Keratinocyte cancers in South Australia: incidence, geographical variability and service trends

The effects of exposure to solar radiation on human health

This assessment by the Environmental Effects Assessment Panel (EEAP) of the Montreal Protocol under the United Nations Environment Programme (UNEP) evaluates the effects of ultraviolet (UV) radiation on human health within the context of the Montreal Protocol and its Amendments. We assess work published since our last comprehensive assessment in 2018. Over the last four years gains have been made in knowledge of the links between sun exposure and health outcomes, mechanisms, and estimates of disease burden, including economic impacts. Of particular note, there is new information about the way in which exposure to UV radiation modulates the immune system, causing both harms and benefits for health. The burden of skin cancer remains high, with many lives lost to melanoma and many more people treated for keratinocyte cancer, but it has been estimated that the Montreal Protocol will prevent 11 million cases of melanoma and 432 million cases of keratinocyte cancer that would otherwise have occurred in the United States in people born between 1890 and 2100. While the incidence of skin cancer continues to rise, rates have stabilised in younger populations in some countries. Mortality has also plateaued, partly due to the use of systemic therapies for advanced disease. However, these therapies are very expensive, contributing to the extremely high economic burden of skin cancer, and emphasising the importance and comparative cost-effectiveness of prevention. Photodermatoses, inflammatory skin conditions induced by exposure to UV radiation, can have a marked detrimental impact on the quality of life of sufferers. More information is emerging about their potential link with commonly used drugs, particularly anti-hypertensives. The eyes are also harmed by over-exposure to UV radiation. The incidence of cataract and pterygium is continuing to rise, and there is now evidence of a link between intraocular melanoma and sun exposure. It has been estimated that the Montreal Protocol will prevent 63 million cases of cataract that would otherwise have occurred in the United States in people born between 1890 and 2100. Despite the clearly established harms, exposure to UV radiation also has benefits for human health. While the best recognised benefit is production of vitamin D, beneficial effects mediated by factors other than vitamin D are emerging. For both sun exposure and vitamin D, there is increasingly convincing evidence of a positive role in diseases related to immune function, including both autoimmune diseases and infection. With its influence on the intensity of UV radiation and global warming, the Montreal Protocol has, and will have, both direct and indirect effects on human health, potentially changing the balance of the risks and benefits of spending time outdoors.

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.

Health care need and health disparities: Findings from the Regional South Australia Health (RESONATE) survey

Regional South Australia has some of the highest rates of psychological distress, chronic disease and multimorbidity of any Australian State or Territory. Yet, the healthcare needs of this population are still not completely understood. To better understand the healthcare needs of regional South Australians, we invited adults living in the region to complete the 44-item consumer utilisation, expectations and experiences of healthcare instrument (CONVERSATIONS), online or in hard-copy. The survey was conducted between April 2017 and March 2018. A multi-modal recruitment campaign was utilised to promote the survey. We examined associations between study outcomes and remoteness area, and drew comparisons between our findings and other surveys reporting pertinent outcomes in the urban SA population. The questionnaire was completed by 3,926 adults (52.5% females; 37.6% aged 60 + years). Among the 264 distinct health conditions reported by participants, the most prevalent were hypertension (31.6%), depression (25.7%), anxiety (23.5%) and hypercholesterolaemia (22.9%). The lifetime prevalence of these conditions among participants exceeded rates reported in urban SA. The largest regional-urban health disparities were observed for eczema/dermatitis, skin cancer, other cancer types and cataracts, where prevalence rates were 2075%, 400%, 373% and 324% higher, respectively, than that reported in urban SA. Participants also reported higher levels of multimorbidity (37.7% higher) relative to urban South Australians. By contrast, participants appeared to be exposed to fewer lifestyle risk behaviours (e.g. smoking, alcohol, inadequate fruit or vegetable intake) than their urban counterparts. In summary, there was a high level of healthcare need, and considerable health disparity among participants when compared with urban settings (particularly for skin and eye conditions). These findings highlight the need for a more targeted approach to delivering health services and health promotion activities in regional areas.

Keratinocyte skin cancer risks for working school teachers: Scenarios and implications of the timing of scheduled duty periods in Queensland, Australia

Relative keratinocyte skin cancer risks attributable to lifetime occupational and casual sunlight exposures of working school teachers are assessed across the state of Queensland for 1578 schools. Relative risk modeling utilizing annual ultraviolet exposure assessments of teachers working in different geographic locations and exposed during periods of measured daily playground duty times for each school were made for local administrative education districts by considering traditional school opening and closing hours, and playground lunchtime schedules. State-wide, basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) relative risk estimates varied by 24% for BCC and 45% for SCC. The highest relative risk was calculated for the state's north (sunshine) coast education district which showed that risk could increase by as much as 32% for BCC and 64% for SCC due to differences in teacher duty schedules. These results highlight the importance of playground duty scheduling as a significant risk factor contributing to the overall burden of preventable keratinocyte skin cancers in Queensland.

