Economic evaluation of skin cancer prevention in Australia

Objectives
Australia has the highest incidence of skin cancer in the world, despite prevention campaigns being implemented since the early 1980s. This study assesses the cost-effectiveness of a skin cancer prevention program (named SunSmart) since it was introduced, together with its potential cost-effectiveness as an upgraded and ongoing national program.

Methods
The reduction in melanoma incidence attributable to SunSmart was modelled as the primary end-point. Historical expenditures on SunSmart were obtained from representative Australian states in three latitude zones. Melanoma incidence rates from these states were used to model key health outcomes. Non-melanoma skin cancer was modelled separately based on national survey results.

Results
We estimate that SunSmart has averted 28,000 disability-adjusted life-years (DALYs), equivalent to 22,000 life-years saved, in the state of Victoria since its introduction in 1988, as well as saving money from cost offset in skin cancer management (dominant). An upgraded national program for the next 20 years is estimated to avert 120,000 DALYs, with associated reductions in the use of health care resources. It remains a dominant intervention in which every dollar invested in SunSmart will return an estimated AU$2.30.

Conclusions
This study demonstrates that a sustained modest investment in skin cancer control is likely to be an excellent value for money.

Economic evaluation of a skin cancer prevention program in Australia : past achievements and future prospects

Objectives
Australia has the highest incidence of skin cancer in the world. Skin cancer prevention campaigns have been implemented in Australia for over two decades. The most notable is under the brand name, SunSmart. The aim of the current study is to assess the cost-effectiveness of SunSmart in the past and the potential cost-effectiveness of an ongoing national SunSmart program with optimal investment in the future.

Methods
An economic evaluation from a health sector perspective was conducted using the reduction in skin cancer incidence attributable to the SunSmart program modelled as the primary end-point. Historical SunSmart program expenditures were obtained from three representative states in three latitude zones, covering different levels of UVR exposure. Melanoma incidence rates from the three representative state cancer registers were used to model the health outcomes. Program effectiveness was assessed by the comparison between the well-resourced SunSmart state (Victoria) and the under-invested states (New South Wales and Queensland). Non-Melanoma Skin Cancer (NMSC) was modelled based on national survey results. 2003 was chosen as the reference year and future costs/outcomes over a 20 year time horizon were discounted at 3%.
The future level of investment in a national SunSmart was chosen to strengthen current practice by increasing current investment to a realistic and achievable level. This conservative increase in investment (expressed as ‘$ per capita’) reflected the investment level that has been achieved in Victoria over sustained periods. To model the potential cost-effectiveness of an upgraded national SunSmart program, a conservative approach was taken, whereby the same magnitude of effectiveness from 1988 to 2003 was applied to future skin cancer incidence.

Results
SunSmart in Victoria has saved 22,300 life-years, averted 27,900 disability-adjusted life-years(DALYs)(discounted) since its introduction in 1988 and achieved an incremental cost-effectiveness ratio (ICER) of $AUD 680 per life-year saved (LYS) and $AUD 540 per DALY averted. When the cost-offset from the estimated reduction in skin cancer treatment costs were taken into account, SunSmart achieved ‘dominance’. The net cost of SunSmart in the past was an estimated saving of $AUD 93 million. An upgraded national SunSmart for the next 20 years would save 91,000 life-years and avert 122,000 DALYs (discounted), involving an increased investment level from the current $AUD 0.07 per capita to the historical average of $AUD 0.28 per capita. The ICER for the upgraded SunSmart program was estimated at $AUD 940 per LYS and $AUD 700 per DALY averted. When the cost-offset is included, the program achieves dominance with a cost saving of $AUD 115 million – an estimated $AUD 2.32 return for every dollar invested between 2003 and 2022.

Conclusions
This study demonstrates that a sustained modest investment in skin cancer control is likely to be excellent value-for-money. While the available data base is certainly not prefect, key parameters would have to change dramatically for this conclusion to be challenged.

A critical analysis of screening for skin cancer: participation among older males

 This thesis was a critical examination of participation in skin cancer screening for men over the age of 50 years. This research explored subjective experiences of skin cancer screening, participation in the process, perceptions of skin cancer and factors that influence men’s willingness to undergo skin cancer screening.

Role of dietary factors in the development of basal cell cancer and squamous cell cancer of the skin

The role of dietary factors in the development of skin cancer has been investigated for many years; however, the results of epidemiologic studies have not been systematically reviewed. This article reviews human studies of basal cell cancer (BCC) and squamous cell cancer (SCC) and includes all studies identified in the published scientific literature investigating dietary exposure to fats, retinol, carotenoids, vitamin E, vitamin C, and selenium. A total of 26 studies were critically reviewed according to study design and quality of the epidemiologic evidence. Overall, the evidence suggests a positive relationship between fat intake and BCC and SCC, an inconsistent association for retinol, and little relation between ß-carotene and BCC or SCC development. There is insufficient evidence on which to make a judgment about an association of other carotenoids with skin cancer. The evidence for associations between vitamin E, vitamin C, and selenium and both BCC and SCC is weak. Many of the existing studies contain limitations, however, and further well-designed and implemented studies are required to clarify the role of diet in skin cancer. Additionally, the role of other dietary factors, such as flavonoids and other polyphenols, which have been implicated in skin cancer development in animal models, needs to be investigated.

Antioxidants and basal cell carcinoma of the skin : a nested case-control study

Objective To investigate the relationship between basal cell carcinoma (BCC) and antioxidant nutrients, specifically carotenoids, vitamin E and selenium.

