Interventions to decrease skin cancer risk in outdoor workers : update to a 2007 systematic review

BACKGROUND: Outdoor workers are at high risk of harmful ultraviolet radiation exposure and are identified as an at risk group for the development of skin cancer. This systematic evidence based review provides an update to a previous review published in 2007 about interventions for the prevention of skin cancer in outdoor workers. RESULTS: This review includes interventions published between 2007-2012 and presents findings about sun protection behaviours and/or objective measures of skin cancer risk. Six papers met inclusion criteria and were included in the review. Large studies with extended follow-up times demonstrated the efficacy of educational and multi-component interventions to increase sun protection, with some higher use of personal protective equipment such as sunscreen. However, there is less evidence for the effectiveness of policy or specific intervention components. CONCLUSIONS: Further research aimed at improving overall attitudes towards sun protection in outdoor workers is needed to provide an overarching framework.

Educational programmes for primary prevention of skin cancer (Protocol)

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of education programmes for skin cancer prevention in the general population. Description of the condition Skin cancer is a term that includes both melanoma and keratinocyte cancer. Keratinocyte cancer (also known as nonmelanoma skin cancer) generally refers to basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), although it also includes other rare cutaneous neoplasms (Madan 2010). Skin cancer is the most common cancer in populations of predominantly fair-skinned people (Donaldson 2011; Lomas 2012; Stern 2010), with incidence increasing (Garbe 2009; Leiter 2012). There are variations in annual incidence rates between these populations, with Australia reporting the highest rate of skin cancer in the world (Lomas 2012). In 2012, the estimated age-standardised incidence rate for melanoma was almost 63 per 100,000 people for Australian men, and 40 per 100,000 people for Australian women (AIHW 2012). In Europe, incidence rates range from 10 to 15 per 100,000 people (Garbe 2009; Lasithiotakis 2006), with rates highest amongst men (Stang 2006). In the United States, incidence rates are approximately 18 per 100,000 people (Garbe 2009),with the highest rates reported forwomen (Bradford 2010). Keratinocyte cancer is much more common than melanoma. In 2012, the estimated Australian age-standardised rates for BCCand SCC were 884 and 387 per 100,000 people, respectively (Staples 2006). The cumulative three-year risk of developing a subsequent keratinocyte cancer is 18% for SCC and 44% for BCC (Marcil 2000).

Can skin cancer prevention and early detection be improved via mobile phone text messaging? a randomised, attention-control trial.

Objective. To test the impact of a theory-based, SMS (text message)-delivered behavioural intervention (Healthy Text) targeting sun protection or skin self-examination behaviours compared to attention-control. Method. Overall, 546 participants aged 18–42 years were randomised using a computer-generated number list to the skin self-examination (N = 176), sun protection (N = 187), or attention-control (N = 183) text messages group. Each group received 21 text messages about their assigned topic over 12 months (12 weekly messages for three months, then monthly messages for the next nine months). Data was collected via telephone survey at baseline, three-, and 12-months across Queensland from January 2012 to August 2013. Results. One year after baseline, the sun protection (mean change 0.12; P = 0.030) and skin self-examination groups (mean change 0.12; P = 0.035) had significantly greater improvement in their sun protection habits (SPH) index compared to the attention-control group (reference mean change 0.02). The increase in the proportion of participants who reported any skin self-examination from baseline to 12 months was significantly greater in the skin self-examination intervention group (103/163; 63%; P < 0.001) than the sun protection (83/173; 48%), or attention-control (65/165; 36%) groups. There was no significant effect of the intervention for participants who self-reported whole-body skin self-examination, sun tanning behaviour, or sunburn behaviours. Conclusion. The Healthy Text intervention was effective in inducing significant improvements in sun protection and any type of skin self-examination behaviours.

User preferences for text message-delivered skin cancer prevention and early detection

Evidence is needed for the acceptability and user preferences of receiving skin cancer-related text messages. We prepared 27 questions to evaluate attitudes, satisfaction with program characteristics such as timing and spacing, and overall satisfaction with the Healthy Text program in young adults. Within this randomised controlled trial (age 18-42 years), 546 participants were assigned to one of three Healthy Text message groups; sun protection, skin self-examination, or attention-control. Over a 12-month period, 21 behaviour-specific text messages were sent to each group. Participants’ preferences were compared between the two interventions and control group at the 12-month follow-up telephone interview. In all three groups, participants reported the messages were easy to understand (98%), provided good suggestions or ideas (88%), and were encouraging (86%) and informative (85%) with little difference between the groups. The timing of the texts was received positively (92%); however, some suggestions for frequency or time of day the messages were received from 8% of participants. Participants in the two intervention groups found their messages more informative, and triggering behaviour change compared to control. Text messages about skin cancer prevention and early detection are novel and acceptable to induce behaviour change in young adults.

