Aspects of melanoma control in Scotland

1
Aspects of melanoma control in Scotland

• What works best
• Rona M MacKie

2
Define the problem

• ?Increasing incidence
• ?Increasing mortality
• ?Many tumours thick at presentation
• ?Delays in patient journey

3
Scottish experience early 1980s

• Slow increase in incidence
• Very slow increase in mortality
• BUT thick tumours compared with Queensland
• The general public knew very little about melanoma

4
Possible explanations for thick tumours

• Patient delay in seeking GP help
• Inappropriate delays in primary care
• Inappropriate delays after hospital referral
• Different tumour biology

5
Scottish approach

• Analysis of possible delay times
• Patient awareness to GP consultation
• GP visit to first hospital consultation
• Hospital consultation definitive treatment

6
Results

• Overwhelming evidence of patient delay
• 50delayed 3-12 months
• 34delayed over one year
• Patient delay mainly due to lack of knowledge
  rather than fear
• Ref BMJ 1986 292 987

7
Solution

• Public education campaign on features of early
  not late melanoma
• Preceded by good preparation of all primary care
  workers
• Systems in place to accurately measure results

8
Desired results

• Immediate rise in thin melanoma referrals
• Over 2-3 years, fall in absolute number, not
  proportion of thick tumours
• Over 5-10 years fall in melanoma mortality
• Minimal overloading of clinics by referral of
  non melanoma pigmented lesions eg naevi and basal
  cell papillomas

9
Scottish Melanoma Group

• Established in 1979, and ongoing
• Details of all new melanomas diagnosed in
  Scotland
• Age sex type site thickness treatment and outcome
• Ref Lancet 2002

10
Scottish Campaign

• Winter 1985-1986 primary care preparation
• GP booklets meetings
• Nurse education
• Spring 1986 public education campaign
• Leaflets,TV, posters radio, newspapers
• Unexpected bonus of Reagan effect

11
(No Transcript)
12
(No Transcript)
13
What publicity route worked best

• TV and newspapers
• Leaflets expensive and poorly taken up

14
Immediate outcome

• Rapid rise in expected number of new melanoma
  referrals over 2-3 months
• Very high proportion of thin tumours (under1.5mm)
• BUT number of thick tumours static
• REF BMJ 1988 297 388

15
Long term audit

• Important to establish if behavioural change on
  part of public maintained
• Patient delay revisited in 2001
• Highly significant effect on tumour thickness
• 2/3s of all patients now seek GP help within 3
  months of noting new lesion
• 72 of melanoma under 1.5mm at diagnosis (38 in
  1986)
• REF BMJ 2003 326 367

16
Scottish scene 2004

• Melanoma incidence continues to rise in both
  sexes
• Thick tumours persist but have not risen in
  absolute numbers
• Thick tumours mainly an elderly male problem
• Melanoma mortality static in both sexes(?slight
  fall in younger females)

17
Are pigmented lesion clinics useful?

• Yes, particularly if long general dermatology
  waiting lists
• All patients seen within 2 days of GP referral
• Immediate surgery available-one stop clinic
• Photography, written information available

18
(No Transcript)
19
Primary prevention of melanoma

• No Scottish experience
• Long term (30 years) and very difficult to
  evaluate
• Main approach is safe sun message
• What works in Brisbane may be quite unsuitable
  for Glasgow or Belfast

20
(No Transcript)
21
Kids cook quick poster

• Responses from both parents and nurses in sick
  childrens hospital
• What attractive children
• Great to see kids getting a holiday
• Is this about healthy eating?
• Is barbecued food healthy for children?

22
The vitamin D debate

• Provitamin D is ingested in our diet
• Very modest UV exposure needed to convert
  provitamin D to vitamin D
• Hollick et al-sunscreens will prevent vitamin D
  synthesis
• Results will be osteoporosis and rickets risk
  increased

23
Vitamin D problems

• MRC childhood nutrition study
• Northern UK winter months, children do have
  subclinically low levels of vitamin D
• No good study in temperate climate to show that
  safe sun practices do not cause vitamin d
  problems
• Accurate plasma vitamin D level estimations
  technically difficult

24
Conclusions 1

• In Scotland secondary prevention activities have
  been successful
• Mean tumour thickness significantly and
  permanently reduced
• Mortality rise in melanomas thus prevented
• But still a problem with small number of thick
  tumours

25
(No Transcript)
26
Conclusions 2

• Primary prevention campaigns long term and very
  difficult to evaluate
• More data needed on individual susceptibility,
  exact UV doses and wavelengths to avoid, possible
  interaction with sunbed UVA etc
• Scottish and N Ireland primary prevention
  campaigns must be tailored to sunstarved UK!
• Data urgently needed to refute vitamin D worries

27
(No Transcript)
28
(No Transcript)