Health and Social Services: 2014 Skin Cancer Prevention Strategy for Jersey.

STATES OF JERSEY

HEALTH AND SOCIAL SERVICES: 2014 SKIN CANCER PREVENTION

STRATEGY FOR JERSEY

Presented to the States on 30th September 2014 by the Minister for Health and Social Services

STATES GREFFE

2014   Price code: C  R.143

Skin Cancer Prevention Strategy for Jersey

Informing skin cancer prevention in Jersey: 2014 and beyond

Health and Social Services

Public Health Directorate 2014

Foreword

Skin cancer rates have increased rapidly in the last 30 years, with Jersey having a statistically higher rate of malignant melanoma and other reported skin cancers than either the Southwest of England or England as a whole. The Southwest Region itself has the highest skin cancer rate in the UK. The two most recent Public Health England reports  which  we  commissioned,  Cancer  in  Jersey'  and  Cancer  in  the  Channel Islands 2010–2012', have demonstrated a clear link between our higher rates and preventable risk factors.

We, as Islanders, are particularly fortunate to benefit from a beautiful Island with its fantastic coastal environment, good climate and high levels of sunshine hours that support and encourage outdoor activity. However, we all need to recognise that these benefits can come with some risk. With simple sun safety behaviours, we can have the best of both worlds. We need to ensure changes in behaviour, now and in the future, that protect our Island's children from early skin damage and help them develop good sun safety habits that last into adulthood.

While awareness of sun safety in Jersey appears to be high, only sustained behaviour change will make a lasting impact on skin cancer rates. Education, policy work and environmental changes all have a part to play in creating a long-term shift in societal attitudes and behaviours around sun safety, as well as helping to encourage people to seek  medical  advice  promptly  about  skin  lesions  that  may  be  cancerous.  Early diagnosis is essential to keeping skin cancer mortality to an achievable minimum.

This strategy sets out an agreed, multi-agency approach to this escalating public health issue and to start turning the tide. If skin cancer rates are to be progressively lowered, co-ordinated and sustained action will need to be taken from now on across a wide variety of settings, using targeted and evidence-based interventions.

Partnership working is vital to the success of this strategy. My thanks go to all who have  contributed  to  the  development  of  this  strategy  and  committed  already  to beginning its implementation.

Dr. Susan Turnbull Medical Officer of Health

Skin Cancer Prevention Strategy for Jersey

Informing skin cancer prevention in Jersey: 2014 and beyond

Contents

1.0  Introduction

2.0  Skin Cancer overview

3.0  International perspective

0. Jersey perspective
   1. Statistics
   2. Economic impact
   3. Patient survey
   4. Local initiatives

0. National policy and guidance

0. Evidence base
   1. Effectiveness of interventions
   2. Considerations when planning initiatives Target groups

Message framing

Barriers

Vitamin D controversy

7.0  Action Plan 2014–18

8.0  Recommendations

Developed in consultation with key stakeholders:

• Dermatology Department
• Public Health
• Donna Annand Melanoma Charity
• Jersey Cancer Trust
• Healthy Schools Jersey

REPORT

0. Introduction

Sunlight is the main preventable risk factor in the development of skin cancer.

Increasing  rates  of  skin  cancer  in  Jersey  have  highlighted  the  need  for  a comprehensive, integrated approach to raising awareness of malignant melanoma and the risks associated with excessive exposure to harmful UV radiation. Skin cancer currently accounts for a third of all new cancers in Jersey, with significantly higher age standardised rates of malignant melanoma compared to the Southwest of England. Malignant melanoma incidence has more than doubled in Jersey since the 1990s.

This strategy outlines a local multi-agency approach to improving both primary and secondary  prevention.  If  skin  cancer  rates  are  to  be  reversed,  co-ordinated  and sustained action will need to be implemented across a variety of settings, involving both private and public partnerships.

While awareness-raising is important, initiatives that result in sustained behaviour change are required to make a lasting impact on rates. Interventions must be both targeted  and  evidenced-based  if  they  are  to  lead  to  a  long-term  shift  in  societal attitudes  and  behaviours  around  sun  safety.  Education,  policy  development, environmental changes and early diagnosis all have a key role to play.

