GP Update Non-Melanoma Skin Cancer

Mark Strickland, SunSmart Manager Cancer Council Western Australia Thursday 8th December 2016

Global (NMSC) skin cancers figures

2 to 3 million non-melanoma skin cancers are diagnosed each year. Most notably basal and squamous cell carcinomas but also including rare Merkel cell carcinoma, dermatofibrosarcoma, sebaceous gland carcinoma Worldwide an estimated 66,000 deaths occur annually from melanoma and other skin cancers. Source: http://www.who.int/uv/health/en/

Lack of registration of NMSC results in poor estimates of: • Cost • 5 year survival • Size of problem

NMSC Skin cancer in Australia

• NMSC = most common cancer in Australia, having more than five times the incidence of all other cancers combined, the highest rate in the world. [23][24] (2002)

• According to Medicare data, almost 3.5% (~820,000) of the whole Australian population had undergone treatment for NMSC in 2010.

• ~1 million GP consultations per year (>2500 per day) • ~$650 million cost per annum for all skin cancer (4)

• 2 in 3 Australians who die from skin cancer are men (2014). (3)

Australian Incidence / Mortality

Source:http://wiki.cancer.org.au/skincancerstats/Skin_cancer_incidence_and_mortality

NMSC skin cancer in WA

NMSC treatments 2016 WA = approx 96,000 (2)

NMSC mortality WA 2014 = 86

– males = 61 females = 25 (1)

1Threlfall TJ, Thompson JR (2016). Cancer incidence and mortality in Western Australia, 2014. Department of Health, Western Australia, Perth. Statistical Series Number 103.

2 Australian Institute of Health and Welfare, Skin cancer in Australia. 2016: Canberra.

Link between UV and Skin Cancer

Now well established after ~50 years of research. In 2009, the International Agency for Research on Cancer (IARC) classified the full UV radiation spectrum as carcinogenic to humans.[9]

Overexposure to UV radiation can result in DNA damage and mutations, and immune suppression. 99% of NMSC is attributed to overexposure to UVR.

Williamstown Beach VIC 1912 www.belonging.org/ place/images/beach2.jpg

Williamstown Beach VIC 1990’s http://ozoutback.com.au/cards/apr7-8540329800.html

National Sun Survey 2013/14 Weekend sunburn incidence - adults (n = 5288)

Reference: Volkov, Dobinson. (2014). National Sun Protection Survey 2013-14. The Centre for Behavioural Research in Cancer, The Cancer Council Victoria. P.54

Weekend time outside and sun protection behaviours – we could be doing better.

Reference: Volkov, Dobinson. (2011). National Sun Protection Survey 2013-14. The Centre for Behavioural Research in Cancer, The Cancer Council Victoria. P.53

Prevention messages

When UV index is 3 or higher Be SunSmart

The UV Index

A typical summer’s day

Below 3 no sun protection is required.

Source: UVDaily.com.au or MyUV.com.au

Check the UV Index

• Sun protection required when UV Index is 3 or above

• Check the UV Index for sun protection times and max UV level

• Download the SunSmart app, available for smartphones and tablets

• Check the newspaper or visit the following websites • My UV www.myUV.com.au • Bureau of Meteorology

www.bom.gov.au/uv/ • ARPANSA

www.arpansa.gov.au/uvindex/realtime/

Think UV not heat.

Early detection messages

Cancer Council Australia's current recommendations include opportunistic screening and skin self-examination in place of routine mass population screening

SunSmart guidance to public: • Know your own skin – ABCDE, ugly duckling, spots that are raised or

bleed easily • Check skin at least 3 monthly • Have new, changed or unusual spots checked by GP or Dermo

promptly • Yearly skin checks at work or by Dr are good - but maintain own

vigilance at all times • No difference in accuracy of diagnosis between GPs and GP Skin

Clinics • Understand the credentials of those examining you.

Who is at risk for (NMSC) skin cancer?

Risk level Factors Average Fair to lighter than olive skin

<40 years of age

Increased Fair complexion Sensitive to sunburn Skin with freckles, moles Light eye colour, Light or red hair Family history of skin cancer Aged >40 years Male Presence of multiple solar keratoses High UV exposure especially as a child Outdoor workers

High As above plus previous history of non-melanoma skin cancer, past exposure to arsenic and immunosuppression.

Vitamin D

Vitamin D?

Source: http://www.who.int/uv/health/en/

Vitamin D should be measured as 25-hydroxyvitamin D (25OH-D) and reported in nmol/L units. It is recommended that vitamin D levels are 60-70 nmol/L at the end of summer or >50 nmol/L at the end of winter. Most should reach this level with incidental sun exposure. There is limited research available to determine exactly how much sun exposure is required to maintain adequate vitamin D levels. Production of vitamin D is influenced by a number of factors including age, skin colour, latitude, season and time of day, making it difficult to provide advice to the population as a whole. Recommendations are listed in the position statement.

How much Vitamin D?

