Training Supervision
• No claims of health benefit
• Maximum repeat exposure
• Compulsory eyewear
• Maximum Exposure Times
• Banning of unsupervised establishments

44
Way Forward

• Focus on restricting access to minors,
  suggest lt18
• Ban unsupervised sunbeds
• Improve current
  evidence base

45
Craig.Sinclair_at_cancervic.org.au