1. Strategic aim

The long-term aim of the strategy is to reduce the incidence of skin cancer and related deaths in Jersey.

2. Objectives

1. To increase public awareness regarding the dangers of overexposure to UV radiation from sunlight and from artificial tanning devices.
2. To increase  individual  and  population-wide  practice  of  sun  safety behaviours.
3. To increase awareness about the early signs of skin cancer and the need for prompt attention.
4. To encourage  earlier  detection  and  treatment  of  malignant melanomas.

2.0  Skin Cancer overview

Sunlight is essential to health. Not only do we require some exposure to the sun to provide us with sufficient Vitamin D levels, but sunlight also has widespread mood- elevating effects, contributing to regular sleep patterns and consequently supporting good mental well-being.

However, too much sunlight, especially Ultraviolet Radiation (UVR), can cause DNA and tissue damage. As ozone levels are depleted, the atmosphere loses more and more of  its  protective  filter  function  and  more  solar  UV  radiation  reaches  the  earth's surface.

Over-exposure to UVR is widely accepted as the underlying cause for skin cancer. However, the main factors that predispose to the development of melanoma seem to be connected with recreational exposure to the sun and a history of sunburn. As such, experts believe 4 out of 5 cases could be prevented by adopting simple precautions.

Broad-spectrum UVR (solar radiation) was first listed as a human carcinogen in 2002. However, natural sunlight is not the only risk factor. In August 2009, the International Agency for Research on Cancer published a report which reclassified UV-emitting tanning devices into the highest cancer risk category, i.e. carcinogenic to humans' (Group 1). Following a review of research, it concluded that the risk of malignant melanoma is increased by 75% when use of tanning devices starts before 35 years of age.

There are many types of skin cancer, but 3 types are responsible for more than 95% of all skin cancers. They are –

• basal cell carcinoma;
• squamous cell carcinoma; and
• malignant melanoma.

The first two of these are sometimes grouped together as non-melanoma skin cancers, which  are  very  common  and  usually  treated  easily.  Malignant  melanoma  is  less common, but is responsible for approximately 75% of skin cancer-related deaths.1

Skin cancer is a serious health issue and the upward trend of skin cancer incidence is predicted to continue. This is due partly to the ageing population and partly to changes in behaviour that leads to increased exposure to ultraviolet radiation (UVR), such as spending more leisure time outdoors, holidaying in hot, sunny climates and the use of sunbeds.

Cheaper air travel has contributed to frequent trips abroad which often result in intense over-exposure to sun over short periods for both adults and children. The majority of sunburn  studies  suggest  a  positive  association  between  early-age  sunburn  and subsequent risk of melanoma. Many people also over-expose themselves to the sun in an attempt to maximize tanning during the days when sunshine is most prevalent at home.

0. International perspective
1. Trends

The increase in skin cancer incidence is a worldwide problem and now accounts for one-third  of  all  new  cancers  diagnosed.  Currently,  between  2  and 3 million non- melanoma skin cancers and 132,000 melanoma skin cancers occur globally each year.2

Malignant melanoma incidence rates have more than quadrupled over the last 30 years and rates have risen faster than any other common cancer. Incidence is expected to triple over the next 30 years if people continue to sunbathe and use sunbeds.3

2. Demographics

Like most cancers, it is more common as age increases, with incidence rates in older people  still  accounting  for  the  majority  of  malignant  melanoma  cases.  However, research has shown that the incidence of skin cancer is rising in adults of working age, particularly those in the 30–39 age bracket.

Malignant melanoma is also disproportionately high in younger people and is the second most common cancer in young adults (age 15-34).4

Although incidence rates for malignant melanoma are higher among females, more men die from it.