Methods The Nambour Skin Cancer Study is an ongoing, community-based study of randomly selected adult residents of a township in sub-tropical Queensland, Australia. Using a nested case–control design, incident cases of BCC (n=90) were compared with age and sex matched controls (n=90). Dietary exposure was measured using food frequency questionnaire estimates of intake as well as serum biomarkers. Other determinants of skin cancer including sun exposure were also considered. Dietary intakes were adjusted for energy intake, and serum carotenoids and vitamin E were adjusted for serum cholesterol. Odds ratios were calculated across quartiles of dietary intake and serum biomarkers and linear trends were assessed using logistic regression, adjusting for age, sex and supplement use.

Results and conclusions In this prospective study no significant associations were found between BCC and carotenoids, vitamin E or selenium, as measured by serum biomarkers or dietary intake, although there was a suggestion of a positive association with lutein intake.

Frequency of excisions and yields of malignant skin tumors in a population-based screening intervention of 360 288 whole-body examinations

Objective To explore the frequency of excisions and yields of histopathologically confirmed skin cancer.

Design A population-based skin cancer screening intervention (the SCREEN project) in the German state of Schleswig-Holstein (July 1, 2003, to June 30, 2004).

Setting Physician offices. Participants could choose between nondermatologist physicians and dermatologists for their initial whole-body skin examination. All screening physicians received a mandatory 8-hour training course.

Participants Inhabitants of Schleswig-Holstein 20 years or older with statutory health insurance (N = 360 288).

Main Outcome Measures Frequency of excisions and yields of malignant skin tumors (malignant melanomas [MMs], basal cell carcinomas [BCCs], and squamous cell carcinomas [SCCs]), stratified by sex and age.

Results Overall, 15 983 excisions were performed (1 of 23 screenees). A total of 3103 malignant skin tumors were diagnosed in 2911 persons: 585 MMs, 1961 BCCs, 392 SCCs, and 165 other malignant skin tumors. Overall, 116 persons (3103 of 360 288) had to be screened to find 1 malignant tumor, with 1 of 620 for MM, 1 of 184 for BCC, and 1 of 920 for SCC. Twenty excisions were performed to find 1 melanoma in men 65 years and older, but more than 50 excisions were required to find 1 melanoma in men aged between 20 and 49 years.

Conclusions The results of SCREEN suggest a high yield of malignant skin tumors in a large-scale population-based screening project. We found that a high number of excisions was performed in the youngest screenees with an associated low yield, suggesting a need in screener training to emphasize a more conservative attitude toward excisions in young screenees.

Is optimistic bias influenced by control or delay?

Optimistic bias is a commonly observed but poorly explained phenomenon. Our aim was to determine whether optimistic bias varied according to the nature of the event. Two event characteristics were explored: control and delay. A sample of 100 participants aged 18–30 years was randomly selected from the local residential telephone directory. Respondents were interviewed over the telephone. The highly structured interview schedule assessed respondents' perceptions of their own risk, and the risk of an average person of their age and sex for experiencing four negative life events: developing skin cancer, being involved in a serious car accident as the driver, being involved in a serious car accident as a passenger and having to wear a hearing aid. It also assessed respondents' perceptions of control and delay for each event. Data analysis using a repeated-measures MANOVA showed that optimistic bias occurred for all four events. Optimistic bias was significantly greater for the two events high in control (skin cancer and accident as the driver) than for those low in control (accident as a passenger and hearing aid). Delay was not related to the magnitude of optimistic bias. These findings have implications for health promotion campaigns and self-protective behaviors.

Vitamin D intake and vitamin D status of Australians

The main source of vitamin D for Australians is exposure to sunlight. Thus, levels of serum 25-hydroxyvitamin D3, the indicator of vitamin D status, vary according to the season and are lower at the end of winter.

In Australia and New Zealand, the prevalence of vitamin D deficiency varies, but is acknowledged to be much higher than previously thought. One study found marginal deficiency in 23% of women, and another frank deficiency in 80% of dark-skinned and veiled women. The groups at greatest risk of vitamin D deficiency in Australia are dark-skinned and veiled women (particularly in pregnancy), their infants, and older persons living in residential care.

Only a few foods (eg, fish with a high fat content) contain significant amounts of vitamin D. In Australia, margarine and some milk and milk products are currently fortified with vitamin D.

The average estimated dietary intake of vitamin D for men is 2.6–3.0 µg/day and for women is 2.0–2.2 µg/day. The estimated dietary requirement of vitamin D is at least 5.0 µg/day and may be higher for older people.

Adequate intake of vitamin D is unlikely to be achieved through dietary means, particularly in the groups at greatest risk, although vitamin D-fortified foods may assist in maintaining vitamin D status in the general population.

An appropriate health message for vitamin D needs to balance the need for sunshine against the risk of skin cancer.

Arsenic contamination in Bangladesh groundwater: a major environmental and social disaster

In attempting to eliminate disease caused by drinking polluted surface water, millions of shallow surface wells were drilled into the Ganges delta alluvium in Bangladesh. The latest statistics indicate that 80% of Bangladesh and an estimated 40 million people are at risk of arsenic poisoning-related diseases because the ground water in these wells is contaminated with arsenic. The clinical manifestations of arsenic poisoning are myriad, and the correct diagnosis depends largely on awareness of the problem. Patients with melanosis, leuco-melanosis, keratosis, hyperkeratosis, dorsum, non-petting edema, gangrene and skin cancer have been identified. The present article reviews the current arsenic contamination of ground water, hydrological systems, groundwater potential and utilization and environmental pollution in Bangladesh. This paper concludes by clarifying the main actions required to ensure the sustainable development of water resources in Bangladesh