Source: http://wiki.cancer.org.au/policy/Position_statement_-_Risks_and_benefits_of_sun_exposure#_ga=1.96309599.253688384.1446691184

The following describe indications for initial testing of vitamin D status for adult patients: o Signs, symptoms and/or planned treatment of osteoporosis or osteomalacia o Increased alkaline phosphatase with otherwise normal liver function tests o Hyperparathyroidism, hypo- or hypercalcaemia, hypophosphataemia o Malabsorption (e.g. cystic fibrosis, short bowel syndrome, inflammatory bowel disease, untreated coeliac disease, bariatric surgery) o Deeply pigmented skin, or chronic and severe lack of sun exposure for cultural, medical, occupational or residential reasons o Medications known to decrease 25OH-D levels (mainly anticonvulsants) o Chronic renal failure and renal transplant recipients • In addition, the following are indications for testing of children: o Signs, symptoms and/or planned treatment of rickets o Infants of mothers with established vitamin D deficiency o Exclusively breastfed babies in combination with at least one other risk factor o Siblings of infants or children with vitamin D deficiency

Vitamin D – who should be tested?

The Australian Bureau of Statistics estimates that one in four Australian adults are vitamin D deficient (<50nmol/L), with 6% having a moderate or severe deficiency (<29 nmol/L) Australian Bureau of Statistics. 4364.0.55.006 - Australian Health Survey: Biomedical Results for Nutrients, Vitamin D 2011-12. Canberra, Australia: Australian Bureau of Statistics; 2014 Available from: http://www.abs.gov.au/ausstats/abs@.nsf/latestProducts/4364.0.55.006Media%20Release22011-12.

Vitamin D deficiency among the general population?

Recommendations: Clinicians should be aware that current vitamin D assay methods, may give different results and should understand the limitations of the method used in the laboratory that most of their patients attend. It is advisable to monitor serum 25OH-D levels following treatment in the same laboratory. Results generated by current immunoassay methods for 25OH-D are highly variable. Thus, changes of less than 20% in two results from the same patient over time may not be significant.

Source: https://www.rcpa.edu.au/Library/College-Policies/Position-Statements/Use-and-Interpretation-of-Vitamin-D-Testing

Vitamin D test limitations

Vitamin D

Weighing up the evidence...

– Link between UV radiation exposure and skin cancer well established (IARC, 2002)

– Link between vitamin D deficiency and bone health also well established

(Holick, Am J Clin Nutr 1994)

– Evidence of vitamin D role in most other conditions is much weaker – mostly associative. (http://www.bmj.com/content/348/bmj.g2035 )

– Useful summary of issues: https://theconversation.com/should-you-be-

worried-about-getting-enough-vitamin-d-25032

How much sun is enough?

www.cancer.org.au

Summary

http://www.nps.org.au/publications/health-professional/medicinewise-news/2011/nps-news-vitamind

In late autumn and winter, in those parts of Australia where the daily max UV Index is below 3, sun protection is not recommended. During these times, to support vitamin D production it is recommended that people be outdoors in the middle of the day with some skin uncovered on most days of the week for around 30 minutes. At all other times, be guided by the UV index and be SunSmart when UV is 3+ Outdoor workers have extended periods of sun exposure and therefore it is unlikely that vitamin D deficiency is an issue for this professional group. It is recommended that outdoor workers use sun protection measures throughout the year regardless of the UV Index, as they have an increased risk of skin cancer.

How much sun is enough?

Given the considerable evidence showing UV to be carcinogenic, skin cancer prevention in Australia must remain as a high public health priority. For this reason, extended and deliberate sun exposure without any form of sun protection when the UV Index is 3 or above is not recommended, even for those diagnosed with vitamin D deficiency. Source: http://wiki.cancer.org.au/policy/Position_statement_-_Risks_and_benefits_of_sun_exposure#_ga=1.218472784.830115417.1478662616

How much sun is enough?

Cancer Council resources (patient)

https://www.cancerwa.asn.au/resources/publications/prevention/

Cancer Council resources (patient)

MyUV.com.au provides UV forecast and protection times

Cancer Council resources (patient)

MyUV.com.au/skincancer Skin self check guide

Cancer Council resources (patient)

UVDaily.com.au Sun protection for outdoor workers.

Useful resources (GP)

Skin Cancer Statistics & Issues http://wiki.cancer.org.au/skincancerstats/Skin_Cancer_Statistics_and_Issues Use and interpretation of Vitamin D testing https://www.rcpa.edu.au/getattachment/8991ad55-be3e-4c9c-b816-3ec3f08eb6bd/Use-and-Interpretation-of-Vitamin-D-Testing.aspx Risks and benefits of sun exposure http://www.cancer.org.au/policy-and-advocacy/position-statements/sun-smart/#jump_3 Cancer Council Position statements http://www.cancer.org.au/policy-and-advocacy/position-statements/ Cancer Council SunSmart Publications https://www.cancerwa.asn.au/resources/publications/prevention/

Thank you

Mark Strickland SunSmart Manager mstrickland@cancerwa.asn.au