Skin cancer in a subtropical Australian population: incidence and lack of association with occupation. The Nambour Study Group

Keratinocyte carcinomas, area-level socioeconomic status and geographic remoteness in Tasmania: cross-sectional associations and temporal trends

OBJECTIVE

This article aims to examine cross-sectional associations and assess temporal trends in keratinocyte carcinoma (KC) incidence by area-level socioeconomic status (SES) and geographic remoteness in Tasmania, Australia.

METHODS

KCs - basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) - registered by the Tasmanian Cancer Registry were assigned to area-level SES and remoteness area. Incidence rate ratios (2014-2018) were estimated using Poisson regression. Average annual percentage changes (2001-2018) were estimated using the Joinpoint Regression Program.

RESULTS

BCC incidence increased with increasing area-level advantage (p-value for trend <0.001), but no trend was found for SCC. SCC incidence was higher in rural than urban areas (p-value <0.001), and BCC incidence was slightly higher in rural than urban areas for females (p-value = 0.009), but not for males (p-value = 0.373). BCC and SCC incidence increased between 2001 and the mid-2010s, when it peaked across most areas.

CONCLUSIONS

Associations were found between BCC and higher area-level SES, and between SCC and geographic remoteness. The findings suggest differences in sun exposure behaviours, skin cancer awareness and access to services, or ascertainment bias.

IMPLICATIONS FOR PUBLIC HEALTH

Efforts to control and deliver KC services in Tasmania should consider targeting populations with specific area-level characteristics.

Occupational solar exposure and basal cell carcinoma. A review of the epidemiologic literature with meta-analysis focusing on particular methodological aspects

BACKGROUND

Numerous epidemiologic studies and a few systematic reviews have investigated the association between occupational solar exposure and basal cell carcinoma (BCC). However, previous reviews have several deficits with regard to included and excluded studies/risk estimates and the assessment of risk of selection bias (RoSB). Our aim was to review epidemiologic studies with a focus on these deficits and to use meta-(regression) analyses to summarize risk estimates.

METHODS

We systematically searched PubMed (including MEDLINE) and Embase for epidemiologic studies. Study evaluation considered four main aspects of risk of bias assessments, i.e. Selection of subjects (selection bias); Exposure variables; Outcome variables; Data analysis.

RESULTS

Of 56 identified references, 32 were used for meta-(regression) analyses. The overall pooled risk estimate for BCC comparing high/present vs. low/absent occupational solar exposure was 1.20 (95% CI 1.02-1.43); among studies without major deficits regarding data analysis, it was 1.10 (95% CI 0.91-1.33). Studies with low and high RoSB had pooled risk estimates of 0.83 (95% CI 0.73-0.93) and 1.95 (95% CI 1.42-2.67), respectively. The definitions of exposure and outcome variables were not correlated with study risk estimates. Studies with low RoSB in populations with the same latitude or lower than Germany had a pooled risk estimate of 1.01 (95% CI 0.88-1.15).

CONCLUSION

Due to the different associations between occupational solar exposure and BCC among studies with low and high RoSB, we reason that the current epidemiologic evidence base does not permit the conclusion that regular outdoor workers have an increased risk of BCC.

Current status of skin cancers with a focus on immunology and immunotherapy

Skin cancer is one of the most widespread cancers, with a significant global health effect. UV-induced DNA damage in skin cells triggers them to grow and proliferate out of control, resulting in cancer development. Two common types of skin cancer include melanoma skin cancer (MSC) and non-melanoma skin cancer (NMSC). Melanoma is the most lethal form of skin cancer, and NMSC includes basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and other forms. The incidence of skin cancer is increasing in part owing to a demographic shift toward an aging population, which is more prone to NMSC, imposing a considerable financial strain on public health services. The introduction of immunostimulatory approaches for cancer cell eradication has led to significant improvements in skin cancer treatment. Over the last three decades, monoclonal antibodies have been used as powerful human therapeutics besides scientific tools, and along with the development of monoclonal antibody production and design procedures from chimeric to humanized and then fully human monoclonal antibodies more than 6 monoclonal antibodies have been approved by the food and drug administration (FDA) and have been successful in skin cancer treatment. In this review, we will discuss the epidemiology, immunology, and therapeutic approaches of different types of skin cancer.

Keratinocyte carcinomas, area-level socioeconomic status and geographic remoteness in Tasmania: cross-sectional associations and temporal trends

OBJECTIVE

This article aims to examine cross-sectional associations and assess temporal trends in keratinocyte carcinoma (KC) incidence by area-level socioeconomic status (SES) and geographic remoteness in Tasmania, Australia.

METHODS

KCs-basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC)-registered by the Tasmanian Cancer Registry were assigned to area-level SES and remoteness area. Incidence rate ratios (2014-2018) were estimated using Poisson regression. Average annual percentage changes (2001-2018) were estimated using the Joinpoint Regression Program.

RESULTS

BCC incidence increased with increasing area-level advantage (p value for trend <0.001), but no trend was found for SCC. SCC incidence was higher in rural than urban areas (p value <0.001), and BCC incidence was slightly lower in rural than urban areas for males (p value = 0.026), but not for females (p value = 0.381). BCC and SCC incidence increased between 2001 and the mid-2010s, when it peaked across most areas.

CONCLUSIONS

Associations were found between BCC and higher area-level SES, and between SCC and geographic remoteness. The findings suggest differences in sun exposure behaviours, skin cancer awareness and access to services, or ascertainment bias.

IMPLICATIONS FOR PUBLIC HEALTH

Efforts to control and deliver KC services in Tasmania should consider targeting populations with specific area-level characteristics.

A meta-analysis of sunburn and basal cell carcinoma risk

Basal cell carcinoma (BCC) is the most common cancer in the United States. Sunburn is a modifiable risk factor for BCC. The objective of this project was to synthesize research on BCC and sunburn to quantify the impact and severity of sunburn at different life stages on BCC risk in the general population. A systematic literature search of four electronic databases was conducted and data were extracted by two independent reviewers using standardized forms. Data from 38 studies were pooled using both dichotomous and dose-response meta-analytic methods. BCC risk increased with ever experiencing a sunburn in childhood (OR=1.43, 95% CI: 1.19, 1.72) and with ever experiencing a sunburn in life (OR= 1.40, 95% CI: 1.02, 1.45). Every five sunburns experienced per decade in childhood increased BCC risk by 1.86 (95% CI: 1.73, 2.00) times. Every five sunburns experienced per decade in adulthood increased BCC risk by 2.12 (95% CI: 1.75, 2.57) times and every five sunburns per decade of life increased BCC risk by 1.91 (95% CI: 1.42, 2.58) times. The data on sunburn exposure and BCC show that an increase in number of sunburns at any age increased the risk of BCC. This may inform future prevention efforts.

