Reducing the impact of skin cancer in NSW Strategic Plan 2007-2009

Reducing the impact of skin
cancer in NSW
Strategic Plan 2007-2009




































Reducing the impact of skin cancer in NSW

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Acknowledgments

This Plan was developed by the NSW Skin Cancer Prevention Working Group, comprising
representatives from The Cancer Council NSW (Anita Tang and Kay Coppa); the Cancer Institute
NSW (Trish Cotter and Anita Dessaix) and NSW Health (Jenny Hughes and Nidia Raya Martinez).

We would also like to thank the many key informants working in skin cancer prevention who
generously gave us their time for interviews and comments in reviewing the 2001-2005 Skin Cancer
Prevention Strategic Plan.


ARTD Project Team
Chris Milne, Greg Davies, Margaret Thomas, Marita Merlene

January 2007
















For more information

Cancer Institute NSW
The Cancer Council NSW
Level 1, Biomedical Building
153 Dowling Street
Australian Technology Park
Woolloomooloo NSW 2011
Eveleigh NSW 2015



PO Box 41
PO Box 572
Alexandria NSW 1435
Kings Cross NSW 1340


Telephone: 02 8374 5600
Telephone: 02 9334 1900
Facsimile: 02 8374 5700
Facsimile: 02 9358 1452

Email: feedback@nswcc.org.au

www.cancercouncil.com.au/sunsmart


ARTD Pty Ltd
Level 4, 352 Kent St Sydney
ABN 75 003 701 764
PO Box 1167
Tel 02 9373 9900
Queen Victoria Building
Fax 02 9373 9998
NSW 1230 Australia




Reducing the impact of skin cancer in NSW

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Reducing the impact of skin cancer in NSW
Strategic Plan 2007-2009

Foreword

Reducing the Impact of Skin Cancer in NSW Strategic Plan 2007-2009 sets out the
commitment of three partner agencies toward skin cancer prevention. The Cancer Council
NSW, the Cancer Institute NSW and NSW Department of Health have collaborated to
develop a plan that will guide and coordinate skin cancer prevention initiatives of the three
agencies. The plan builds on the efforts and learning’s of the previous strategic plan and
considers current priorities in skin cancer prevention.

The need for continued investment in the area of skin cancer prevention is evident with
figures showing melanoma cases rising. Between 1995 and 2004 NSW incidence rates of
melanoma rose by 18% in males and 21% in females. While survival for melanoma is high,
so are the costs of treatment with skin cancer (melanoma and non-melanoma) being the
most costly cancer to the Australian health system.

The plan has been developed and informed through consultation with stakeholders from the
Alliance of NSW Divisions, Northern Sydney Central Coast Area Health Service and Mid
North Coast Area Health Service. The plan recognises the challenges and opportunities in
this area, as well as the resources that each partner agency can contribute.

The plan outlines a coordinated approach to activities, identifying specific priority groups and
settings to maximise impact. The overarching goal is to reduce the incidence of skin cancer
in NSW. However, as with many public health issues, the benefits of interventions may not
be evident for a number of decades.

Therefore the plan specifically sets out an objective of reducing people’s exposure to UV
radiation, as the key contributor to skin cancer risk. Key result areas include improved sun
protection behaviour, early detection and treatment of skin cancer, increased community
awareness of the importance of sun protection, implementation of sun protection policies by
industry groups, coordinated action by core partners and research to inform current and
future decision making. These are concrete and intermediate areas where progress now will
reduce the impact of skin cancer later.

Reducing the Impact of Skin Cancer in NSW Strategic Plan 2007-2009 provides an overview
of actions by partner agencies to deliver key result areas. Together this coordinated action
will continue the already good work in skin cancer prevention to benefit the people of NSW
now and for the future.







JAMES F BISHOP
DR DENISE ROBINSON
DR ANDREW PENMAN
MD MMed MBBS
Chief Health Officer and
CEO, Cancer Council NSW
FRACP FRCPA
Deputy Director-General

Chief Cancer Officer and
Population Health

CEO, Cancer Institute NSW
NSW Department of Health

Professor of Cancer Medicine,


University of Sydney






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Table of Contents


1
The Plan...................................................................................................................................... 1

2
Targets ........................................................................................................................................ 2
2.1
Long term aims & results......................................................................................................... 2
2.2
Priority groups ......................................................................................................................... 2
2.3
The wider community .............................................................................................................. 3

