Journal of the New Zealand Medical Association, 11-February-2011, Vol 124 No 1329
Non-melanoma skin cancer
In their paper on non-melanoma skin cancer (NMSC) Brougham et al raise a number of important issues.1 Their paper is very timely, given recent upwardly revised estimates of the scale and substantial cost burden on the health system of treatment,2 for a problem that is, largely, considered potentially preventable through control of excessive exposure to UV radiation.3
In addition to treatment issues, Brougham et al. identify the need for ‘community-wide preventive measures.’ One of the challenges with these is to ensure that resources are allocated to implementing interventions for which there is evidence of effectiveness.
With respect to interventions implemented to reduce harmful UVR exposure, a systematic review found ‘sufficient evidence’ for the effectiveness of only two classes of interventions: education and policy approaches in (a) primary schools and (b) recreational and tourism settings.4 It is, therefore, fortunate that a national SunSmart Schools Accreditation Programme has been implemented by the Cancer Society in New Zealand,5 and it is important that the SSAP continues to receive adequate resourcing.
Greater attention to recreational and tourism settings is warranted. However, the review found insufficient evidence to determine the effectiveness of interventions in other settings, including workplaces, or interventions focused on healthcare settings and providers, parents or caregivers of children, media campaigns alone or community-wide multi-component interventions.
Since that review was undertaken, substantial numbers of additional interventions have been implemented and plans to up-date the review are under way. An up-dated review would provide an important guide for decisions made in New Zealand. In the meantime, planning for interventions in New Zealand should take into account not only existing evidence for effectiveness, but identified international research needs, which include better design, measurement and description of interventions and studies among multi-ethnic populations.
Although it is currently not possible to quantify their NMSC burden, one population group which clearly deserves greater attention is those who work outdoors, potentially 14% of the workforce.6 There is evidence that outdoor workers in NZ can be exposed to high levels of real-time UVR at work,6 that better workplace sun protective behaviours are found where there is perceived workplace support,7,8 and perceived prioritisation of sun protection at work.8
Another area for increased attention should be sun-bed regulation, given the increased skin cancer risks associated with their use,9 their wide distribution in NZ10 and a recent Australian report of their sometimes very high emissions (up to a UVI of 48, or about four times higher than the midday summer sun in NZ).11 Taken together, these factors provide strengthened support for arguments about the need for better controls on this potential hazard in New Zealand, which would bring us more into line with existing regulations in Australian states.
So, in addition to the immediate need for adequate treatment services and surveillance there is also a need to plan for long term reduction in the scale of the skin cancer burden through targeted, carefully evaluated, often settings-based interventions while maintaining the overarching context of population health-promotion messages about the need for sensible UVR protection. This should not only help to reduce the substantial NMSC burden, but also the around 300 deaths from melanoma in NZ every year – given that excessive UVR exposure is also currently the only potentially readily modifiable risk factor for melanoma.
Anthony I Reeder
Cancer Society of New Zealand Social & Behavioural Research Unit
Department of Preventive & Social Medicine
Dunedin School of Medicine
University of Otago, Dunedin
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