Trends in keratinocyte skin cancer incidence, mortality and burden of disease in 33 countries between 1990 and 2017

BACKGROUND

Keratinocyte cancers (KCs) are the most common type of cancer in the White population worldwide, with associated high healthcare costs. Understanding the epidemiological trends for KCs, namely basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (SCCs), is required to assess burden of disease, project future trends and identify strategies for addressing this pressing global health issue.

OBJECTIVES

To report trends in BCC and SCC incidence, and SCC mortality and disability-adjusted life-years (DALYs).

METHODS

An observational study of the Global Burden of Disease (GBD) database between 1990 and 2017 was performed. European Union countries and other selected high-income countries, including the UK and the USA, classified as having high-quality mortality data, were included. Annual age-standardized incidence rates (ASIRs), age-standardized death rates (ASDRs) and DALYs for each country were obtained from the GBD database. Trends were described using joinpoint regression analysis.

RESULTS

Overall, 33 countries were included. For both BCC and SCC in 2015-2017, the highest ASIRs were observed in the USA and Australia. Males had higher ASIRs than females at the end of the observation period in all countries for SCC, and in all countries but two for BCC. In contrast, the highest ASDRs for SCC were observed in Australia and Latvia for males, and in Romania and Croatia for females. The highest DALYs for SCC for both sexes were seen in Australia and Romania. Over the observation period, there were more countries demonstrating decreasing trends in mortality than in incidence, and disparities were observed between which countries had comparatively high mortality rates and which had high incidence rates. Overall reductions in SCC DALYs were observed in 24 of 33 countries for males, and 25 countries for females.

CONCLUSIONS

Over the past 27 years, although trends in SCC incidence have risen in most countries, there is evidence that mortality rates have been decreasing. Burden of disease as assessed using DALYs has decreased in the majority of countries. Future work will explore potential explanatory factors for the observed disparity in trends in SCC incidence and mortality.

Incidence Trends of Melanoma and Nonmelanoma Skin Cancers in Jordan From 2000 to 2016

PURPOSE

Skin cancers are among the commonest cancers worldwide, and the incidence of melanoma and non-melanoma skin cancer (NMSC) continues to rise worldwide. However, there are no comprehensive reports on skin cancer incidence in Jordan during the past two decades. This report investigates the incidence of skin cancers in Jordan, in particular their time trends for the period 2000-2016.

MATERIALS AND METHODS

Data on malignant melanomas (MMs), squamous cells carcinomas (SCCs), and basal cell carcinomas (BCCs) were extracted from the Jordan Cancer Registry for the period between 2000 and 2016. Age-specific and overall age-standardized incidence rates (ASIRs) were computed.

RESULTS

Two thousand seventy patients were diagnosed with at least one BCC, 1,364 with SCC, and 258 with MM. ASIRs were 28, 19, and 4 per 100,000 person-years for BCC, SCC, and MM, respectively. The BCC:SCC incidence ratio was 1.47:1. The risk of men developing SCCs was significantly higher than women (relative risks [RRs], 1.311; 95% CI, 1.197 to 1.436), but significantly lower for BCCs (RR, 0.929; 95% CI, 0.877 to 0.984) or melanomas (RR, 0.465; 95% CI, 0.366 to 0.591). Persons older than 60 years were at a significantly higher risk of developing SCCs (RR, 1.225; 95% CI, 1.119 to 1.340) or melanomas (RR, 2.445; 95% CI, 1.925 to 3.104), but at a significantly lower risk of developing BCCs (RR, 0.885; 95% CI, 0.832 to 0.941). The overall incidence rates of SCCs, BCCs, and melanomas increased over the 16-year study period, but this was not statistically significant.

CONCLUSION

To our knowledge, this is the largest epidemiologic study regarding skin cancers in Jordan and in the Arab world. Despite low incidence rates in this study, rates are higher than reported regional figures. This is likely due to standardized, centralized, and mandatory reporting of skin cancers, including NMSC.

Polygenic risk score as a determinant of risk of keratinocyte cancer in an Australian population-based cohort

BACKGROUND

Keratinocyte cancer (KC) risk is determined by genetic and environmental factors. Genetic risk can be quantified by polygenic risk scores (PRS), which sum the combined effects of single nucleotide polymorphisms (SNPs).

OBJECTIVES

Our objective here was to evaluate the contribution of the summed genetic score to predict the KC risk in the phenotypically well-characterised Nambour population.

METHODS

We used PLINK v1.90 to calculate PRS for 432 cases, 566 controls, using 78 genome-wide independent SNPs that are associated with KC risk. We assessed the association between PRS and KC using logistic regression, stratifying the cohort into 3 risk groups (high 20%, intermediate 60%, low 20%).

RESULTS

The fully adjusted model including traditional risk factors (phenotypic and sun exposure-related), showed a significant 50% increase in odds of KC per standard deviation of PRS (odds ratio (OR) =1.51; 95% confidence interval (CI) =1.30-1.76, P=5.75 × 10^-8 ). Those in the top 20% PRS had over three times the risk of KC of those in the lowest 20% (OR=3.45; 95% CI=2.18-5.50, P=1.5×10^-7 ) and higher absolute risk of KC per 100 person-years of 2.96 compared with 1.34. Area under the ROC curve increased from 0.72 to 0.74 on adding PRS to the fully adjusted model.

CONCLUSIONS

These results show that PRS can enhance the prediction of KC above traditional risk factors.

Temporal trends in the incidence rates of keratinocyte carcinomas from 1978 to 2018 in Tasmania, Australia: a population-based study

OBJECTIVES

We described incidence trends of keratinocyte carcinomas (KCs)-namely basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)-in the Australian state of Tasmania.

METHODS

We identified histologically confirmed KCs within the Tasmanian Cancer Registry (TCR) and conducted assessments to ensure data quality. Age-standardised incidence rates were calculated for first (1985-2018) and annual KCs (1978-2018). Average annual percentage changes were computed using Joinpoint regression models.

RESULTS

The TCR is a reliable source of KC data. A total of 83,536 people were registered with a KC between 1978 and 2018. Age-standardised incidence rates of first KCs increased on average by 3% per annum for BCCs and 4% per annum for SCCs, reaching 363/100,000 and 249/100,000 in 2018, respectively. Age-standardised incidence rates of annual KCs increased on average by 5% per annum for BCCs and 6% per annum for SCCs, up to 891/100,000 and 514/100,000 in 2018, respectively. This increase was steeper for females than males and highest during the late 1980s and early 1990s. A change in trend around 2014 suggested that incidence rates have started to decline.