Redefining dermatologists’ role in skin cancer early detection and follow-up care

Early diagnosis of melanoma leads to the best prognosis for patients and may be more likely achieved when those who are at high risk for melanoma undergo regular and systematic monitoring. However, many people rarely or never see a dermatologist. Risk prediction models (recently reviewed by Usher-Smith et al ) could assist to triage people into preventive care appropriate for their risk profile. Most risk prediction models contain measures of phenotype including skin, eye and hair colour as well as genetic mutations. Almost all also contain the number and size of naevi, as well as the presence of naevi with atypical features which are independently associated with melanoma risk. In the absence of formal population-based screening programs for melanoma in most countries worldwide, people with high risk phenotypes may need to consider regular monitoring or self-monitoring of their naevi , especially since the vast majority of melanomas are found by people themselves or their friend and relatives. Another group of patients that will require regular monitoring are patients who have been successfully treated for their first melanoma, whose risk to develop a second melanoma is greatly increased . In a US study of 89,515 melanoma survivors those with a previous diagnosis of melanoma had a 9-fold increased risk of developing subsequent melanoma compared with the general population, equating to a rate of 3.76 per 1000 person-years, while in an Australian study, risk of subsequent melanoma was 6 per 1000 person-years. Regular follow-up is therefore essential for melanoma survivors, especially during the first few years after initial melanoma diagnosis.

Non-melanoma skin cancer: Ten years of cancer-registry-based surveillance

The Tasmanian Cancer Registry carried out population-based surveillance of non-melanoma skin cancer (NMSC) from 1978 to 1987. A total of 8,651 NMSC were recorded in 7,160 individuals, representing an age-standardized rate of 161/100,000 per year. Ninety-four percent of cases were based on histological diagnosis. Incidence of basal-cell carcinoma (BCC) was higher than the incidence of squamous-cell carcinoma (SCC). The incidence of NMSC was twice as high in men as in women. Incidence increased substantially with age, more markedly for SCC than BCC. For most body sites, BCC was more frequent, but on highly exposed sites such as the backs of hands, lower limbs in women and ears in men, the incidence of SCC was higher. There was an overall increase of 7% per year in the age-standardized incidence rate of NMSC. The increase was more marked for BCC than for SCC, and was consistent across age groups and both sexes. A first NMSC during the study period was associated with a 12-fold increase among men and a 15-fold increase among women in the risk of development of a new NMSC within 5 years, when compared with the NMSC incidence recorded for the population as a whole.

Design thinking using a collaborative model for skin cancer prevention

Physical activity is well recognised as a means to reduce cancer risk; however, outdoor activity can increase sun exposure and consequential skin cancer risk. It is proposed, one of the key potential solutions to promote active lifestyles whilst enhancing protection against skin cancer is design resolution for active apparel that considers Australia’s sub-tropical climate whilst maintaining comfort, aesthetic appeal and performance. Using a design thinking approach, facilitated through collaboration between an NGO and a university, student designers were tasked with developing apparel prototypes to explore this challenge. Through practical ideation of problems, potential design solutions were developed within a modest NGO budget and adherence to specific brand guidelines. This project is novel as it demonstrates a low cost yet effective way of collaboratively creating a product to meet multiple needs, rather than reactively assessing already manufactured sun protection products for endorsement. It is a nimble and unique stepping stone in integrating sun safety considerations into clothing that is appealing to the population and creating cross-industry understandings of how design can better contribute to human health and wellbeing. Outcomes to be shared include empirical insights for updating sun safe clothing guidelines, issues around the aesthetic nature of sun safe apparel, and the role of design education for sun safety.

