Appendix 1: Priority population groups
All people in NSW are at risk of overexposure to UVR, thus the Strategy focuses on a universal, population level approach. However, to address specific risk factors some strategies may require a more targeted approach.
The comprehensive approach outlined in the Strategy includes a combination of both population‑level strategies and complementary strategies targeted to priority population groups and to individuals at higher risk of developing skin cancer.
The major causative factor in the development of melanoma and non‑melanoma skin cancer (NMSC) is UVR exposure and for most individuals, the main source of exposure to UVR is the sun.14 An individual’s risk of skin cancer from UVR exposure is determined by:
- personal behaviours (i.e. attitudes toward tanning, intentional tanning including the use of solaria, adoption of sun protection behaviours, social and group norms, participation in outdoor activities and/or work)
- personal characteristics (i.e. skin type, hair and eye colour, number of freckles or moles, personal and family history of skin cancer, and genetic constitution).15,16
Both childhood and adult exposures contribute to the risk of developing skin cancer and it is likely that both cumulative and episodic exposures are important.11,17,18
Regular and frequent exposure (commonly occupational) increases the risk of squamous cell carcinoma (SCC), while more ‘intermittent’ exposure to UVR (commonly recreational and to parts of the skin usually covered on most days) increases the risk of basal cell carcinoma (BCC) and melanoma.14
There is growing evidence that relative risk of melanoma increases with cumulative UVR exposure and thus that overexposure later in life continues to add to the risk of developing melanoma.17,18 Solaria use, particularly before the age of 35 years and more frequent use, increases a person’s risk of developing melanoma.19
Children (under 12 years of age)
Children are a key priority group for sun protection since the risk of developing melanoma and other skin cancers are strongly related to spending childhood in a high UVR environment, such as in NSW. Childhood is also associated with the development of melanocytic nevi (moles) which are a risk factor for melanoma.
Those responsible for the care of children, particularly parents and care providers, have a direct role to play in achieving adequate sun protection for children. This highlights the need for targeted interventions to model appropriate sun protection behaviours and create protective environments.
Adolescents and young adults (13–24 years of age)
In adolescent years parental influence tends to diminish while peer influence and broader social norms play an increasingly important role in shaping attitudes and behaviours.
Adolescents and young people generally adopt UVR protection behaviours less frequently than adults and it is more challenging to achieve attitude and behaviour changes among teenagers.20
Adolescents spend more time in the sun than any other age group. While they have been shown to have a high level of knowledge of the dangers of sun exposure, they engage in relatively fewer UVR protection behaviours.
Particular interventions are required to address young people’s perception of sun tanning as desirable.
Adult males (40 years of age and older)
There is growing evidence that relative risk of melanoma increases with UVR exposure in later life.17,18
The incidence of melanoma increases dramatically for males from around 45 years of age and of further concern is the statistically significant 11 per cent increase in male mortality rates from melanoma reported for the period 1999–2008.13
This increasing evidence suggests older adults, particularly males, should be targeted with specific UVR protection strategies, in addition to workplace strategies, from the age of 40 years, if not earlier.
High risk individuals
People at higher risk of melanoma include individuals who:
- are light‑skinned, always or usually burn in the sun and rarely or never tan or are classified as Skin Type I and II under the Fitzpatrick Skin Photo Type Classification system*
- have more than a few moles
- have lived in Australia from childhood
- have a personal history or family history of skin cancer, especially melanoma
- use solaria or other artificial tanning devices that emit UVR
- have high levels of recreational sun exposure (particularly for melanomas on parts of the body that are mainly exposed recreationally)
- work outdoors (specifically for melanomas on parts of the body usually exposed to the sun when working outdoors).
Of these, all are also factors that predict a higher risk of other skin cancers except having more than a few moles and a personal or family history of melanoma. In addition, squamous cell carcinomas of the skin are more associated with occupational exposure and basal cell carcinomas appear more strongly associated with recreational exposure.
*Fitzpatrick Skin Photo Type classification system means a system for the classification of skin photo types, as referred to in Australian and New Zealand Standard entitled AS/NZS 2635:2008, Solaria for cosmetic purposes.
Note on culturally and linguistically diverse communities
Figure 1 shows melanoma incidence and mortality rates in NSW by region of birth and highlights that people born in Australia are significantly more likely to develop and die from melanoma than people born in all other regions.
People born in Southern Europe, Asia or the Middle East are significantly less likely to develop and die from melanoma.22
Figure 1: Melanoma incidence by region of birth
Melanoma - age standardised rates
Persons, 2006-2010 by region of birth
The risk of developing skin cancers is strongly associated with skin type.21 People with fairer skin which burns easily are at higher risk than those with darker skin (see Figure 1).
Figure 2: Skin types
|Skin reaction to the sun||What you need to know|
|Type I||Always burns easily, never tans, extremely sun sensitive||You are at greatest risk of developing skin cancer so make sure you protect your skin. You should also check your skin regularly, be aware of any changes and see a doctor if you notice anything.|
|Type II||Always burns easily, tans minimally, very sun sensitive|
|Type III||Sometimes burns, tans gradually to light brown, minimally sun sensitive||Even though your skin tans, this is still a sign of UV damage which can lead to skin cancer and your skin is vulnerable. Remember that a tan is not a healthy glow. Always protect your skin from the sun whenever the UV Index is 3 and above.|
|Type IV||Burns minimally, always tans to moderate brown, minimally sun sensitive|
|Type V||Rarely burns, tans well, skin not sensitive to sun|
|Type VI||Never burns, deeply pigmented, skin not sensitive to sun||Your skin offers more protection against UV radiation than other skin types, but skin cancers can occur in people with very dark skin. Your eyes are vulnerable to damage from UV radiation so wear a hat and sunglasses and avoid excessive exposure.|
Note on Aboriginal and Torres Strait Islander communities
Melanoma is less common amongst Aboriginal and Torres Strait Islander people than the rest of the Australian population, with 9.30 cases per 100,000 compared to 33 cases per 100,000 for non‑Aboriginal and Torres Strait Islander people.23
This low incidence is primarily due to protection provided by the increased epidermal melanin in darker‑coloured skin that filters twice as much UVR as fairer skin.24
While incidence of melanoma in Aboriginal and Torres Strait Islander people is one‑quarter of that for other Australians, the incidence to mortality rate is higher, with 28 per cent of Aboriginal and Torres Strait Islander people diagnosed with melanoma dying, compared to 19 per cent for other Australians.25 This suggests that Aboriginal and Torres Strait Islander people more commonly present with an advanced stage of melanoma24 or have less access to health services.26
It should be noted that the analysis discussed above draws on a limited sample, with only 60 people being diagnosed with melanoma identifying as Aboriginal or Torres Strait Islander in a four year period (2004–2008). The Indigenous status is not stated for a large proportion of those people diagnosed (41 per cent).25
Given the lower rate of melanoma amongst Aboriginal and Torres Strait Islander people, they are not currently identified as a priority population for skin cancer prevention in NSW.