CONCLUSION

While the incidence of KCs in Tasmania increased substantially over 41 years, rates have recently plateaued and started to decline. The findings may reflect changes in sun exposure behaviours due to awareness campaigns, but high incidence rates in 2018 indicate that KCs still pose a substantial burden to this population.

Ultraviolet radiation and risk of cutaneous melanoma and squamous cell carcinoma in males and females in the Norwegian Offshore Petroleum Workers cohort

BACKGROUND

Increased risk of cutaneous melanoma and squamous cell carcinoma (SCC) has been reported among petroleum workers, but few studies include females, exposure data on ultraviolet radiation (UVR), and potential confounding factors. We aimed to examine UVR exposure in relation to risk of melanoma and SCC among male and female offshore petroleum workers. We also examined the association between UVR exposure and melanoma (Breslow) thickness.

METHODS

The Norwegian Offshore Petroleum Workers (NOPW) cohort (n = 27,917) holds information on sunbathing, indoor tanning, sunburns, sunscreen use, and other lifestyle factors recorded in 1998. Linkage to the Cancer Registry of Norway gave information on cancer diagnosis through 2017. We used Cox and logistic regression to estimate hazard ratios (HRs) of skin cancer and odds ratios (OR) of thick (≥1 mm) melanomas, respectively, with 95% confidence intervals (CIs).

RESULTS

Melanoma risk increased with increasing frequency of sunbathing after age 20 (ptrend  = 0.031), sunburn average intensity (ptrend  = 0.028), and sunscreen use (HR = 2.16; 95% CI: 1.42 -3.27 for almost always vs. never/rarely). The risk of thick melanoma was inversely associated with sunbathing frequency after age 20 (OR = 0.38; 95% CI: 0.16 - 0.90 for ≥4 weeks/year vs. 1 week/year). SCC risk increased with increasing frequency of indoor tanning after age 20 (HR = 2.72; 95% CI: 1.22 - 6.05 for ≥3 times/months vs. never), sunburn average intensity (ptrend  < 0.001), and sunscreen use (ptrend  < 0.001).

CONCLUSIONS

Our results support associations between UVR exposure and skin cancer risk in male and female offshore petroleum workers. This occupational group may be especially relevant for targeted sun protection advice.

Occupation and cutaneous melanoma: a 45-year historical cohort study of 14·9 million people in five Nordic countries

BACKGROUND

The age-adjusted incidence of cutaneous melanoma (CM) in the Nordic countries has increased during the last 60 years. Few prospective population-based studies have estimated the occupational variation in CM risk over time.

OBJECTIVES

To determine occupational variation in CM risk.

METHODS

A historical prospective cohort study with a 45-year follow-up from 1961 to 2005 (Nordic Occupational Cancer Study, NOCCA) based on record linkages between census and cancer registry data for Nordic residents aged 30-64 years in Denmark, Finland, Iceland, Norway and Sweden. National occupational codes were converted to 53 occupational categories, and stratified into indoor, outdoor and mixed work, and into socioeconomic status. The standardized incidence ratios (SIRs) were estimated as observed number of CM cases divided by the expected number calculated from stratum-specific person-years and national CM incidence rates.

RESULTS

During a follow-up of 385 million person-years, 83 898 incident cases of CM were identified. In all countries combined, men with outdoor work had a low SIR of 0·79 [95% confidence interval (CI) 0·77-0·81] and men with indoor work had a high SIR of 1·09 (95% CI 1·07-1·11). Differences in women pointed in the same direction. High socioeconomic status was associated with an excess risk: SIR 1·34 (95% CI 1·28-1·40) in men and SIR 1·31 (95% CI 1·26-1·36) in women. Technical, transport, military and public safety workers with potential skin exposure to carcinogens had excess risks.

CONCLUSIONS

Occupational variation in CM risk may be partly explained by host, socioeconomic and skin exposure factors. Differences in CM risk across socioeconomic groups attenuated slightly over time.

Narrative review of the epidemiology/biology of basal cell carcinoma: a need for public health consensus

Basal cell carcinoma (BCC) is the most common skin malignancy afflicting modern Australian society. The most influential response to rising BCC incidence rates has been through public health primary prevention campaigns (PPC) which have persevered since the 1980s. These campaigns are widely heralded a success but clinical data quantifying these benefits are limited due to an absence of legislation around BCC reporting. A non-systematic search of the literature was conducted identifying articles investigating the incidence and clinical characteristics of BCC over the past 40 years, as well as the economic viability of the PPC. There is robust evidence supporting stabilizing rates of BCC incidence in Australia. Similarly, multiple studies have shown the economic benefits of PPC through cost analysis. Anatomical and histological data are reported inconsistently, consequently limiting analysis of changes in BCC clinical characteristics. The consensus throughout the literature is that BCC is a significant public health issue that requires legislative reform. This narrative literature review serves to highlight the need for statutory changes around non-melanocytic skin cancer data collection to enable appropriate analysis and evaluation of current management strategies.

Genetic ancestry, skin pigmentation, and the risk of cutaneous squamous cell carcinoma in Hispanic/Latino and non-Hispanic white populations

Although cutaneous squamous cell carcinoma (cSCC) is one of the most common malignancies in individuals of European ancestry, the incidence of cSCC in Hispanic/Latinos is also increasing. cSCC has both a genetic and environmental etiology. Here, we examine the role of genetic ancestry, skin pigmentation, and sun exposure in Hispanic/Latinos and non-Hispanic whites on cSCC risk. We observe an increased cSCC risk with greater European ancestry (P = 1.27 × 10⁻⁴²) within Hispanic/Latinos and with greater northern (P = 2.38 × 10⁻⁶⁵) and western (P = 2.28 × 10⁻⁴⁹) European ancestry within non-Hispanic whites. These associations are significantly, but not completely, attenuated after considering skin pigmentation-associated loci, history of actinic keratosis, and sun-protected versus sun-exposed anatomical sites. We also report an association of the well-known pigment variant Ala111Thr (rs1426654) at SLC24A5 with cSCC in Hispanic/Latinos. These findings demonstrate a strong correlation of northwestern European genetic ancestry with cSCC risk in both Hispanic/Latinos and non-Hispanic whites, largely but not entirely mediated through its impact on skin pigmentation.