3. Socio-economic

Historically, skin cancer has been linked to more affluent groups, probably due to higher frequency of foreign holidays. There is a 60–70% lower incidence among people from deprived areas compared with their more affluent peers. While evidence shows that wealthier individuals are still more likely to develop skin cancer, the overall pattern is changing as increasing numbers of people can afford to holiday abroad or use sunbeds.5

People  from  disadvantaged  groups  are  less  knowledgeable  about  skin  cancer prevention, practice less protective behaviour, and are less likely to check their skin.6

As a result of poor awareness and lower levels of protective behaviour, people from disadvantaged groups are more likely to be diagnosed with advanced stage tumours and have poorer survival outcomes.7 There is concern that sunbed salons, particularly coin-operated sunbeds, are predominantly located in deprived areas and therefore most often used by people from disadvantaged groups.

People working outdoors are more at risk of sun exposure. Outdoor workers receive on average 3 to 4 times more UV exposure each year than those who work indoors.8

People from lower social class groups, particularly men, are more likely to work outside and are therefore more at risk for certain skin cancers than those from higher social class groups.

0. Jersey perspective
1. Local statistics

Skin  cancer  in  Jersey  is  a  serious  health  problem,  with  around  350 new  cases diagnosed annually.9 Skin cancer accounts for around 40% of all new cancer cases

diagnosed each year in Jersey.

In addition to around 300 cases of non-melanoma skin cancer (NMSC), Jersey has around 30–40 individuals of all ages diagnosed with malignant melanoma each year and around 4 deaths each year from the disease. Malignant melanoma age standardised incidence  rates  (ASR)  are  significantly  higher  in  Jersey  in  comparison  to  the Southwest or England. The overall ASR in Jersey is 48 per 100,000 compared with 30 per 100,000 in SW and 22 per 100,000 in England as a whole, with a mean age of diagnoses of 61 years.

Malignant melanoma (C43) – Incidence

70 60 60 50 50

40 40

30 30

20 20 10 10 0 0

Diagnosis Period Diagnosis Period

Jersey Guernsey South-West England Jersey Guernsey South-West England

70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0

Area Area

Source: Channel Islands Cancer Registration Report, 2013

There are about 14 more cases of malignant melanoma than expected each year in Jersey: 60% higher than the Southwest rate.10

There are about 86 more cases of NMSC than expected each year in Jersey, 41% higher than the Southwest rate.

There are links between skin cancer rates and sunshine hours, age, ethnicity, and deprivation. This has relevance to Jersey given that –

• Jersey has 1,912 hours of sunshine per year compared to the national average of 1,420.
• 97.7% of Jersey's population are white, compared to the national average of 88%.
• 10.6% of Jersey's population are aged over 70.
• Jersey does not have a score to compare to the Index of Multiple Deprivation. However Jersey's unemployment rate is 4.7% compared to 7.7% in the UK.11 Nationally, an individual is more likely to get skin cancer if they are affluent, but mortality rates are higher in those from a deprived background.
• Jersey is defined as a coastal area, which generally have higher incidence of melanoma than inland areas.

In terms of prevention, fewer than one in ten (8%) adults in Jersey in 2012 reported that they never' take precautions to protect their skin from sun damage; over two- fifths  (43%)  always'  do  so.  A  higher  proportion  of  men  (13%)  never'  took precautions, compared to just 4% of women.12

2. Local economic impact

Although the number of deaths from skin cancer is relatively low compared to lung cancer or heart disease, the much higher number of skin cancer patients indicates economic costs should not be underestimated.

The cost to the NHS of diagnosing and treating skin cancer was estimated in 2011 to be £2,607 per registration of malignant melanoma, and £889 per registration of non- melanoma skin cancers.13 This rises to £20,020 and £1,413 respectively if indirect morbidity and mortality costs are taken into account.14

Based on these estimates, the direct cost of treatment of new malignant melanoma in Jersey  would  be  approximately  £104,000  per  year,  with  newly  diagnosed  non- malignant melanoma cases costing a further £300,000 per year. This equates to a total cost to the health service of £400,000 per year. The average national NHS spend in 2009/10 was £2,053 per 1,000 population; however, the higher estimated spend in Jersey  reflects  the  significantly  higher  incidence  rates  compared  to  the  England average.