A new method to quantify the application thickness of sunscreen on skin

Proper application of sunscreen is essential as an effective public health strategy for skin cancer prevention. Insufficient application is common among sunbathers, results in decreased sun protection and may therefore lead to increased UV damage of the skin. However, no objective measure of sunscreen application thickness (SAT) is currently available for field-based use. We present a method to detect SAT on human skin for determining the amount of sunscreen applied and thus enabling comparisons to manufacturer recommendations. Using a skin swabbing method and subsequent spectrophotometric analysis, we were able to determine SAT on human skin. A swabbing method was used to derive SAT on skin (in mg sunscreen per cm2 of skin area) through the concentration–absorption relationship of sunscreen determined in laboratory experiments. Analysis differentiated SATs between 0.25 and 4 mg cm−2 and showed a small but significant decrease in concentration over time postapplication. A field study was performed, in which the heterogeneity of sunscreen application could be investigated. The proposed method is a low cost, noninvasive method for the determination of SAT on skin and it can be used as a valid tool in field- and population-based studies.

Workers’ UV exposure and the subsequent impact on skin

Introduction: Excessive exposure to ultraviolet (UV) radiation from sunlight is a causative factor in the development of skin damage and skin cancer. Little research has been undertaken into assessing the sun exposure linking to skin damage inside buildings or behind window glass. This project directly addressed this issue by aiming to assess the role that UV exposure has on skin damage for indoor workers and drivers. Methods: Measurements of personal UV exposure using UV sensitive polymer dosimeters were undertaken of 41 indoor workers and 3 professional drivers. Physical measurements of skin characteristics including skin pigmentation and UV induced skin photoaging were also determined. In addition, demographic information along with phenotypic characteristics, sun exposure and sun protection practice history, and history of skin damage were assessed through a questionnaire. Results: Indoor workers typically received low doses of UV radiation. However, one driver received a high dose (13J/cm2 UVA and 4.99 MED UVB on the arm). Age and years residing in Australia had a positive correlation with UV induced skin pigmentation. The number of major sunburns before 18 years was a risk factor for skin damage in adults. Those participants with fair skin, non-black hair and blue/green /blue-grey eye were more likely to have skin damage related to sun exposure. Conclusions: A person’s age, years residing in Australia, numbers of major sunburn, skin colour, hair colour and eye colour are important factors associated with the development of sun-related skin damage in workers. ‘Real World’ implications: 1. The number of major sunburns before 18 years was a risk factor for skin damage in adults. This clearly confirms the importance of early prevention. To protect the skin from extensive sun exposure for your generation should have significance for further prevention of skin damage. 2. It is unsurprising that age and years residing in Australia were associated with skin damage related UV radiation. Therefore, the general public should reinforce their sun protective measures and check skin regularly. 3. Drivers should take sun protective measures during their working hours between sunrise and sunset.

A tan in a test tube -in vitro models for investigating ultraviolet radiation-induced damage in skin

Presently, global rates of skin cancers induced by ultraviolet radiation (UVR) exposure are on the rise. In view of this, current knowledge gaps in the biology of photocarcinogenesis and skin cancer progression urgently need to be addressed. One factor that has limited skin cancer research has been the need for a reproducible and physiologically-relevant model able to represent the complexity of human skin. This review outlines the main currently-used in vitro models of UVR-induced skin damage. This includes the use of conventional two-dimensional cell culture techniques and the major animal models that have been employed in photobiology and photocarcinogenesis research. Additionally, the progression towards the use of cultured skin explants and tissue-engineered skin constructs, and their utility as models of native skin's responses to UVR are described. The inherent advantages and disadvantages of these in vitro systems are also discussed.

Characteristics of men aged 50 years or older who do not take up skin self-examination following an educational intervention

Men aged 50 years or older are at high risk of melanoma, and both incidence and mortality are increasing in this group1. Skin self-examination (SSE) could be one avenue to improve outcomes from melanoma. Several recent intervention trials successfully increased SSE, but resistance to such interventions is less well studied. This posthoc secondary analysis of interventional study data aimed to identify characteristics of older men who did not take up SSE for the early signs of skin cancer, despite exposure to educational materials during a randomized intervention trial

Uptake of skin self-examination and clinical examination behavior by outdoor workers

This study investigated the association between outdoor work and response to a behavioural skin cancer early detection intervention among men 50 years or older. Overall, 495 men currently working in outdoor, mixed or indoor occupations were randomised to a video-based intervention or control group. At 7 months post intervention, indoor workers reported the lowest proportion of whole-body skin self-examination (wbSSE; 20%). However, at 13 months mixed workers engaged more commonly in wbSSE (36%) compared to indoor (31%) and outdoor (32%) workers. In adjusted analysis, the uptake of early detection behaviours during the trial did not differ between men working in different settings. Outdoor workers compared to men in indoor or mixed work settings were similar in their response to an intervention encouraging uptake of secondary skin cancer prevention behaviours during this intervention trial.