Eric Jorgenson and Hélène Choquet et al. find that northwestern European genetic ancestry is associated with increased risk of cutaneous squamous cell carcinoma (cSCC) in non-Hispanic whites, and more so in Hispanic/Latinos of the US. The ancestry effect is largely, but not entirely explained by genetic determinants of skin pigmentation in both populations.

Injuries during the first hour at work in the U.S. mining industry

BACKGROUND

The first hour of a shift in a mine is characterized by a large movement of miners from incoming and outgoing shifts, in addition to safety and maintenance checks of mining equipment. These activities rely on communication to ensure a safe transition between shifts. This study aims to identify risk factors for injury among miners during the first hour of a work shift and to characterize injury outcomes.

METHODS

Data from U.S. Mine Safety and Health Administration Part 50 reports, 1983-2015, were used to identify injuries occurring within the first hour of a shift. Multivariable logistic regression was used to evaluate predictors of injuries occurring during the first shift-hour and to assess the outcome of these injuries.

RESULTS

Out of the 545,537 cases included in the analysis, 16,446 injuries occurred during the first hour of a shift. Risk factors associated with these injuries included being female, being older, working on Sunday and Monday, having an irregular shift start, working night shifts, employed in surface mining operations, and mine operations with <200 employees, and mechanisms of injury related to falls, movement of equipment and personnel, and being struck by or caught between boxes and containers. Injurious incidents occurring during the first hour of work were associated with mass injury events involving five or more workers (aOR = 3.58; 95% CI: 2.77, 4.64).

CONCLUSIONS

Although injury rates were substantially lower during the first hour of work compared to all other work hours, this study identified risk factors and mechanisms of injury that are highly preventable during the first hour of work.

Global evidence on occupational sun exposure and keratinocyte cancers: a systematic review

Individual studies have suggested that the association between occupational exposure to solar ultraviolet radiation (UVR) and the development of keratinocyte cancers (KCs) may only be valid in populations of European ancestry living in certain geographical regions. Comparative global data are scarce and so this review aimed to summarize current evidence on the association between occupational exposure to solar UVR and the development of KCs, with a specific focus on geographical location and skin colour. Ovid MEDLINE, PubMed, Embase and Web of Science were searched for potentially relevant records. Extracted data were summarized by study, country and region. We included one prospective cohort study and 18 case-control studies (n = 15 233) from 12 countries in regions where the majority of the population is white skinned (Americas, Europe and Oceania). Eighteen of the 19 studies reported effect estimates suggesting an increased risk of basal cell carcinoma (BCC) and/or squamous cell carcinoma (SCC) among outdoor workers. Only 11 studies found a significantly increased risk and many had imprecise estimates. There was a significantly increased risk of BCC and SCC in individual studies in North America, Latin America and the Caribbean, Western Europe and Southern Europe, but not across regions or countries. Overall, 95% of studies reported higher risks among outdoor workers, although the increases in risk were statistically significant in just over half of the studies. Well-designed and sufficiently powered occupational case-control and cohort studies with adequate adjustment for confounding factors and other risk factors are required to provide more accurate risk estimates for occupational KC.

Trichoblastomas Mimicking Basal Cell Carcinoma: The Importance of Identification and Differentiation

Trichoblastoma is a rare, slow-growing, benign cutaneous tumor derived from follicular germinative cells. Trichoblastoma commonly appears as an asymptomatic, symmetrical, well-circumscribed, skin-colored to brown or blue-black papule or nodule. It may appear clinically and histologically similar to basal cell carcinoma, making its diagnosis challenging. Even on dermoscopy, it is challenging to differentiate trichoblastoma from basal cell carcinoma. In practice, it is important to differentiate the two, because the choice of treatment and resulting prognosis differ between the lesions. Surgical biopsy to analyze histopathological and immunohistochemical differences is the gold standard for diagnosing and differentiating trichoblastoma from basal cell carcinoma. Trichoblastoma typically has a favorable prognosis, with a low incidence of recurrence, progression or association with malignancy. This paper provides a review of the epidemiology, clinical presentation, dermoscopy, histology, immunochemistry, treatment, and prognosis of trichoblastoma.

Level of UV Exposure, Skin Type, and Age Are More Important than Thiopurine Use for Keratinocyte Carcinoma Development in IBD Patients

BACKGROUND

Retrospective studies observe an increased risk of keratinocyte carcinomas (KCs) in patients with inflammatory bowel disease (IBD) on thiopurine (TP) medication. The role of traditional risk factors such as skin type and sun protection behavior has not been studied in this population. This study aimed to examine traditional KC risk factors and thiopurine use on skin cancer development in an IBD cohort.

METHODS

Consecutive IBD patients were recruited from four specialist centers in Australia and New Zealand, each with varying UV exposure indices. Data pertaining to race, skin color, freckling and sun protection behavior, dose of TP therapy, and skin cancer development were elicited through a self-reported questionnaire.

RESULTS

A total of 691 IBD patients were included with 62 reporting KC development. Thiopurine usage was similar among patients who developed skin cancer compared with those who did not (92% vs. 89%, p = 0.3). There was no statistically significant association between KC development and TP dose or 6-thioguanine nucleotide levels. In multivariate modeling, four factors were independently and significantly associated with KC: age over 61 years old versus less than 30 years old (OR 6.76; 95% CI 2.38-19.18), residing in Brisbane versus Christchurch (OR 3.3; 95% CI 1.6-6.8), never staying in the shade versus staying in the shade ≥ 50% of the time (OR 3.8; 95% CI 1.4-10.5), and having a skin type that never tanned versus other skin types (OR 6.9; 95% CI 2.9-16.0).

CONCLUSION

Skin type, age, and sun protection behavior are more important risk factors for KC development than thiopurine medication use in this IBD population.

Sun Safe Workplaces: Effect of an Occupational Skin Cancer Prevention Program on Employee Sun Safety Practices

OBJECTIVE

Occupational skin cancer prevention is a priority because outdoor workers are exposed to high levels of ultraviolet radiation, the primary risk factor for skin cancer.

METHODS

A 2-year follow-up assessment of the impact of Sun Safe Workplaces (SSW), a workplace sun safety program that promoted policy adoption and education, on employee sun safety behavior was conducted. Sixty-three of 98 local government organizations from the original study participated.

RESULTS

Outdoor workers (n = 1724) completed surveys on personal sun protection practices. Employees' sun protection improved statistically significantly in the intervention group receiving the SSW program. SSW's effect was mediated by the number of workplace actions to implement elements of the policy, including sun protection messages and equipment and employee reports of sun safety training.

