Skin Cancer

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Joint Strategic Needs Assessment (healthysomerset.co.uk/JSNA)

What is Skin Cancer?

There are two main categories of skin cancer - melanoma and non-melanoma. Melanoma (also known as 'malignant melanoma') is less common than non-melanoma cancers, but is the most dangerous. Non-melanoma skin cancers are mainly comprised of 'Basal Cell Carcinoma' (BCC) and 'Squamous Cell Carcinoma' (SCC). BCC is the most common and the least dangerous. 

The main cause of all types of skin cancer is excessive exposure to UV radiation from sunlight. Less significant causes are exposure to other radiation sources and exposure to harmful chemicals. Sun exposure is particularly damaging to people with fairer skin, to infants and children and to adults facing repeat exposure such as outdoor workers.

Nationally, between 1995 and 2015, even after allowing for the effect of an ageing population, skin cancer registrations doubled in England.

Key Facts for Somerset

• More people develop skin cancer and die from it in Somerset than the England average.
• The number of new cases in Somerset has risen by almost 50 % in the past ten years
• The incidence of malignant melanoma for all ages in Somerset is significantly higher than the England average with 574 cases diagnosed between 2011 and 2013, a rate of 34.0 cases per 100,000 population against an England average of 23.3 cases per 100,000 population.
• The incidence in those aged below 75 is also significantly higher than the England average at 25.3 cases vs 18.5 (383 new diagnoses between 2011-2013).
• For every new case of malignant melanoma there were about 8 new cases of other skin cancers.
• Although not statistically significant, the mortality rates in Somerset for all ages and under-75s are also above the national averages .
• Factors contributing to this may be the higher than average proportion of the population aged over 75 and that 98% of Somerset’s population is White.
• Deaths from skin cancer can be prevented by avoiding sun exposure, early diagnosis and treatment.. The best way to promote these messages are through mass media and multi-component education campaigns directed at specific groups. In Somerset the groups most likely to benefit from these messages are outdoor manual workers, their employers, primary school-aged children and their parents.
• New NICE guidance recommends promoting messages which balance the benefits of sunlight exposure for vitamin D intake with avoiding too much sun to prevent sun burn.
• Despite being a significant and preventable risk to life, resources for skin cancer awareness are limited. Awareness raising has been left primarily to national media campaigns, however in the last two years Somerset has run its own campaigns.

Current Needs in Somerset

Public Health England skin cancer profiles were updated in 2015 with data covering 2011-2013. These figures were still 'current' in 2021.  These show a picture of Somerset that is consistently higher in morbidity and mortality from skin cancer than the England average.

Incidence (newly diagnosed cases)

Somerset has the 14^th highest incidence (all ages) of skin cancer diagnosis of 152 former PCT areas in England. The number of diagnosed cases has risen considerably since 2000 (see Chart 1 below).

Source: Health and Social Care Information Centre (HSCIC)

In the period 2008-12 there were:-

• an average of 178 new cases of malignant melanoma per year
• an average of 1,443 new cases of other skin cancer per year
• so for every new case of malignant melanoma there were about 8 new cases of other skin cancers.

Incidence rates for malignant melanoma in Somerset were significantly higher than the England average, for all ages and for under-75s (see Table 2):

All-age incidence rates for malignant melanoma were significantly above the national average amongst all districts, apart from West Somerset.

Nationally, in 2014, skin cancer was the second most common type of cancer diagnosed for 15-49 eyar-olds.

Mortality

In the 2012-14 period, on average, there were 96 skin cancer deaths in Somerset, an average of 32 a year. broken down by District as follows:-

The mortality rate of malignant melanoma of 4.0 deaths per 100,000 population is in line with the England average (2012-2014). The under 75 mortality rate is 2.3 per 100,000 against an England average of 2.5 per 100,000. 

