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3 Slip, Slop, Slap and Wrap: Turning-up the heat on sun safety and skin cancer prevention! PHO Grand Rounds, April 3 th, 2018 Thomas Tenkate, DrPH School of Occupational and Public Health

4 Presentation Overview Why is skin cancer prevention important? What is UV Radiation Sources of UV Radiation Health Effects of UV Exposure Solar UV Exposure Prevention Measures What is our Call to Action? 4

5 Why is Skin Cancer Prevention Important? Skin cancer is the most commonly diagnosed cancer in the United States, yet most cases are preventable. Every year in the Unites States, nearly 5 million people are treated for skin cancer, at an estimated cost of $8.1 billion. Melanoma, the most deadly form of skin cancer, causes nearly 9,000 deaths each year... The rates of skin cancer in our nation are increasing, creating a serious public health concern we cannot ignore. (US Surgeon General s Call to Action to Prevent Skin Cancer, 2014) 5

6 WHAT IS UV? 6

7 Radiation can be thought of as energy in transit waves or particles Photon energy and wavelength inversely proportional. Photons with <12.4eV (>100nm) don t have sufficient energy to ionize matter. (Tenkate, 1994) 7

8 SOURCES OF UV 8

9 Sources of UV Natural: the sun exposure is unavoidable! Electrical or gaseous discharge: incandescent lamps, fluorescent lamps, welding arcs, tanning beds. Lasers Artificial sources: Emit UV either deliberately (e.g. for medical therapy, tanning beds) or as a by-product (e.g. welding). Most sources also emit other wavelengths of radiation (e.g. infrared, visible). Some sources also emit UV-C (for solar UV, this is absorbed by the ozone layer). 9

10 0.5% 1.5% 6.3% 38.9% 52.8% (Source: 10

11 What Factors Influence Solar UV Levels at the Earth s Surface? MAJOR Time of day Season Latitude Altitude Total column ozone Aerosols Cloud cover Tilt of earth s axis Earth-Sun Distance MINOR (Not well known) Short term TCO 3 variations due to weather systems Quasi-Biennial Oscillation The El Niño-Southern Oscillation (ENSO) Sunspots (solar activity) Volcanic eruptions Unresolved long term trends (Source: Dr Michael Kimlin) 11

12 (Source: Pinault etal, 2017, Health Reports 28(5):

13 ( TN065/uv/dailymaxuv-Brewer gif ) 13

14 (Source: Australian Bureau of Meteorology) 14

15 HEALTH EFFECTS OF UV 15

16 Adverse Health Effects of Solar UV Skin: Erythema (S) Chronic sun damage (V) Photodermatoses (S) Basal cell carcinoma (S) Squamous cell carcinoma (S) Malignant melanoma (S) (Based on: Armstrong, 1994; Armstrong & Kricker, 2001; Oliva & Taylor, 2005) Eyes: Climatic droplet keratopathy (L) Pinguecula (L) Pterygium (L) Photokeratitis (S) Cortical Cataract (S) Solar retinopathy (S) Uveal melanoma (S) AMD (I) Weight of evidence: S = sufficient, L = limited (suggestive, not conclusive), I = inadequate, V = variable 16

17 Skin Cancer BCC, SCC and Melanoma account for 99% of skin cancers BCC and SCC together are referred to as Non-Melanoma Skin Cancer (NMSC); new preferred term is keratinocyte carcinoma Worldwide: 3 million cases of NMSC & 132,000 cases of melanoma occur each year ( 1 in 3 cancers is a skin cancer); global incidence continues to rise NMSC: In Canada, 78,300 new cases expected in 2015, with 440 deaths in 2014 (Canadian Cancer Society, 2014 & 2015) Melanoma: In Canada, 6,800 new cases expected and 1,170 deaths expected in 2015; rates are increasing; 8 th most prominent type of cancer (Canadian Cancer Society, 2015) All cancer: In Canada, 202,400 new cases in 2016, not including NMSC; cases of skin cancer = cases of top 4 cancers combined (lung & bronchus, colorectal, breast, prostate) (Canadian Cancer Society, 2016) 17