CONCLUSION

Policy promotion is a feasible approach to occupational skin cancer prevention.

Basal cell carcinoma: Epidemiology; pathophysiology; clinical and histological subtypes; and disease associations

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education article will provide a comprehensive and contemporary review of basal cell carcinoma. The first article in this series describes our current understanding of this disease regarding epidemiology, cost, clinical and histopathologic presentations, carcinogenesis, natural history, and disease associations.

Implementation of Occupational Sun Safety at a 2-Year Follow-Up in a Randomized Trial: Comparison of Sun Safe Workplaces Policy Intervention to Attention Control

PURPOSE

Implementation of employer sun safety actions was assessed in a 2-year follow-up to an occupational sun protection policy intervention.

DESIGN

Two-year follow-up assessment in a randomized pretest-posttest controlled design.

SETTING

Local government organizations with workers in public safety, public works, and parks and recreation.

PARTICIPANTS

Sixty-three local government organizations (participation = 64%) and 330 frontline supervisors and 1454 workers.

INTERVENTION

Sun Safe Workplaces (SSW) intervention promoting occupational sun safety policy and education.

MEASURES

Observations of SSW messages and sun safety items and surveys on organizations' communication and actions on sun safety.

ANALYSIS

Comparison between SSW and control groups was conducted using regression models and adjusted for clustering where appropriate, with α criterion set at P = .05 (2-tailed).

RESULTS

At intervention worksites, more SSW messages ( P < .001) and sun safety items ( P = .025) were observed; more frontline supervisors reported organizations provided free/reduced price sunscreen ( P = .005) and communicated about sun safety ( P < .001); and more workers recalled receiving sun safety messages ( P < .001) and sun safety training ( P <.001) compared to control organizations. Implementation was greater at larger than smaller intervention organizations for wide-brimmed hats ( P = .009), long work pants ( P = .017), and shade structures ( P = .036). Older workers received the most written messages ( P = .015).

CONCLUSIONS

Sun Safe Workplaces appeared to produce actions by organizations to support employee sun safety. Large organizations may have processes, communication channels, and slack resources to achieve more implementation.

'Mind your Moles' study: protocol of a prospective cohort study of melanocytic naevi

INTRODUCTION

Having many melanocytic naevi or 'moles' on the skin is the strongest predictor of melanoma; thus, much can be learnt from investigating naevi in the general population. We aim to improve the understanding of the epidemiology and biology of naevi by conducting a 3-year prospective study of melanocytic naevi in adults.

METHODS AND ANALYSIS

This is a population-based cohort study of melanocytic naevi in 200 adults aged 20-69 years recruited via the Australian electoral roll. At baseline, participants will complete a questionnaire on their sun behaviour and health and undergo a clinical examination. Three-dimensional (3D) total-body photography will be used to record the images of skin lesions. Pigmented naevi will be analysed in terms of number, diameter, colour and border irregularity using automated analysis software (excluding scalp, beneath underwear and soles of feet). All naevi ≥5 mm will be recorded using the integrated dermoscopy photographic system. A saliva sample will be obtained at baseline for genomic DNA analysis of pigmentation, naevus and melanoma-associated genes using the Illumina HumanCoreExome platform. The sun behaviour and health follow-up questionnaire, clinical examination and 3D total-body photography will be repeated every 6 months for 3 years. The first 50 participants will also undergo manual counts of naevi ≥2 mm and ≥5 mm at baseline, 6-month and 12-month follow-ups. Microbiopsy and excision of naevi of research interest is planned to commence at the 18-month time point among those who agree to donate samples for detailed histopathological and molecular assessment.

ETHICS AND DISSEMINATION

This study was approved by the Metro South Health Human Research Ethics Committee in April 2016 (approval number: HREC/16/QPAH/125). The findings will be disseminated through peer-reviewed and non-peer-reviewed publications and presentations at conferences.

Proteins involved in cutaneous basal cell carcinoma development

Basal cell carcinoma (BCC) is the most common skin malignancy type in the Caucasian population, with a continuously increasing incidence rate. The etiology of BCC remains unknown, but it appears to have a multifactorial origin resulting from intrinsic and extrinsic factors, including short-wavelength ultraviolet B radiation. The role of specific proteins in BCC that are known to be responsible for the regulation of cell division and are involved in skin aging, including transforming growth factor (TGF)-β, Smad2, matrix metalloproteinases (MMPs)-1, -3, -8 and -9, cathepsin-K and progerin, remains unknown. The aim of the present study was to assess the mRNA and protein expression profile of samples with diagnosed nodular BCC (nBCC) compared with that of healthy skin samples collected from matched areas. The study group included 22 patients (10 men and 12 women; mean age, 59 years; range, 44-82 years) with pathologically confirmed nBCC, and 22 healthy volunteers (10 men and 12 women; mean age, 59 years; range, 43-78 years) as a control group. The expression of the studied proteins was assessed in all samples by western blotting and reverse transcription-quantitative polymerase chain reaction analysis. Statistically significant increases in the expression of TGF-β, Smad2, cathepsin-K, progerin and MMP-1, -3, -8 and -9 were detected in skin biopsies with diagnosed nBCC compared with the control group, confirming the important role of these proteins in skin carcinogenesis.

Cancer Mortality by Urbanization and Proximity to the Sea Coast in Campania Region, Southern Italy

Aims and background

The risk for several cancers is higher in urban than in rural areas. The gradient has seldom been studied in southern Europe.

Patients and methods

The geographical pattern of mortality for different cancers and all causes was studied in the Campania Region (about 5.6 million inhabitants), whose largest town is Naples. The key variables were residence in urban/rural and coastal/inland municipalities. Relative risks of death and corresponding 95% confidence intervals by residence were evaluated by means of Poisson log-linear regression models.

Results

Significantly increased mortality rates in urban compared to rural municipalities were found for several cancer causes of death. In particular, in both sexes, excesses in the order of 30-50% were observed for tobacco-related neoplasms (i.e., larynx, lung, and bladder) and cancers of the intestine, liver, brain, multiple myeloma and non-Hodgkin's lymphoma, in addition to all-cancer, and all-cause mortality. In females, specific excesses were also noticed for cancer of the gallbladder, pancreas, breast and uterus (corpus and cervix). Conversely, significantly decreased mortality rates in urban with respect to rural municipalities were observed for cancer of the oral cavity and pharynx in males. Coastal location and degree of urbanization were strongly correlated, thus showing similar associations with most causes of death. However, a significant excess of cancer of the pleura in males was restricted to coastal municipalities.

