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NZ tops world for melanoma deaths – Expert Reaction

New Zealand had the highest melanoma death rate in 2020, according to a new study in JAMA Dermatology, which also predicts cases will rise 50 per cent globally by 2040.

The study authors took a look at the global burden of melanoma, estimating there was a worldwide total of 325,000 new melanoma cases and 57,000 deaths for 2020. Based on these rates, the authors estimate the burden from melanoma will increase to 510,000 new cases (a roughly 50 per cent increase) and to 96,000 deaths (a 68 per cent increase) by 2040.

The SMC asked experts to comment on the research.

Amanda Oakley, Adjunct Associate Professor, Department of Medicine, University of Auckland; and Dermatologist, Waikato District Health Board, comments:

“High rates of melanoma and having the highest mortality from melanoma in the world is not news to New Zealand melanoma experts. The MelNet Melanoma Summit a couple of weeks ago was sobering, with excellent talks from the experts. One of the authors of the JAMA Dermatology paper, Dr David Whiteman, was a keynote speaker.

“Not only are our incident and mortality rates high (especially in males more than 50 years old), but we have a burgeoning ageing population of white New Zealanders (baby boomers) that baked in the sun during their youth or have worked outdoors with little protection from sunburn or daily relentless ultraviolet radiation — the cause of >90 per cent of melanomas in New Zealand. Our health services are under a great strain with far too few dermatologists, surgical specialists, and GPs to effectively manage our skin cancer epidemic.

“MelNet has recently published Quality Statements to guide patient care.

“MelNet’s priorities for action include an emphasis on training primary care doctors to examine the skin for melanoma (including dermoscopy). These doctors are signing up in droves to upskill.

“On the bright side, some patients with advanced melanoma are surviving whereas they would have died a few years ago, thanks to new immunotherapy drugs. However, the options for treatment are fewer than in comparable countries overseas despite our dubious honour of having the highest mortality rates from melanoma in the world.”

Conflict of interest statement: “I am on MelNet’s board (the Melanoma Network of New Zealand). I am a diagnosing consultant for MoleMap New Zealand.”

Dr Geri McLeod, Christchurch Health and Development Study, University of Otago, Christchurch, comments:

“The results of this study send a clear message to the New Zealand government and local territorial authorities that more investment is needed to reduce risk factors for the development of melanoma.

“Previous research has shown that the New Zealand population is too optimistic about their ability to sun-protect and as a consequence are experiencing sunburn. This is known as the sunburn paradox. That is, individuals have a tendency to incorrectly believe that their chosen sun protection method will be adequate. For example, we often see media reports of people becoming badly sunburned after only using sunscreen as their form of sun protection.

“The easiest way to protect yourself from excess UV radiation is to restrict outdoor activity when UV radiation is at a peak, usually a few hours either side of midday. To properly protect the skin from excess UV radiation when outdoors, we need to use physical cover such as a shirt and hat, in addition to seeking shade where practical.

“The use of sunscreen should only be an adjunct form of sun protection, rather than the main/only form of sun protection used. It is very important that those using sunscreen use it properly by applying enough, applying prior to going outdoors, apply a second coat of sunscreen to cover any thin spots and gaps missed in the first coat, and reapplying frequently when outdoors.

“Therefore, this study has shown that education campaigns such as the successful SunSmart programs launched in Australia need to be continued. Territorial authorities can help reduce over exposure to UV radiation and sunburn by scheduling public events so that they occur outside of peak UV and provide effective shade (trees or shade sails).”

Note: Dr McLeod is also 0.5FTE at University of Canterbury, Department of Psychology, Speech and Hearing.

Conflict of interest statement: “I have analysed data from the Health Promotion Agency in the past but am not paid or sponsored by them currently.”

Dr Louise Reiche, vocationally registered dermatologist, member and immediate past president of the New Zealand Dermatological Society, comments:

“Melanoma causes a significant cancer burden to New Zealanders and our health system. Both the incidence and mortality figures are higher in New Zealand than any other country (as described in this article), for multiple reasons including our large proportion of fair skin ethnicities, outdoor lifestyle, and high year-round UV exposure.

“The gravity of this issue was thoroughly discussed at this year’s Melnet Summit, highlighting multiple areas of concern related to melanoma including:

  • Insufficient funding for New Zealand epidemiology studies
  • Insufficient infrastructure support and funding for education in sun prevention strategies in all levels of education (beyond pre-school and primary school) and general population
  • Inequities – although Māori and Pacific peoples have a lower incidence melanoma, their melanoma diagnosis is made late with associated poorer health outcomes including disproportionately higher mortality
  • Need for total ban of commercial sunbeds (not just for under 18 year olds)
  • Priority for routine permanent shade provision in public places e.g., schools, parks, and recreational facilities, in city planning, building consents, and so forth
  • Mandatory therapeutic product sunscreen standards compliance and testing
  • Equitable access to medical experts for high-risk patient screening and monitoring
  • Infrastructure and financial support to correct and build the health workforce
  • Infrastructure and funding support for research and provision of world-standard therapies and treatment for early, intermediate, and late-stage melanoma

“Reformation of our health system is a wonderful opportunity to address these considerable holistic health measures for the long-term benefit of all New Zealanders to reduce the current and pending melanoma health burden.”

Other affiliations and conflict of interest statement: “I am NZDSI spokesperson regarding sunscreen, member of Melnet (represented Melnet on the Australian New Zealand Sunscreen standards committee 2021) and provide expertise to Cancer Society NZ, Melanoma NZ and Consumer NZ I have worked will all these groups to advocate for banning of commercial sunbed use, promoting mandatory sunscreen standards and testing, and advocating for better outdoors shade provision, and mandatory records for non-melanoma skin cancers namely basal cell and squamous cell carcinomas (greater patient and health system burden than melanoma even!), Chairperson for New Zealand Dermatology Research Trust (NZDRT) and ex-officio trustee for Dermnet NZ Trust.”

Dr Bronwen McNoe, Social and Behavioural Research Unit, University of Otago, comments:

“Melanoma is a substantial public health burden in New Zealand with more than 350 deaths annually.

“The cost of diagnosing and treating melanoma in New Zealand is estimated to be in excess of $51 million annually.

“About three-quarters of melanoma results from DNA damage triggered by exposure to ultraviolet radiation (UVR), primarily from the Sun.

“High rates of melanoma in New Zealand are primarily due to higher levels of exposure to UVR and a high proportion of our population having European ancestry and fair-coloured skin.

“Strategies that focus on reducing the amount of harmful UVR New Zealanders are exposed to is the best way to reduce the melanoma burden.

“Unfortunately New Zealand lags behind Australia in virtually every dimension of skin cancer prevention including Government investment. For example, funding for skin cancer prevention (2020/21) to the Te Hiringa Hauora Health Promotion Agency was just $500,000 (including salaries). In comparison:

  • The number of road fatalities in New Zealand is similar to the number of melanoma deaths. Waka Kotahi has just spent $15 million on one campaign.
  • The Commonwealth Government in Australia has just invested $10 million in a single two-year campaign focusing on skin cancer prevention.

“Although we continue to encourage individual’s to slip, slop, slap and wrap, it is also important that environments in which we live, work and play provide protection from high levels of UVR. For example, installing shade in playgrounds can provide great protection for our young people while they enjoy the outdoors.”

Conflict of interest statement: “My salary is partially funded by the Cancer Society of New Zealand.”