18 (Source: 18

19 Types of Skin Cancer Basal cell carcinoma (BCC): Most common type of cancer and are generally treatable. Arise from the cells in the bottom layer of the epidermis. Occur more frequently on skin which is chronically exposed, e.g. face, head, neck; treatment noticeable disfigurement. BCC are 70-80% of NMSC in males & 80-90% in females. In USA, BCC appears to be increasing. (US Dept. Health & Human Services, 2014) (Photo: courtesy of Kathryn Tenkate) 19

20 Types of Skin Cancer Squamous cell carcinoma: Second most common form of skin cancer: 20% of NMSC Arise form the squamous cells in the outer layers of the epidermis; often from actinic keratosis rough, scaly patches on sun-exposed areas Usually occur in the prominent, sun-exposed areas, like face, head, neck. More deadly than BCC; in the USA, approx. 4,000 people die each year from SCC (US Dept. Health & Human Services, 2014) 20

21 Types of Skin Cancer Melanoma: 3 rd most common type of skin cancer, but most deadly. Lifetime probability of developing melanoma = 1.7% (vs. 44.7% for all cancers) (Canadian Cancer Society, 2016) Develop from melanocytes. Nodular and superficial spreading melanomas: can occur in any location on the body Lentigo maligna melanoma: usually on head, neck, face Acral lentigninous melanoma: palm of hands, soles of feet, under nails. (US Dept. Health & Human Services, 2014) Suspicious moles: A Asymmetry B Boarder (irregular) C Colour D Diameter (>6mm) E Evolving Ugly 21 duckling

22 UV & Skin Cancer Most important risk factor is exposure to ultraviolet (UV) radiation (Elwood, 2004) IARC: solar radiation, UV radiation (UV-A, UV-B, UV-C), UVemitting tanning devices = Group 1 carcinogen (IARC, 2012) 14 th Report on Carcinogens: solar radiation = known human carcinogen (US Dept. Health and Human Services, 2016) Most important factor in determining level of UV exposure is outdoor work (Kimlin & Tenkate, 2007) UV exposure is the most preventable cause of skin cancer ; prevention focus on: excessive, avoidable or unnecessary UV exposures & intentional exposure for skin tanning (US Dept. Health & Human Services, 2014) 22

23 Environmental Burden of Cancer in Ontario Only Melanoma cases; NMSC = 12x melanoma = total cases ~ 30,480 (Source: CCO & PHO, 2016: _of_cancer_in_ontario_2016.pdf) 23

24 Economic Burden of Skin Cancer USA: Skin cancer treatment: est. $8.1 billion/year ($4.8 billion for NMSC, $3.3 billion for melanoma). Lost workdays + restricted activity costs: $76.8 million for NMSC, $29.4 million for melanoma Lost years of life/case = 20.4 years (vs 16.6 years for all malignant cancers) annual productivity losses ~ $4.5 billion ($3.5 billion for melanoma, $1.0 billion for NMSC). Canada: 2004 est: $531 million CAD/year (direct = $66.05 million, indirect = $465.7 million) 2031 est: $921 million CAD/year (direct = $ million, indirect = $ million) (US Dept. Health & Human Services, 2014; Krueger etal, 2010) 24

25 SOLAR UV EXPOSURE 25

26 Human Exposure to UV from the Sun Combination of direct + diffuse + reflected UV radiation from the sun Exposures to humans vary according to: Time spent outdoors Time of day and year (ambient UV levels) Activity undertaken Body posture Personal behavior UV protection used Exposure to artificial sources School children: log-normal distribution, 2-fold difference in exposure based on activity/behavior (Diffey etal, 1996; Gies etal, 1998) Indoor vs outdoor worker 26

27 Levels of Solar UV Exposure Study Category % of Ambient Larko and Diffey (1983) Holman etal (1983) Gies and Wright (2003) Leach etal (1977) Larko and Diffey (1983) Holman etal (1983) Outdoor workers 10 to 70% Physical Education Teachers 30 to 50% Gardner, Carpenter, Bricklayer 44 to 85% Construction workers (median, all) 26% Pavers-Tilers 114% Traffic controllers 69% Roofer 45% Indoor workers 2 to 4% Indoor workers 6% Classroom Teacher 7 to 11%