Incorporating indirect costs would bring the overall cost to £800,000 for melanoma cases  and  £400,000  for  NMSC  cases  respectively,  with  a  total  cost  to  Jersey  of £1.2 million. These figures are in keeping with estimates that the direct cost to the NHS of treating skin cancer only accounts for approximately 42% of total costs, after taking into account indirect patient costs and indirect morbidity and mortality costs.

3. Local Patient Survey 2012

During the first 6 months of 2012, melanoma patients attending follow-up clinics at the Jersey General Hospital were asked to complete a questionnaire in order to identify risk factors relevant to the local population which would help inform the development of a targeted social marketing campaign, in accordance with NICE guidance.15

A  summary  of  the  survey  can  be  found  in  Appendix A.  However, the following findings may be important in informing local prevention initiatives –

52% had a hobby spending significant time outdoors, including 63% of all diagnosed males

only 25% had lived exclusively in Jersey under the age of 18

nearly half of respondents had moved to Jersey after the age of 18

87% recalled a severe sunburn in the past:

• 70%  reported  experiencing  severe  sunburn  while  away  from  the Island

• 1/3 experienced sunburn only in their adult years

63% had 10 or more sun holidays

average age of diagnosis of those with a history of sunbed use was 40 years compared to overall average age of diagnosis of 56 years

66% of those diagnosed under 40 had history of sunbed use compared to 15% of those diagnosed over the age of 40

nearly half were diagnosed over the age of 60

77% reported having heard or seen sun safety messages.

4. Local prevention and early detection initiatives

Several initiatives designed to raise awareness and prevent skin cancers in Jersey have taken place over a number of years. However, in the absence of a planned, integrated strategy, activities have lacked co-ordination and evaluation.

Recent activities include:

UV forecast

Since 2000, Public Health has funded Jersey Met in producing the UV forecast from May  to  September,  including  the  production  of  supporting  guidance  in  the  first 3 years.  The  UV  forecast  is  reported  several  times  a  day  on  BBC  radio  Jersey; Channel 103; the JEP and Channel TV, as well as being faxed/e-mailed to various business and tourist establishments.

Evaluation of the impact of the UV forecast was carried out in 2012, in conjunction with Highlands College. A survey of 100 outdoor workers and parents of pre-school children indicated that 96% had heard of the UV index, of which 98% reported that it always' or sometimes' prompted respondents to take precautions in the sun, even though only 71% reported knowing the purpose of the Index. This was comparable to findings from the JASS survey 2012, where 95% indicated they had heard of the UV index, with 85% reporting it always' or sometimes' prompted respondents to take precautions in the sun.

Healthy Schools

The Jersey  Healthy  Schools  website  provides teachers  with lesson  plans,  activity sheets, posters and resources for teaching sun safety, as developed by the Cancer Research  UK  SunSmart  campaign.  In  addition, the  development  of  a  Sun  Safety policy was included as one of the criteria for achieving a Healthy Schools award locally when the programme was modified in 2010. Eleven schools currently have Healthy Schools status and several schools have devised shade structures for their playgrounds in recent years.

Child Accident Prevention (CAP)

CAP provides an annual interactive workshop to Year 5/6 students, which includes a scenario on sun and beach safety.

Donna Ann and Melanoma Charity

During  2012–14,  the  Charity  has  worked  in  partnership  with  the  Dermatology Department,  Cleveland  Clinic  and  Channel 103  to  develop  a  media  campaign promoting sun safety and early detection.

The Charity also provided a free mole' clinic on the beach in August 2012, followed by a series of free mole' clinics by appointment in 2012–14.

General Information

Over the past 10 years, the Public Health department has supplied leaflets, posters and advice  on  policy  development  to  various  organisations,  including  pharmacies, outpatients department, schools and construction companies. Press release and media opportunities occur on an annual basis, particularly during the summer months. Health visitors also routinely give appropriate information on skin care to children of young parents.

