2 Public health need and practice

Background

There are two main types of skin cancer:

  • Non‑melanoma is the most common and is usually less complex to treat. There are two main sorts: basal cell carcinoma (BCC) and the more serious squamous cell carcinoma (SCC):

    • BCC is rarely fatal. However, if it is not diagnosed early enough – or is not properly treated – it can result in tumors that destroy important anatomical structures (such as the nose, eye, ear and lip). As such it can be more challenging to treat and can result in the tumour becoming inoperable (see NICE cancer service guidance 'Skin tumours including melanoma' 2010[3]). Its development is associated with intensive ultraviolet radiation exposure in childhood and adolescence, particularly in those who burn easily.

    • SCC can be disfiguring and can be fatal if it spreads. Its development is associated with chronic ultraviolet radiation exposure in the earlier decades of life (Leiter and Garbe 2008).

  • Malignant melanoma is the most serious and is responsible for the majority of skin cancer deaths. Treatment is more likely to be successful when it is caught early. It has most strongly and consistently been associated with reported 'intermittent sun exposure' mostly accrued through recreational activities (Gallagher and Lee 2006; Gandini et al. 2005; Walter et al. 1999).

In 2002, it was estimated that skin cancer (malignant melanoma and other malignant neoplasms of the skin) cost the NHS approximately £71 million (Morris et al. 2005).

Incidence

Non‑melanoma skin cancer is estimated to account for around a third of all cancers detected in the UK. In England more than 69,000 people were registered with it in 2007 (Office for National Statistics 2009a). However, due to incomplete registration, the actual number of cases may be over 100,000 (Cancer Research UK 2010a).

Research has shown that the incidence of non‑melanoma is rising in the young, especially among those aged 30–39 (Bath‑Hextall et al. 2007).

In England, more than 8800 cases of malignant melanoma were diagnosed in 2007 (Office for National Statistics 2009a). In 2008, it caused 1847 deaths in England and Wales (Office for National Statistics 2009b).

Since the 1970s, the incidence of malignant melanoma has more than tripled in Great Britain. Among males it has increased from around 2.5 per 100,000 in 1975 to 14.6 in 2007. The rate among females has increased from 3.9 to 15.4 per 100,000 during the same period (Cancer Research UK 2010b). Although incidence rates are higher among females, more men die from it (Office for National Statistics 2009b).

Risk factors

Exposure to ultraviolet (UV) radiation is the leading cause of skin cancer. This can occur naturally via sunlight and artificially through the use of sun lamps and tanning beds.

A range of factors can increase the risk of someone developing skin cancer including:

  • Age and sex – the number of cases of malignant melanoma increases with age and is more common in women (Cancer Research UK 2010b). Skin damage (sunburn) at any age is associated with an increased risk of developing skin cancer later in life (Elwood and Jopson 1997).

  • Ethnicity – although incidence rates are lower among people with darker skin (National Cancer Intelligence Network 2009), it is often diagnosed late, which can increase the risk of death (Cornier et al. 2006).

  • Occupation – a range of outdoor workers and people involved in outdoor sports are particularly at risk for example, construction workers, cricketers and golfers, farmers, gardeners, military personnel and postal workers.

  • Personal and family history – of skin cancer, lowered immunity or a transplant (Cancer Research UK 2010c).

  • Physical characteristics – some people are more likely than others to develop skin cancer, such as those with fair skin that burns easily, those with lots of moles or freckles and those with red or fair hair or light coloured eyes (Cancer Research UK 2010c).

  • Regional variation – London and the north have the lowest incidence, while the highest incidence is in the south‑west of England (Office for National Statistics 2005).

  • Socioeconomic status – malignant melanoma is associated with affluence. There is a 60–70% lower incidence among people from deprived areas compared with their more affluent peers (Cancer Research UK 2010b). However, people from more affluent areas are more likely to survive the condition (Coleman et al. 2001). In addition, it should be noted that sunbed outlets are particularly prevalent in areas of socioeconomic deprivation (Walsh et al. 2009) – and that this could affect the rate among lower socioeconomic groups in the future.

Prevention

The risk of developing skin cancer can be reduced by, for example, avoiding getting burnt, opting to stay in the shade during the middle of the day, wearing protective clothing and using high‑SPF products.

In a 2003 survey, 80% of those questioned mentioned using sunscreen to reduce the risk of skin cancer, but less than half (44%) specifically mentioned using a sunscreen with a 15+ SPF (Office for National Statistics 2003).

Policy background

This guidance should be viewed in light of the following policy documents:

  • 'Cancer reform strategy' (DH 2007) committed the UK government to increase funding for skin cancer prevention through awareness‑raising activities.

  • The Local Government and Public Involvement in Health Act (Department of Communities and Local Government 2007) outlines how primary care trusts and local authorities should undertake a joint strategic needs assessment of their population's health and social care needs.

  • 'The NHS cancer plan: a plan for investment, a plan for reform' (DH 2000) sets out a comprehensive national cancer programme for England. It covers prevention, screening, diagnosis, treatment and care.



[3] Available from the NICE website.

  • National Institute for Health and Care Excellence (NICE)