Conclusions

Anti-smoking campaigns, sanitation improvements, hepatitis B vaccination, and a decrease in obesity emerge as high priorities with respect to cancer control strategies in the Campania Region, particularly in overpopu-lated, underprivileged urban areas.

Epidemiology of skin cancer in the mature patient

Epidermal cancers include keratinocyte cancer, melanocyte cancer, and Merkel cell carcinoma. These cancers account for the vast majority of new cancers diagnosed in Australia, North America, and Europe. Keratinocyte cancer is the most common epidermal cancer and accounts for 7 out of 8 new cancers diagnosed in Australia. Melanoma and Merkel cell carcinoma are less common than keratinocyte carcinoma but are more important causes of mortality in Australia. Keratinocyte cancer has also been demonstrated to be a marker of cancer-prone phenotype. Risk factors for epidermal cancer include intrinsic and environmental factors, in particular exposure to ultraviolet radiation and advanced age. Actinic keratosis has an approximate prevalence of 79% of men and 68% of women between 60 and 69 years of age, and has a low risk of malignant transformation into squamous cell carcinoma. Basal cell carcinoma is the most common malignancy in Caucasians worldwide, with the incidence increasing by 2% per year in Australia. Squamous cell carcinoma is the second most common epidermal cancer, with an incidence of approximately 1035 or 472 per 100,000 person-years in men and women, respectively. Primary risk factors for both basal cell carcinoma and squamous cell carcinoma include light skin color, UV radiation exposure, and chronic immunosuppression. Although the rate of melanoma is increasing, the mortality in Australia is reducing and is currently 9%. The overall incidence of melanoma in Australia is approximately 50 cases per 100,000 persons (62 for men and 40 for women). Keratinocyte carcinoma and melanoma are risk factors for developing further skin cancer and primary malignancy. This contribution reviews the incidence, prevalence, and risk factors associated with the development of epidermal cancer and premalignant epidermal neoplasia.

Final diagnosis of 86 cases included in differential diagnosis of American tegumentary leishmaniasis in a Brazilian sample: a retrospective cross-sectional study

BACKGROUND

Cutaneous leishmaniasis is distributed worldwide, including Brazil. Its several clinical forms need to be distinguished from other dermatoses. Clinical similarities and lack of a gold standard diagnostic tool make leishmaniasis-like lesions a challenging diagnosis.

OBJECTIVES.

To report the final diagnosis of patients primarily suspected of having American tegumentary leishmaniasis (ATL).

METHODS.

A retrospective cross-sectional study was conducted on the basis of medical records of 437 patients with clinical suspicion of ATL, registered in electronic hospital system between 1980 and 2013. Demographic, clinical, and laboratory data were compiled.

RESULTS.

Analysis of 86 cases (19.7%) registered as ATL in one of the hypothesis revealed a different final diagnosis; 55 (63.9%) and 31 cases (36.1%) had skin and mucosal lesions, respectively. In 58 cases (67.4%), the requested PCR did not identify Leishmania sp. In 28 cases (32.5%), biopsies established the diagnosis and confirmed tumors, mycobacteriosis, and subcutaneous or systemic mycosis. Overall, 27% of the cases had inflammatory etiology, mainly nasal nonspecific inflammatory processes; 27% had infectious etiology, especially paracoccidioidomycosis and leprosy; 20% had neoplastic etiology, mainly basal and squamous cell carcinoma; 15% had miscellaneous etiology, including neuropathic ulcer, traumatic ulcers, idiopathic ulcer; 11% missed the follow-up.

STUDY LIMITATIONS

Some cases had no final diagnosis due to loss of follow-up.

CONCLUSION.

ATL can be confused with several differential diagnoses, especially inflammatory and infectious granulomatous diseases as well as non-melanoma skin cancers. Clinicians working in tropical areas should be aware of the main differential diagnosis of leishmaniasis-like lesions.

Incidence of Nonmelanoma Skin Cancer in New Brunswick, Canada, 1992 to 2001

Background:

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), collectively referred to as nonmelanoma skin cancer (NMSC), cause significant morbidity and generate a substantial cost to the health care system. Canadian data on the incidence of NMSC are lacking.

Objective:

To study the incidence and characteristics of NMSC in New Brunswick, Canada (population 729,498 people in 2001), by using the Provincial Cancer Registry.

Method:

Data were obtained from 1992 to 2001 from the New Brunswick Provincial Cancer Registry, to which reporting of all cancers is mandatory. Multiple tumors of a given histologic type are recorded only once in the registry per individual per lifetime. A descriptive analysis of incidence rates of BCC and invasive SCC of the skin was performed in relation to gender, age, and anatomic location. The main outcome measures were the age- and sex-specific incidence rates of BCC and SCC. Age standardization was performed using the Canadian, US, and world standard populations.

Results:

When adjusted to the world standard population, the age-standardized incidence rates (ASIRs) per 100,000 population for BCC from 1992 through 2001 were 87 for males and 68 for females. For invasive SCC, the ASIRs per 100,000 population were 34 for males and 16 for females. There was an increasing incidence trend for both BCC and invasive SCC over the 10-year study period, with minimal change in the incidence of SCC in women. The overall ratio of BCC to invasive SCC in the population was 2.8 to 1. The approximate lifetime probabilities of developing BCC and invasive SCC were 13% and 5%, respectively.

Conclusions:

The incidence of NMSC in the province of New Brunswick is similar to that reported from 1973 through 1987 in the province of British Columbia, higher than those reported in most parts of Europe, and lower than all published rates in the United States and Australia. Owing to the inability of the registry to account for tumor multiplicity, the actual annual number of all NMSC lesions in this population is likely much higher.

Randomized Trial Testing a Worksite Sun Protection Program in an Outdoor Recreation Industry

Health communication campaigns intended to reduce chronic and severe exposure to ultraviolet radiation in sunlight and prevent skin cancer are a national priority. Outdoor workers represent an unaddressed, high-risk population. Go Sun Smart (GSS), a worksite sun safety program largely based on the diffusion-of-innovations theory, was evaluated in a pair-matched, group-randomized, pretest-posttest controlled design enrolling employees at 26 ski areas in Western North America. Employees at the intervention ski areas were more aware of GSS (odds ratio [OR] = 8.27, p < .05) and reported less sunburning (adjusted OR = 1.63, p < .05) at posttest than employees at the control areas. A dose response was evident (OR = 1.46, p < .05) with greater observed program implementation associated with fewer sunburns among employees. Program awareness per se was not predictive ( p > .05) of reduced sunburning in a mediational analysis. Analyses of nonrespondents, including intent-to-treat analyses, further supported the success of GSS.