28 Exposure Time for Erythema/Sunburn Summer in Toronto (Tenkate, 2016; based on data from Gies etal, 2009) 28

29 UV Exposure vs Skin Type (Tenkate, 2016; based on data from ICNIRP, 2010) 29

30 ( nary/max/stn065/uv/dailymaxuv-brewer gif ) (WHO, 2003 INTERSUN Guide & Compendium) 30

31 Sun Exposure Canadian Community health Survey On a typical summer day (weekend or day off), respondents (n=53,130): 13% did not spend time in the sun between 11am and 4pm 41% reported < 2 hours in the sun 29% reported 2 to 4 hours in the sun 17% reported > 4 hours in the sun (Pinault & Fioletov, 2017) 31

32 Occupational Sun Exposure Canada Levels of Exposure: Low: almost never exposed truck & delivery drivers Moderate: indoor/outdoor mix crane operators, carpenters, maintenance labourers, couriers High: >75% outside farmers, construction (Peters etal, 2012) (OCRC & CAREX, 2016)

33 Outdoor workers: spend more time in sun during work and leisure than other adults; more likely to get burnt 33 (CPAC nd National Sun Survey)

34 UV Exposure (SED) Outdoor Workers Solar UV Exposures Outdoor workers in 12 workplaces in 3 provinces in Canada wore PSF badges for one work day in August/September 2016; 347 worker measurements Average UV Exposure of Outdoor Workers (SED) All Municipalities (n=306) All Utilities (n=41) British Columbia (n=95) Nova Scotia (n=97) Ontario (n=154) All sites (n=347) TLV (Tenkate etal, 2017) 34

35 PREVENTION MEASURES 35

36 Reducing the Risk of Skin Cancer Comprehensive suite of strategies at multiple levels: Individuals Clinicians Communities and schools Outdoor work settings Local, State & National Policies, Legislation & Regulation (US Dept. Health & Human Services, 2014) 36

37 Individual Sun Protection Measures (WHO, 2003 INTERSUN Guide & Compendium)

38 Individual Sun Protection Practices Canadian Community Health Survey: Protection measures used: sunscreen to face (45%), sought shade (41%), wore a hat (39%), sunscreen on body (38%), long pants/skirt (27%). Varied by sex: women more likely to seek shade and use sunscreen; men were more likely to wear a hat and long pants Varied by age: seeking shade and wearing protective clothing more common for older ages; sunscreen use more common for younger individuals. Sunburn: 33% reported a sunburn in the last 12 months; men more likely to report sunburn Sun avoidance and protective clothing use more associated with lower risk of sunburn, while sunscreen users had a higher risk of sunburn (Pinault & Fioletov, 2017) 38

39 Barriers to Individual Use of Sun Protection Lack of general knowledge or awareness about the risks associated with sun exposure Think that they are low risk (particularly for darker skinned individuals) Do not perceive cancer as preventable Lack of understanding of the UV Index Costs of protective clothing & sunscreen Personal clothing style preferences Resistance to using sunscreen due to perceptions that it is messy, inconvenient, feminine (US Dept. Health & Human Services, 2014) 39

40 Survey of Worker Sun Protection Behaviours Workers who reported Usually/Always using.. Tinted safety glasses or sunglasses (80% ) SPF 30 Sunscreen (35%) Long pants (91%) Hard hat with brim (22%) Enclosed boots or shoes (99%) UV rated clothing (11%) Survey administered in 2015 as part of SSAWC project to 14 workplaces in 4 provinces (836 workers responded) (Tenkate etal, 2016)

41 Had a sunburn 60% 40% 4% missed work 20% 0% 60% 40% 20% 0% Natural Shade Portable or artificial shade Limit time in sun 11am-4pm (Tenkate etal, 2016) 41

42 Case Study: Sun Safety Practices of Lifeguards City of xxxx has a Sun Protection Policy & Guidelines Aim: to determine what sun safety practices are being undertaken by lifeguards at public swimming pools, wading pools and beaches Methods: Checklists developed of engineering, admin.& PPE controls Observational study over July & 1 st week of August 2014 Student RA visited ½ of all venues in xxxx (29 outdoor pools, 48 wading areas, 6 beaches) & observed sun safety practices of 198 / 235 staff present (84%) Results: Variable levels of sun protection, mainly PPE (tanktop, shorts, sunglasses), limited hat use, some use of shade; overall not in compliance with Sun Protection Policy or Good Practice Guidelines (Tenkate & Leman-Veggers, in preparation) 42