5. Summary of national and regional guidance on skin cancer prevention

There  are  no  current  national  or  local  targets  specifically  related  to  skin  cancer prevention;  however,  there  are  examples  of  national  and  regional  guidance  and programmes which support local initiatives:

1. The  National  Institute  for  Health  and  Clinical  Excellence  (NICE)  has produced  guidance  on  skin  cancer  prevention.  A  summary  of  the recommendations can be found in Appendix B.
2. SunSmart is a national campaign to promote behaviour change in order to prevent skin cancer and raise awareness of the early signs of the disease. It was commissioned by the United Kingdom Health Departments in 2003 and is managed by Cancer Research UK. The campaign emphasizes evaluation and evidence-based practice, and takes a strategic approach to targeting messages to key groups such as children and young adults, new parents and outdoor workers.

The key messages are –

• Avoid burning, with particular emphasis on young children.
• Move to the shade between the hours of 11 a.m. – 3 p.m. when the UV rays are strongest.
• Wear protective clothing, hat and sunglasses.
• Apply generous amounts of sunscreen with a SPF of at least 15 and choose a broad-spectrum' brand that protects against UVA rays (the more stars the better) and re-apply regularly.
• Sunbeds are not a safe' alternative to sun-tanning.

3. The  Southwest  Public  Health  Observatory  is  currently  leading  a  project designed to increase awareness of skin cancer in the Southwest and nationally. The project has 3 main elements –

• Production of Skin Cancer Profiles to provide needs assessment data for commissioners, to enable local figures to be compared to national and regional ones, and to enable local target setting.
• Production of skin cancer prevention toolkits for cancer networks, local  authorities,  voluntary  organisations,  schools,  strategic  health authorities, and regional departments of health.
• Design  and  production  of  social  marketing  interventions  with  the University of the West of England.

Six priority audiences have been identified, including –

• Mothers of young children and childcare providers
• Parents of school-age children
• Teenagers
• Outdoor workers
• Sports and leisure participants and spectators
• Older people (early diagnosis).

0. Evidence base and best practice for skin cancer prevention initiatives:

The prevalence of skin cancer, its seriousness and preventability makes sun safety an ideal focus for health promotion efforts, but results of efforts to promote sun safety to date have generally been disappointing. For example, despite intensive publicity over the last 30 years aimed at prevention, Australia continues to be at the forefront of a global epidemic in skin cancer among fair-skinned people. Since the establishment of the Slip Slap Slop campaign in 1981, melanoma rates continue to increase in Australia despite a decrease in non-melanoma skin cancers.16

While  the  evidence  on  multi-component  interventions  to  prevent  skin  cancer  is generally weak, there is evidence to indicate that information provision (including one-to-one and group-based verbal advice) can have a positive, short-term effect on people's knowledge and attitudes. There is also evidence to indicate that national mass-media  campaigns  can  help  raise  awareness  of  the  risks  of  ultraviolet  (UV) exposure and can also have a positive impact on knowledge, attitudes, behavioural intentions and actual behaviour in the short term.

1. Effectiveness of interventions

• The Skin Cancer 2012 Expert Group agreed that campaigns like SunSmart are likely to lead to increased awareness and may promote earlier detection of skin cancer, which influences prognosis and treatment complexity. It proposed sustained action be taken to prevent and/or encourage earlier diagnosis of skin cancer through several routes. However, the long lag-time between ultraviolet radiation exposure and detection of most forms of skin cancer means the ultimate  effectiveness  of sun-protection  campaigns on  cancer  rates  is  still uncertain.
• The key findings from the Office of National Statistics trend analysis of the SunSmart campaign over 5 years show that there has been a significant trend towards  increased  awareness  of  the  importance  of  protecting  children, checking moles and going to the doctor about moles, as well as avoiding getting sunburned. No significant trends in attitudes towards the benefits or risks of the sun were observed, although significantly more people reported using shade, covering up and avoiding sunbeds to protect themselves from skin cancer. Overall, reported awareness levels are low, as are the proportions

of people reporting SunSmart behaviour.17

• There  is  evidence  that  teenagers  are  susceptible  to  appearance-based interventions. Some studies have examined the relation between appearance concern and responses to an intervention targeting tanning and sunscreen use among  young  adults.18  The  interventions  produced  increases  in  safe  sun attitudes, intentions, and behaviour.
• There  is  currently  no  evidence  to  support  a  national  population-based screening programme for melanoma.19
• There is currently a lack of evidence to support the cost-effectiveness of:20

• specific  multi-component  interventions  (for  example,  combining information with resources such as hats or sunscreen),

• the addition of shade structures to existing buildings.

