Out, damned spot! Burden of skin cancer in Australia

THIS week marks National Skin Cancer Action Week and despite advances in the field of cutaneous oncology, non-melanoma skin cancer (NMSC) continues to pose a significant burden on the health of Australians.

Australia leads the world in incidence of melanoma and NMSC; a reflection of its unique constitution of a predominantly Caucasian population in a geographic location with significant ultraviolet radiation. Australians have the highest incidence of cutaneous neoplasms per capita internationally, with two out of three Australians diagnosed with a skin cancer by retirement age.

Non-melanoma skin cancer also poses the largest financial burden of all cancers within Australia, with costs estimated at $1.2 billion for 2020 (here, here and here). NMSC is a largely preventable disease and through increased public awareness and sun protection measures we have the power to eliminate much of its burden. The “Slip! Slop! Slap!” campaign of 1981 marks one of Australia’s most successful public health interventions. Along with associated SunSmart campaigns it is estimated to have saved the government $2.60 for every dollar spent as well as preventing over 100 000 skin cancers by 2014 alone.

Although the incidence of NMSC is still on the rise, the rate of this rise has reduced in recent times. The lower overall mortality rate of NMSC (and here)reflects the increasing awareness and early detection in large part by patients and their primary care physicians. The use of dermoscopy over the past three decades has revolutionised the diagnosis of skin cancer. This simple bedside clinical tool, employing magnification and polarised or non-polarised light, has been shown to improve the sensitivity and specificity of diagnosis in well trained hands.

In general practice, dermatological presentations represent approximately 16% of patient encounters, with cutaneous neoplasms being a significant portion of these (here and here). Despite the significant burden of dermatological disease, structured training for general practice registrars and medical students remains poor, in our opinion. A study including 17 of the 18 medical schools within Australia revealed on average just five lectures are dedicated to dermatology during each program and only 35% of medical schools required dermatological learning targets to be met for exam purposes. Increased teaching and fostering of interests among trainee doctors are important grassroot tools to ensure adequate future access to high level care.

Despite the burden of skin cancer in Australia, access to specialist dermatology services remains a challenge for many Australians. One US study from 2017 suggested a minimum of four dermatologists per 100 000 population was needed to provide adequate care. In Australia, this figure is currently closer to 2 per 100 000. Access to specialised dermatological services is further complicated in Australia by its vast landmass and concentrated core of dermatologists in large metropolitan areas. For example, in our local area health district of south-west Sydney there is one dermatologist per 100 000 population, compared with inner Sydney where the ratio is 5.9 per 100 000 (Australasian College of Dermatologists, Key Demographics NSW Faculty — Distribution of active Fellows and training positions by Local Health District. 2019). With 92% of dermatologists working in major cities there is an increasing burden on regional and remote GPs to service this population (here and here).

An increase in both the numbers of regional dermatologists and structured dermatological teaching programs targeting GPs in areas of need is required to provide adequate care to patients in these communities. Digital resources are increasingly used by health professionals and patients in regional and remote settings to improve accessibility and standard of care. With the advent of digital technologies and platforms such as teledermatology, HealthPathways, and novel educational tools such as medical social media platforms, greater awareness and uptake of these resources are hoped to lead to upskilling, in turn helping with triaging and referral pathways.

The skin is one of the most complex organs in the body, serving multiple physiological roles, and any of its cellular components can become neoplastic. Fibroblasts, adnexal structures, nerves, and blood vessels all have the potential for malignant transformation. Diagnosis and management of such lesions can be challenging, further supporting the need for subspecialty expertise in cutaneous oncology.  This makes a strong case for enhancing public hospital services, in particular with multidisciplinary teams comprising of dermatologists, dermatopathologists, surgical oncologists, radiation oncologists and medical oncologists that provide best care for patients with advanced or rare cutaneous neoplasms.

Australia is a world leader in skin cancer research.  The landscape of management of metastatic melanoma has been revolutionised in the past decade. Advances have also been made in terms of basal cell carcinoma with treatments such as the hedgehog inhibitors vismodegib and sonidegib now available on the Pharmaceutical Benefits Scheme. For advanced squamous cell carcinoma, promising results have been noted in trials investigating epidermal growth factor receptor inhibitors and checkpoint inhibition immunotherapy.

Australian research has also featured prominently in recent years with regards to preventive interventions for keratinocyte cancers, including daylight photodynamic therapy and oral nicotinamide.

The NSW Reporting for the Better Cancer Outcomes Program has identified four key areas important for cancer control: prevention, screening, treatment and research. As Australians and New Zealanders together take first and second place in the world in skin cancer numbers, we are uniquely positioned to take on this challenge. This National Skin Cancer Action Week we should all be proud of the advances made in this field as we strive towards even better outcomes for our patients.

Dr Deshan Sebaratnam is a staff specialist at Liverpool Hospital and Conjoint Senior Lecturer at UNSW. He works in private practices across Sydney and services an outreach clinic in Dubbo, NSW.

Dr Samuel Der Sarkissian is a GP on the south coast of New South Wales. He is an Honorary Senior Clinical Lecturer at the University of Wollongong and Conjoint Lecturer at UNSW with a special interest in dermatology.

Dr Alicia O’Connor is a Visiting Medical Officer at Prince of Wales Hospital and a Conjoint lecturer at UNSW and University of Notre Dame Australia (Sydney). She works in private practices across Sydney.

Dr Monisha Gupta is the Head of the Dermatology Department at Liverpool Hospital, NSW. She holds a conjoint appointment at UNSW and Western Sydney University, and works in private practices across Sydney.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.