43 Sun Safety Messages for Public Education in Canada Enjoy the sun safely, Protect your skin, Protect your eyes When the UV Index is 3 or higher, protect your skin as much as possible; in general, the UV Index in Canada can be 3 or higher from 11am to 3pm between April and September, even when it s cloudy Seek shade or bring your own Wear clothing and a wide-brimmed hat that cover as much skin as possible, as appropriate to the activity and weather Use sunscreen labelled,broad spectrum and water resistant, with an SPF of at least 30, on skin not covered by clothing. Apply sunscreen generously and reapply when required. Don t use UV tanning equipment or deliberately try to get a suntan, and avoid getting sunburnt Wear sunglasses or prescription eyeglasses with UV-protective lenses + wear wide-brimmed hat for added eye protection (Marrett etal, 2016) 43

44 Skin Cancer Prevention Intervention Evidence Intervention Outdoor recreational & tourism settings Outdoor occupational settings Child care centre-based interventions Primary & middle school-based interventions Multicomponent community-wide interventions High school and college-based interventions Mass media Interventions targeting children s parents & caregivers Healthcare settings and providers Recommendation Recommended Recommended Recommended Recommended Recommended Insufficient evidence Insufficient evidence Insufficient evidence Insufficient evidence - Behavioural counseling (children & adults with fair skin)* Recommended - Behavioural counseling (adults >25years old)* Recommended (depends on patient) - Counseling about skin self-examination* Insufficient evidence (Community Preventive Services Task Force; *US Preventive Services Task Force 2018) 44

45 US Surgeon General s Call to Action Goals 1. Increase opportunities for sun protection in outdoor settings 2. Provide individuals with the information they need to make informed, healthy choices about UV exposure 3. Promote policies that advance the national goal of preventing skin cancer 4. Reduce harms of indoor tanning 5. Strengthen research, surveillance, monitoring, and evaluation related to skin cancer prevention (US Dept. Health & Human Services, 2014) 45

46 Recommendations from the 2 nd National Sun Survey (2006) Develop personal skills by improving knowledge, attitudes and behaviours Build healthy public policy to reduce overexposure to UV Strengthen community actions to enhance skin cancer prevention Create supportive environments to enable good sun-safety behaviours Re-orient health services towards skin cancer prevention through enhanced education, training and professional development around the need for comprehensive programs and strategies Generate evidence through ongoing surveillance, evaluation and research to support skin cancer prevention (Ontario Sun Safety Working Group, 2010) 46

47 Economic Evaluation of Skin Cancer Prevention Studies consistently show that skin cancer prevention represents excellent value for money (Carter etal, 1999) and are considered to have substantial impact on population health (Vos etal, 2010). Return-On-Investment: Australia s SunSmart program = $2.30 for every $1 invested (Shih etal, 2009); SunWise School Program (USA) = $4 for every $1 invested (Kyle etal 2008) If a SunSmart type program was implemented in Canada (2004 to 2031), the cumulative cost would be $270 million, but would result in 2,500 avoided deaths and the avoided costs would be $2.1 billion = 7.8 x cost of prevention (Krueger etal, 2010) 47

48 (Krueger etal, 2010) 48

49 A Call to Action The evidence is clear... Skin cancer is a significant burden on Canada s public health system The levels of sun exposure and current sun safety practices within the community and specific settings are unacceptable if we wish to address skin cancer in a meaningful way Broad range of prevention initiatives are known to be effective, but need a comprehensive approach Skin cancer prevention initiatives provide a good ROI Its time to turn-up the heat on skin cancer prevention 49

50 You are invited to the 4 th International Conference on UV and Skin Cancer Prevention, May 1 to 4, 2018 in Toronto. May 1 st workshops: most free; including the Shade Bootcamp ( May 2 nd to 4 th conference sessions; including a public session on May 4 th 50