World Melanoma Month to raise awareness is held every year in May, with global partner countries conducting their own outreach and public health initiatives to meet their own unique cultural needs. In the UK, Sun Awareness Week took place in mid-May, but how many BJN readers were aware of these public health campaigns? Did you reflect on how you could incorporate sun awareness and skin cancer prevention in patient education into your daily practice? This is health education for all and not just the domain of dermatology practice.
Melanoma is the fifth most common cancer in the UK, accounting for 4% of all new cancer cases (Cancer Research UK, 2019). There were 15 400 new cases each year in 2013-15—that's 42 every day—and over the past decade rates of melanoma have increased by 50% (Cancer Research UK, 2019). Non-melanoma skin cancer (basal cell, squamous cell and rarer carcinomas) is less likely to metastasise, but still accounts for 950 deaths annually. Survival rates for melanoma are improving due to faster diagnosis and improvements in treatment. Early detection and screening is crucial: for example, prostate cancer has the largest increase in survival, largely due to PSA [prostate specific antigen] testing (Cancer Research UK, 2019). However, the UK, has no national skin cancer screening programmes and the wealth of available information on self-checking needs to be communicated to all our patients.
Educating the public on self-assessment is important. Regular self-examination can help detect changing and suspicious skin lesions. The British Association of Dermatologists (BAD) (2019) recommends that people dedicate 10 minutes once a month to examine their entire skin, following the ABCDEasy rules (looking for Asymmetry, uneven Borders, uneven/changing Colour, Diameter changes, different or patchy colours, expanding diameters and consulting an Expert, if there are any changes) and being aware of the ‘ugly duckling’ sign (moles that differ from the patient's norm). Patients should be advised to look for moles or patches of skin that are changing shape, developing new colours, inflamed, bleeding, crusting, red around the edges, particularly itchy or behaving unusually (BAD, 2019). If a patient detects a change, they should seek medical advice. Remember to tell your patients: ‘If in doubt, check it out.’
There are smartphone apps that include services for taking images of skin lesions, with an email sent if a suspicious lesion is detected. However, a Cochrane review concluded that apps that use automated analysis have a high chance of missing melanomas (false negatives) and, although ‘store and forward image’ could have a potential role, there are limitations (Chuchu et al, 2018).
The NHS does not offer a skin screening service, but private providers do offer a full skin check, which includes the use of dermoscopy and teledermatology by dermatology departments. Dermoscopy is the gold standard for examining suspicious skin lesions by health professionals. In primary care, there should be a teledermatology link for expert dermatologist advice. The Royal College of General Practitioners' (2019) Spotlight dermatology toolkit is freely available to all health professionals and includes lots of useful resources for health professionals and patients.
All health professionals should be able to provide patients and the general public with informed sun awareness advice. Promoting self-examination and giving information on skin cancer prevention is key. Prevention should be a concern for all nurses and incorporated in their daily practice alongside education.
The British Association of Dermatologists recommends that people use a sunscreen with an SPF of 30 and a UVA rating of 4-5 stars, which provides a satisfactory form of sun protection, in addition to covering up with clothing. Application is recommended every 2 hours (most people do not apply enough sunscreen), because exposure to water, sweating, towel drying and any form of abrasion can remove sun protectors from the skin's surface (BAD, 2019). Protecting children from the sun is extremely important, as sunburn in childhood increases the risk of both melanoma and non-melanoma skin cancers.
Risk factors for skin cancer include having a type 1-2 skin (usually burns, rarely tans), being an outside worker and being exposed to high intensity UVA/UVB.
Sunbeds have been shown to increase the risk of malignant melanoma, especially among those aged under 35 years. Cancer Research UK and the All Party Parliamentary Group on Skin (2014) successfully campaigned for a ban on under-18s using sunbeds in England. The UK charity Melanoma UK campaigned for a total ban on commercial sunbeds in 2018, but the petition was rejected, with the parliamentary response that the UK sunbed policy would not be reviewed. In Australia, commercial sunbeds are illegal and Brazil prohibits trade in artificial tanning, unless prescribed by a doctor, for all age groups.
Patient education and public health messages on sun protection need to improve in the UK. Melanoma is a significant cancer that metastasises rapidly but, if caught early, can often have a 100% remission. The use of adequate sun protection measures and self-checking can have a big impact on reducing the rising rates of skin cancer in the UK.