Association of Age-Related Cataract With Skin Cancer in an Australian Population

Purpose

Ultraviolet radiation from sunlight contributes to age-related cataract and skin cancer. The EPHA2 gene is implicated in both these diseases. The purpose of this study was to determine whether age-related cataract and skin cancer are associated in a cohort of older Australians.

Methods

A cross-sectional study was performed using the Historical Cohort of the Registry of Senior Australians. Individuals aged ≥65 years or aged ≥50 years and of Aboriginal or Torres Strait Islander descent, who had an aged care eligibility assessment between July 2005 and June 2015, and had a history of cataract surgery and/or skin cancer according to the Australian Government Medicare Benefits Schedule dataset, during the 3-year period prior, were evaluated (N = 599,316). A multivariable logistic regression model was used to determine association and multiple hypothesis correction was employed.

Results

Of the evaluated individuals, 87,097 (14.5%) had a history of cataract and 170,251 (28.4%) a history of skin cancer. Among those with a history of cataract, 20,497 (23.5%), 1127 (1.3%), and 14,730 (16.9%) individuals had a concurrent history of keratinocyte, melanoma, and premalignant/solar keratosis, respectively. Those with a history of cataract were 19% more likely to have a history of skin cancer (odds ratio [OR], 1.19; 95% confidence interval [CI], (1.17–1.21). Co-occurrence of keratinocyte skin cancer was 16% (OR, 1.16; 95% CI, 1.14–1.18), melanoma 21% (OR, 1.21; 95% CI, 1.13–1.29), and premalignant/solar keratosis 19% (OR, 1.19; 95% CI, 1.17–1.22) more in the presence than absence of history of cataract.

Conclusions

Age-related cataract is positively associated with skin cancer and its subtypes, including premalignant lesions in an older Australian population.

Incidence and mortality for cutaneous squamous cell carcinoma: comparison across three continents

BACKGROUND

Population-based incidence and mortality studies of cutaneous squamous cell carcinoma (SCC) have been few owing to the commonness of the disease, and rare deaths making accurate mortality statistics difficult.

OBJECTIVES

Our aim was to summarize SCC incidence and mortality in populations across three continents, exemplified by Australia, the United States (US) and Germany.

METHODS

We estimated age-specific and age-standardized (Australian Standard 2001 Population) incidence and mortality rates per 100 000 person-years.

RESULTS

Squamous cell carcinoma incidence is plateauing or falling in Australia, stable in the United States (2013-2015) and rising in Germany (2007-2015). Current incidence estimates in men and women are 341 and 209, 497 and 296, and 54 and 26, respectively, for the three countries. Incidence increases strongly with age in all countries. Mortality of non-melanoma skin cancer appears to be increasing in Germany and stable in Australia (unavailable for the US population).

CONCLUSIONS

Squamous cell carcinoma is an important health issue, particularly among older men, with incidence exceeding most other cancers. More precise and uniform population-based studies of incidence and mortality are needed to better quantify the impact of SCC on healthcare systems worldwide and to gauge the effect of new treatments such as anti-PD1 therapy on mortality.

Environmental effects of stratospheric ozone depletion, UV radiation and interactions with climate change: UNEP Environmental Effects Assessment Panel, update 2019

This assessment, by the United Nations Environment Programme (UNEP) Environmental Effects Assessment Panel (EEAP), one of three Panels informing the Parties to the Montreal Protocol, provides an update, since our previous extensive assessment (Photochem. Photobiol. Sci., 2019, 18, 595-828), of recent findings of current and projected interactive environmental effects of ultraviolet (UV) radiation, stratospheric ozone, and climate change. These effects include those on human health, air quality, terrestrial and aquatic ecosystems, biogeochemical cycles, and materials used in construction and other services. The present update evaluates further evidence of the consequences of human activity on climate change that are altering the exposure of organisms and ecosystems to UV radiation. This in turn reveals the interactive effects of many climate change factors with UV radiation that have implications for the atmosphere, feedbacks, contaminant fate and transport, organismal responses, and many outdoor materials including plastics, wood, and fabrics. The universal ratification of the Montreal Protocol, signed by 197 countries, has led to the regulation and phase-out of chemicals that deplete the stratospheric ozone layer. Although this treaty has had unprecedented success in protecting the ozone layer, and hence all life on Earth from damaging UV radiation, it is also making a substantial contribution to reducing climate warming because many of the chemicals under this treaty are greenhouse gases.