Basal Cell Carcinoma: Review of Epidemiology, Pathogenesis, and Associated Risk Factors

Background:

Basal cell carcinoma (BCC) is extremely common, and its incidence continues to rise.

Objective:

This review presents the literature pertaining to the epidemiology, pathogenesis, and risk factors associated with BCC.

Conclusions:

The risk of developing BCC depends on both genetic predisposition and exposure to risk. Fair-skinned people account for the overwhelming majority of patients, beyond what would be expected by skin phototype alone. Damage to multiple lines of defense appears to be necessary for cancer development and spread. This damage distorts the concerted effort of deoxyribonucleic acid (DNA) repair, immunosurveillance, and cellular growth regulation to protect against malignant progression. Ultraviolet light exposure is the most critical modifiable factor determining early expression and frequency of BCC development.

Sex differences in the incidence of skin and skin-related diseases in Olmsted County, Minnesota, United States, and a comparison with other rates published worldwide

Many skin and skin-related diseases affect the sexes unequally, with attendant implications for public health and resource allocation. To evaluate better the incidence of skin and skin-related diseases affecting males vs. females, we reviewed published population-based epidemiology studies of skin disorders performed utilizing Rochester Epidemiology Project data. Females had a higher incidence of the following diseases: connective tissue diseases (scleroderma, morphea, dermatomyositis, primary Sjögren syndrome, systemic lupus erythematosus [not in all studies]), pityriasis rosea, herpes progenitalis, condyloma acuminatum, hidradenitis suppurativa, herpes zoster (except in children), erythromelalgia, venous stasis syndrome, and venous ulcers. Males had a higher incidence of psoriasis and psoriatic arthritis, basal cell carcinoma (exception, females aged ≤40 years), squamous cell carcinoma, and lentigo maligna. Incidence rates were equal in males and females for cutaneous malignant melanoma (exception, higher in females aged 18-39 years), lower-extremity cellulitis, cutaneous nontuberculous mycobacterial infection, Behçet disease, delusional infestation, alopecia areata, and bullous pemphigoid. Many of the population-based sex-specific incidence rates of skin and skin-related diseases derived from the Rochester Epidemiology Project are strikingly different from those estimated elsewhere. In general, females are more commonly affected by skin and skin-related diseases. The reasons for this imbalance remain to be determined and are likely multifactorial.

p16-positive lymph node metastases from cutaneous head and neck squamous cell carcinoma: No association with high-risk human papillomavirus or prognosis and implications for the workup of the unknown primary

BACKGROUND

The incidence of p16 overexpression and the role of human papillomavirus (HPV) in cutaneous head and neck squamous cell carcinoma (cHNSCC) are unclear.

METHODS

One hundred forty-three patients with cHNSCC lymph node metastases involving the parotid gland were evaluated for p16 expression by immunohistochemistry. The detection of 18 high-risk HPV subtypes was performed with HPV RNA in situ hybridization for a subset of 59 patients. The results were correlated with clinicopathological features and outcomes.

RESULTS

The median follow-up time was 5.3 years. No differences were observed in clinicopathological factors with respect to the p16 status. p16 was positive, weak, and negative in 45 (31%), 21 (15%), and 77 cases (54%), respectively. No high-risk HPV subtypes were identified, regardless of the p16 status. The p16 status was not prognostic for overall (hazard ratio, 1.08; 95% confidence interval [CI], 0.85-1.36; P = .528), cancer-specific (hazard ratio, 1.12; 95% CI, 0.77-1.64; P = .542), or progression-free survival (hazard ratio, 1.03; 95% CI, 0.83-1.29; P = .783). Distant metastasis-free survival, freedom from locoregional failure, and freedom from local failure were also not significantly associated with the p16 status.

CONCLUSIONS

p16 positivity is common but not prognostic in cHNSCC lymph node metastases. High-risk HPV subtypes are not associated with p16 positivity and do not appear to play a role in this disease. HPV testing, in addition to the p16 status in the unknown primary setting, may provide additional information for determining a putative primary site.

Consensus for Nonmelanoma Skin Cancer Treatment, Part II: Squamous Cell Carcinoma, Including a Cost Analysis of Treatment Methods

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in the United States. Cutaneous squamous cell carcinoma has an estimated incidence of more than 700,000 new cases per year and a 5% risk of metastasis.

OBJECTIVE

To provide clinicians with guidelines for the management of cSCC based on evidence from a comprehensive literature review and consensus among the authors.

MATERIALS AND METHODS

The authors conducted an extensive review of the medical literature on treatment methods for cSCC, taking into consideration cure rates, recurrence and metastatic rates, aesthetic and functional outcomes, and cost effectiveness of the procedures.

RESULTS

Surgical treatments provide the best outcomes for cSCC. Mohs micrographic surgery is a cost-effective procedure that affords the highest cure rate, maximal tissue preservation, and superior cosmetic outcomes. Nonsurgical methods may be used as a primary treatment for low-risk squamous cell carcinomas, but the cure rates are lower.

CONCLUSION

The cure rate remains the most important consideration in choosing the treatment method, but additional factors, such as the patient's general medical condition, psychosocial circumstances, the location of the tumor and cost effectiveness of the therapy should be considered. Mohs micrographic surgery remains the preferred treatment for high-risk tumors and tumors located in cosmetically sensitive areas.

Validating the use of Medicare Australia billing data to examine trends in skin cancer

Background:  Epidemiological data surrounding non-melanomatous skin cancer (NMSC) is highly variable, in part due to the lack of government cancer registries. Several studies employ the use of Medical Australia (MA) rebate data in assessing such trends, the validity of which has not been studied in the past. Conversely, melanoma skin cancer is a notifiable disease, and thus, MA and cancer registry data is readily available. The aim of the current study is to assess the use of MA for epidemiological measures for skin cancers, by using melanoma as a disease sample.

Methods:  Following ethics approval, data from MA and Victorian Cancer Registry (VCR) from 2004-2008 were extracted. Incidence of MA and VCR unique melanoma cases were compared and stratified by age and local government area (LGA). Regression and a paired-samples t-test were performed.

Results: During the study period; 15,150 and 13,886 unique melanoma patients were identified through VCR and MA data sources respectively. An outlier in the >80­ year age group was noted between MA and VCR data. When stratified by age, significant correlation between MA and VCR was observed for all patients (gradient 0.91, R²= 0.936) and following exclusion of >80 patients (gradient 0.96, R²= 0.995). When stratified by LGA, a high degree of observation was observed for all patients (gradient 0.94, R²= 0.977) and following exclusion of >80 patients (gradient 0.996, R²= 0.975).