2. Considerations when planning interventions

Target audience

• Unlike most cancers, melanoma is disproportionately high in younger people. Malignant melanoma is the second most common cancer in young adults (aged 15–34)21 and approximately one third of all cases of melanoma occur in people under 50.
• Malignant melanoma is twice as common in young women as in young men, but more men die from it. Given this, the importance of intervention strategies that focus on men in terms of prevention and early detection is paramount.
• Research has shown that one incidence of serious childhood sunburn can double the risk of malignant melanoma22. Simple behavioural changes such as avoiding the strongest sun and appropriate use of sunscreen, hats and long' clothes could prevent 90% of cases.23
• Melanoma incidence increases with age; almost three-quarters of male cases occur in those aged over 50. Among men over 50, core risk groups include –

• Outdoor labourers and those who have spent time working in hot climates abroad, such as former merchant seamen

• People who spend large amounts of leisure time outdoors, for example golfers

• Those who do not use any protection in the sun

• Sunbed users

• Sun lovers' who holiday abroad often.

• There has been an increase in overseas holidays, often to destinations where sunburn  can  occur  far  quicker  than  in  the  UK.  Here,  previous  research

indicates that British tourists, especially men, place a high value on tanning.24

Message framing

The medium by which the communication occurs can have a significant impact on the effectiveness of the communication.

• There is strong evidence that positively framed messages are more effective than  negatively  framed  messages  for  prevention  behaviour  such  as  sun protection strategies, with the reverse being evident for detection strategies such as skin cancer screening.25 26 It has been argued that positive framing fosters a greater self-efficacy, which in turn is a major factor in compliance behaviour and therefore long-term behaviour change.
• Conversely, negative message framing has been found to be more effective for illness-detecting behaviour,27 where there is uncertainty about the outcome of the behaviour but awareness of the danger of not getting a problem detected early,  i.e. promoting  screening  programmes  that  prevent  a  more  serious outcome.
• NICE guidance PH32 recommends messages be simple, succinct and tailored to the target group. Messages should include a simple explanation of how UV

exposure can damage skin, how individuals can assess their own risk and take protective measures, and give a balanced picture of both the risks of over- exposure and the benefits of being out in the sun.

Barriers

Failure to convert increased awareness into actual behavioural change is a recurring theme within the sun safety literature. There are a number of contextual factors that affect the development of potential interventions –

• The perception that skin cancer risk in the UK is low. The population is not sensitised  to  skin  cancer  as  a  major  health  risk  in  the  same  way  as Australasian populations.
• The lack of central government support for and endorsement or funding of interventions.
• Strong  normative  beliefs,  particularly  among  young  people,  about  the attractiveness and social value of suntans. Social norms are very strong in regard  to  the  perceived  benefits  of  acquiring  a  suntan.  While  these  are strongest among adolescents and young adults and weaken somewhat with age, they still impact on adult behaviour, with parents tending to use less protective strategies for themselves than for their children.
• Current debates across both academic and consumer media regarding sun exposure and Vitamin D must be recognised as complicating factors that are not  fully  controllable.  For  example,  in  relation  to  the  Vitamin D  debate, messages from sources such as consumer media regarding the positive effects of sun exposure in building Vitamin D levels can undermine those from other sources, such as official sun protection recommendations regarding limiting exposure to sunlight.