Risk Factors

Factors contributing to Somerset's above-average incidence and mortality rates for skin cancers may be the higher than average proportion of the population aged over 75. Also, 98% of Somerset’s population is White, and people with fairer skin are at more risk of damaging the skin through sunburn which can cause the development of skin cancers.

Other possible risk factors do not appear to contribute:-

• Somerset’s income deprivation score (linked to poorer health outcomes) is not significant at 10.8 against a national average of 14.6.
• The county's average annual sunshine total of 1481 hours is in line with the England average of 1492.
• Somerset has a low concentration of commercial sun-bed outlets (“tanning salons”).

Significant risk factors we cannot assess are excessive sun exposure in childhood and the proportion of the population that are or have been outdoor manual workers.

Public Attitudes

Face to face “outreach” was undertaken in 2014 at events promoting the campaign directed at men aged 50 and over. 1,174 people were approached with 800 engaging in conversation about skin cancer and symptoms. 

Key findings were that:

• Over 65% said they “never” or only “sometimes” wore a hat to prevent sun burn and 42% “never” or “sometimes” covered up with clothing
• 55% said they “never” or only “sometimes” used sun cream
• 67% said they thought a tan was attractive
• 33% said they “didn’t know” when asked if there was a chance they may get skin cancer
• 60% agreed that sun exposure in childhood is related to skin cancer in adulthood
• Most people knew the potential signs of skin cancer, with 96% identifying a change in the appearance of a mole and 79% a sore that doesn’t heal
• 83% said that hearing about other people’s experiences would make them think more about skin cancer

Future Needs

Changes in skin cancer diagnosis and mortality in the long term are dependent on the overall changes in Somerset’s demographic and the effectiveness of primary and secondary prevention campaigns. As much of the evidence indicates a link between childhood exposure to UV radiation and skin cancers it is unlikely that the benefits of current campaigns will be seen for many years. 

Incidence rates for both melanoma and other skin cancers have increased over past years. In then past decade, incidence of all skin cancers has risen by almost 50% It is reasonable to predict a continuing slight upward trend.

Current Service Provision

Health services for diagnosis and treatment of skin cancer are commissioned by Somerset CCG and NHS England. 

“Sun safe” and skin cancer prevention messaging are commissioned by Public Health England (PHE) for national and regional campaigns and through Somerset County Council’s Public health team for local awareness raising. Resources for local awareness campaigns are limited. 

In 2014, Somerset’s campaign was an extension of Public Health England’s sub-regional campaign for Cornwall, Devon and Somerset. This was a secondary prevention campaign focused on men aged over 50 and their partners or wives. Its message was to identify any changes to the skin and contact their GP if worried. PHE also ran a campaign with primary care staff about early identification and onward referral to secondary care services. 

In 2015, Somerset’s campaign targeted the parents of primary school aged children. This was a primary prevention campaign aimed at ensuring that children do not become sunburnt. The campaign reflects the recommendations in the NICE guidance published in July 2015 which recommend balanced advice on avoiding sunburn whilst spending time exposed to the sun to ensure an adequate intake of vitamin D.

Recommendations for Action

In line with current and forthcoming NICE guidance, recommendations for future action are: 

• Local, consistent primary prevention awareness raising campaigns that focus on targeted groups such as primary school aged children and their parents and outdoor manual workers and their employers
• Local campaigns that support the messages of regional and national campaigns
• Awareness raising, resources and support to professionals working with “at risk” groups such as;
  •  Those working with infants and children
  •  Those working in residential and care settings
  •  Planners and developers
  •  Employers, particularly those that employ people who work outdoors

For More Information:-

• Skin Cancer Safety for children (Somerset Choices for Families)
• NICE draft guideline: Sunlight exposure: risks and benefits to the general public 
• NICE Preventing skin cancer pathways 
• Health and Social Care Information Centre indicator portal 
• Public Health England Skin Cancer Profiles (National Cancer Intelligence Network)
• The ONS has produced a slideshow on national skin cancer trends since 1995