Conclusion: Despite the inclusion of outlier data groups, acceptable correlation between MA and VCR melanoma data was observed, suggesting that MA may be suitable for assessing epidemiological trends. Such principals may be used to validate the use of MA data for similar calculations assessing NMSC trends.

UVR exposure and vitamin D in a rural population. A study of outdoor working farmers, their spouses and children

BACKGROUND

Living and working in the countryside may result in excessive UVR exposure, with increased risk of skin cancer. Some sun exposure is, however, recommended, since vitamin D production is UVB-dependent.

OBJECTIVES

To examine UVR exposure and vitamin D levels in a rural population of outdoor working male farmers, their indoor working spouses and their children, expected to receive high UVR exposure.

METHODS

Prospective, cohort study. During the summer 2009 daily, personal UVR exposure and sun behaviour were recorded by dosimetry and diaries (17 403 days). Vitamin D was measured at the end of summer and the following winter.

RESULTS

Risk behaviour (= exposure of shoulders/upper body to the sun), beach days, sunscreen use and sunburns were infrequent. Farmers and boys had the highest daily UVR exposure (both 1.5 SED per day), likewise on work days. On non-work days the UVR exposure was even higher (up to 2.0 SED per day). Farmers, girls and boys had a higher chronic UVR exposure than the spouses, who had more intermittent high UVR exposure. Vitamin D levels did not differ between family members. At the end of summer 16% of the participants were vitamin D insufficient, the following winter, 61%. Some UVR exposure variables correlated positively, but weakly, with vitamin D levels.

CONCLUSIONS

UVR exposure was generally high among this study population, however, vitamin D levels still dropped below the recommended level during winter for most participants. Differences in UVR exposure between the groups did not result in differences in vitamin D levels.

Cellular and biological evaluation and diagnostic immunohistochemistry of cytokeratin 15/19 expression in distinguishing cutaneous basal cell carcinoma

Recent studies have investigated the expression of proliferative markers, but little is known about the expression of cytokeratin 15 and 19 in different histological subtypes of basal cell carcinoma (BCC). We conducted cellular, biological, clinicopathological and immunohistochemical analysis on the manifestations of 8 BCC by hematoxylin and eosin stain (H&E) staining and immunohistochemistry and reviewed relevant literature. Microscopically, the tumor cells were multiple remarkable foci of epidermolytic hyperkeratosis with large pleomorphic nuclei and scant cytoplasm together with peripheral palisading and forming solid nests. Furthermore, the most tumors were composed of highly cellular areas with a homogenous population of round, ovoid and spindle cells, hyperchromatic nuclei, high cellular pleomorphism, high mitotic index and various morphologic patterns. Moreover, the tumors displayed an invasive growth, with positive expression of Cytokeratin 19 (CK19) and negative expression of CK15. Our study revealed that the expression of CK19 was associated with progression and invasion in cases with BCC and immunohistochemistry is indispensable in distinguishing this tumor from other types of cutaneous carcinoma. To our best knowledge, it may be a considerable biomarker to assess invasiveness of cutaneous-surface BCC and to guide clinical management of such tumors.

Incidence and prevalence of non-melanoma skin cancer in Australia: A systematic review

Non-melanoma skin cancer (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common cancer occurring in people with fair skin. Australia has been reported to have the highest incidence of NMSC in the world. Using a systematic search of the literature in EMBASE and Medline, we identified 21 studies that investigated the incidence or prevalence of NMSC in Australia. Studies published between 1948 and 2011 were identified and included in the analysis. There were six studies that were conducted on national level, two at state level and 13 at the regional level. Overall, the incidence of NMSC had steadily increased over calendar-years in Australia. The incidence of NMSC per 100,000 person-years was estimated to be 555 in 1985; 977 in 1990; 1109 in 1995; 1170 in 2002 and 2448 in 2011. The incidence was higher for men than women and higher for BCC than SCC. Incidence varied across the states of Australia, with the highest in Queensland. The prevalence of NMSC was estimated to be 2% in Australia in 2002. The incidence and prevalence of NMSC still need to be accurately established at both national and state levels to determine the costs and burden of the disease on the public health system in Australia.

The influence of age and gender in knowledge, behaviors and attitudes towards sun protection: a cross-sectional survey of Australian outpatient clinic attendees

OBJECTIVE

The aim of this study was to evaluate the differences in knowledge, attitudes, and behaviors regarding sun protection in different age groups and between men and women.

METHOD

A multicenter cross-sectional study using a population-based survey of 416 individuals over the age of 18 years was undertaken during 2014.

RESULTS

Of individuals aged 18-30 years, 94% had experienced at least one episode of sunburn in the previous year. The likelihood of self-examining increased as age increased (p < 0.001). Only 15% of participants used the recommended amount (40 ml) of sunscreen. Women were twice as likely to put on sunscreen as men. Women had better knowledge about sun protection and sunscreen use, and were twice as likely to know that sunscreen was denatured by heat and had an expiry date (p = 0.01). Women were more than twice as likely to put on sunscreen every day compared with men (p = 0.002). Reported barriers to sunscreen use included greasiness and forgetfulness and this was more commonly reported as age decreased (p = 0.002; p = 0.004). The younger population was less likely to use more than one modality of sun protection (p = 0.05).

CONCLUSION

This study highlights a number of gender- and age-specific findings with regards to sun protection. There are knowledge, attitude, and behavior deficiencies within each demographic group that need to be specifically targeted through educational and public health efforts in order to improve general sun protection measures and decrease the incidence of skin cancers.

Bauxite mining and alumina refining: process description and occupational health risks

Objective:

To describe bauxite mining and alumina refining processes and to outline the relevant physical, chemical, biological, ergonomic, and psychosocial health risks.

Methods:

Review article.

Results:

The most important risks relate to noise, ergonomics, trauma, and caustic soda splashes of the skin/eyes. Other risks of note relate to fatigue, heat, and solar ultraviolet and for some operations tropical diseases, venomous/dangerous animals, and remote locations. Exposures to bauxite dust, alumina dust, and caustic mist in contemporary best-practice bauxite mining and alumina refining operations have not been demonstrated to be associated with clinically significant decrements in lung function. Exposures to bauxite dust and alumina dust at such operations are also not associated with the incidence of cancer.

Conclusions:

A range of occupational health risks in bauxite mining and alumina refining require the maintenance of effective control measures.