• A significant problem exists in relation to a perceived conflict between the SPF factors recommended by health sources and by commercial marketing sources. SPF15 or more' recommendations are made in the range of existing leaflets provided by Cancer Research UK and other health organisations. In relation to children, SPF30+' recommendations are made by major brands. This perceived conflict may cause other information in the health organisation leaflets to be disregarded as they are seen to lack credibility.
• A lack of integration of messages and behaviours among stakeholder groups may be an issue. For example, despite sun care policies in schools, children may actually be discouraged from applying sunscreen at school. In addition, there  is  a  perceived  discrepancy  between  messages  promoting  physical activity and messages advising avoidance of the sun between 11 a.m.–3 p.m.

Cost

NICE guidance suggests that mass-media campaigns and local activities to provide skin cancer prevention information need to be low cost to be cost-effective, due to the –28

• small effects associated with the interventions
• high costs of the interventions assessed
• small, quality-adjusted life year (QALY) gain associated with prevented cases of non-melanoma skin cancer
• small number of avoided cases of malignant melanoma.

Sun exposure and Vitamin D controversy

Vitamin D is acknowledged as essential for good bone health. Low levels are linked to bone conditions such as rickets in children, and osteomalacia and osteoporosis in adults. The evidence suggesting that Vitamin D might protect against cancer, heart disease, diabetes, multiple sclerosis and other chronic diseases is growing, but remains inconclusive.

Exposure to ultraviolet B (UVB) radiation in sunlight is the most efficient way to boost  Vitamin D  supply,  but  it  is  still  unclear  how  much  sunlight  is  required  to produce a given level of 25(OH)D. Environmental and personal factors greatly affect Vitamin D production in the skin, making it difficult to recommend a one-size-fits-all level of exposure for the general population.

The best estimates suggest that for most people, everyday casual exposure to sunlight is  enough  to  produce  Vitamin D  in  the  summer  months,  provided  optimal environmental conditions.29 It has been consistently shown that Vitamin D can be efficiently and sufficiently produced at doses of UV below those which cause sunburn (i.e. reddening of the skin). After prolonged UV exposure, Vitamin D is converted into inert substances in the skin. Thus, additional UV exposure provides no additional Vitamin D but linearly increases levels of DNA damage and risk of skin cancer. Some unprotected exposure in the hours close to solar noon may be necessary, but people should not be advised to deliberately sunbathe or expose themselves to the sun for long periods of time in order to produce more Vitamin D.

The Public Health Interventions Advisory Committee (PHIAC) believes a balance should be struck in ensuring that messages regarding protective measures also outline the benefits of sun exposure, including an increased sense of wellbeing, synthesis of Vitamin D and opportunities for physical activity.

7.0  Action Plan for Jersey

Given the rising incidence of skin cancer in Jersey, there is clearly a need for an integrated, multi-agency strategy to promote the prevention and early detection of skin cancers which is consistent with the evidence base.

Appendix C outlines an action plan (2014–2018) consistent with NICE guidance and developed in consultation with key stakeholders as follows –

Short-term

• Establish a Working Group with key stakeholders to agree and monitor the strategy
• Continue  established  ongoing  initiatives  (clinics/G.P. training/Healthy Schools/UV forecast)
• Scope and develop Love your Skin' campaign with Highlands College
• Provision of SunSmart resources to pre-school settings
• Develop guidance for maternity/health visitor/early years/special needs staff.

Medium-term

• Scope and develop Know your Skin' campaign for men over 50
• Extend Love your Skin' campaign to secondary schools/youth service.

Long-term

• Engage holiday companies in promoting sun safety
• Develop social marketing campaign for outdoor workers/sport venues
• Consider introduction of sun bed legislation to prohibit use under age of 18, in line with UK legislation.

8.0  Recommendations:

• Establish  a  multi-agency  working  group  to  oversee  the implementation and monitoring of the agreed integrated strategy for 2014 and beyond.
• Ensure measurable objectives and evaluation processes are established for proposed initiatives.
• Ensure the agreed strategy has support from the Health and Social Services management executive for consideration and development of potential future initiatives and funding requirements.

APPENDIX A Summary of melanoma patient survey January–July 2012

Total: 31 patients:

1. Gender:

61% male (19)

39% female (12)

Not entirely representative of local patient population, as 2012 C.I. Cancer Registration Report indicates 3 year average (2007–2009) of 51% females diagnosed, to 49% males.

2. Age:

20–40 – 10%

40–60 – 42%

60 + – 39%

No age given – 9%

3 (10%) were outdoor workers (all male).

52% had a hobby spending significant time outdoors – this represented 63% of all diagnosed males; (12 males/4 females).

3. Residence history:

Only 8 (25%) had lived exclusively in Jersey.

8 (25%) lived only in Jersey under age of 18.

9 (35%) lived partly in Jersey under age of 18.

14 (45%) had not lived in Jersey under age of 18 – i.e. moved to Jersey as adults.

4. Severe sunburn:

87%  (27)  recalled  a  severe  sunburn  in  the  past.  Of  those,  26%  suffered sunburn in Jersey and 55% suffered sunburn away; 15% both home and away. Therefore 41% suffered sunburn in Jersey; 70% suffered sunburn elsewhere.

9 as an adult only (33%).

10 as a child or teenager (36%). 5 as both (19%).

5. Frequency of sun holidays: Under 10 – 23%

10–20 – 32%

20+ – 32%

6. Sunbed use:

7 had used sunbeds (23%).

Average age of diagnosis = 40 years compared to overall average of 56 years. 66% of those diagnosed under 40 had history of sunbed use compared to 15% of 40+.

7. Sunbathing:

Only 10% reported never' sunbathing under the age of 18. Only 6% reported never' sunbathing over the age of 18.

32% often' sunbathed under the age of 18. 39% often' sunbathed over the age of 18.

8. Precautions:

People were more likely to have taken precautions against sunburn over the age of 20.

68% sometimes; 26% always; only 3% reported never' taking precautions, compared to 23% reporting never' taking precautions under the age of 20.

9. Skin type:

67% classified themselves as having Type III or IV skin. This is based on self-assessment.

10. Age of diagnosis:

20–30 – 10% 30–40 – 13% 40–50 – 10% 50–60 – 26% 60+ – 42%

11. Family history:

Yes – 23%

No – 65%

Don't know –10%

12. Awareness:

77% had heard/seen sun safety messages (should have asked previous to diagnosis').

13. Location of melanoma:

8 back (all male)

6 arm (3 male/3 female)

4 neck/face (2 male/2 female) 5 leg (4 female/1 male)

1 abdomen (male)

1 breast (female)

APPENDIX B NICE Guidance PH32

Summary of

Skin cancer prevention: information, resources and environmental changes

Recommendation 1: Information Provision: Delivery

• Continue to raise awareness of the risk of UV exposure and how to protect against it via:

• National mass media campaign
• Local, low-cost information related activities
• Ensure national and local messages are regularly repeated and revised.

Recommendation 2: Information Provision: Developing national campaigns and local activities

• Identify groups, behaviour or activities which need to be targeted
• Ensure activities are evidence-based
• Establish clear, measurable objectives
• Develop and pilot national campaigns (where feasible run pilots for local activities).

Recommendation 3: Information Provision: Message content

• Include a simple explanation of how UV exposure can damage the skin
• Explain how someone can assess their own risk
• Give a balanced picture of the risks and benefits of being out in the sun
• Offer a range of options to help protect the skin against UV damage.

Recommendation 4: Information Provision: Tailoring the message Messages should:

• Be simple, succinct and tailored to target groups
• Address the social and practical barriers to using sun protection
• Enhance people's belief in their ability to change
• Be positive rather than negative.

Recommendation 5: Protecting Children, Young People and Outdoor workers

• Assess if there is a risk of harmful exposure to the sun
• Aim to prevent children and young people from getting sunburned
• Encourage outdoor workers to wear protection to avoid getting sunburned
• Assess training needs of the staff.

Recommendation 6: Providing Shade

• Consider  providing  areas  of  shade  when  building  and  constructing  new building
• For all new developments, ensure there is adequate access to areas of shade for people with disability
• Check whether it is feasible to provide areas of shade when developing or redeveloping communal outdoor areas

APPENDIX C Skin Cancer Prevention Strategy Action Plan 2014–2018

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