3
Roles of the partner organisations .............................................................................................. 3
3.1
NSW Cancer Council............................................................................................................... 3
3.2
Cancer Institute NSW .............................................................................................................. 4
3.3
NSW Health............................................................................................................................. 4
3.4
National and interstate agencies............................................................................................... 5

4
Implementing the Plan................................................................................................................ 5
4.1
Core partners............................................................................................................................ 5
4.2
Other sectors ............................................................................................................................ 6
4.3
Priority actions......................................................................................................................... 6

5
Results logic for the strategic plan ............................................................................................. 6

6
Reduced harmful UVR exposure (KRA 1)................................................................................. 9

7
Cancers detected and treated early (KRA 2) ............................................................................ 11

8
Increased community awareness (KRA 3) ............................................................................... 14

9
Partner organisations implement sun protection policies and practices (KRA 4) .................... 17

10
Coordinated action by core partners (KRA 5).......................................................................... 21

11
Research informs decision-making (KRA 6) ........................................................................... 23

12
Monitoring and evaluation ....................................................................................................... 24
12.1 Monitoring ............................................................................................................................. 24
12.2 Evaluation activities............................................................................................................... 24




Reducing the impact of skin cancer in NSW

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The Plan
Skin cancer remains a significant health issue in NSW and Australia has the highest rate of skin cancer
in the world. Prevention is a key action in managing skin cancer at a population level. Action in
NSW is undertaken between three key agencies – the NSW Cancer Council, the Cancer Institute and
NSW Health, and is also influenced by national activities either through the Australian Government
Department of Health and Ageing or The Cancer Council Australia (a national body of state and
territory non-government cancer control organisations). There is therefore a need to provide a
common basis to coordinate action and decision-making in NSW to optimise the use of the limited
resources available for skin cancer prevention.

The purpose of the Plan is to:
•
outline key activities for the next three years
•
indicate where there are gaps or opportunities, and
•
articulate principles for how the three core partner agencies in NSW will work together in
managing skin cancer prevention and how the implementation of the Plan will be monitored

This Plan is supported by a companion document, ‘Skin Cancer in NSW – Evidence Update’, which
summarises our current knowledge of skin cancer, the incidence in NSW and approaches to cancer
prevention.


Key facts about skin cancer in NSW1

Melanoma
• There were 3,402 new cases in 2004.
• There were 388 deaths in 2004 in NSW from melanoma, around 3% of all cancer deaths.
• There has been a dramatic increase in the incidence of melanoma over the last twenty years.

However, death rates have stabilised despite the increase in incidence.

Non-melanoma (basal cell carcinoma and squamous cell carcinoma)

• There has been a steady increase in the incidence of non-melanoma skin cancers from 1985 to
2002 – 29% increase for basal cell carcinoma and 122% increase for squamous cell carcinoma.

The rate of increase has been significantly greater in females than males.

• On an age-standardised basis, the incidence in 2002 of basal cell carcinoma was 1015 per
100,000 people, and the incidence of squamous cell carcinoma was 354 per 100,000 people.

• There are no NSW specific data on death rates from non-melanoma skin cancer.


Health costs
• Skin cancers were estimated to account for a total of $294m in health expenditure for the year

of 2001. $30m of this was for treating melanoma and $264m for treating non-melanoma skin

cancers.

Current behaviours
• People in NSW report spending more time in the shade than previously.
• Around half the population report wearing hats, sun glasses and protective clothing.
• Slightly more than half of all women, and less than half of all men, report using sunscreen.

Interventions
•
The most effective preventative action at a population level is to reduce the cumulative lifetime
exposure to UV radiation for each person and avoiding incidents of extreme exposure which
lead to sunburn. These will reduce the incidence of melanoma and non-melanoma skin
cancers.
•
There is a need to increase all protective behaviours.
•
There are overall benefits from early detection and treatment of skin cancers

1 Skin Cancer in NSW – Evidence Update, NSW Skin Cancer Prevention Working Group, 2007




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1
Targets
1.1
Long term aims & results
The long term aim of skin cancer prevention is to reduce the incidence of skin cancer (both melanoma
and non-melanoma) in NSW on an age-standardised basis, and also to reduce the cost to individuals,
the community and to the health system. However, skin cancer generally has a very long development
time, occurring mostly in the older proportion of the population (aged 55+). As a consequence, much
of the benefit of prevention action now may not become manifest for up to 50 years.

A realistic result for this Plan is a reduction in the exposure of the general population to UV radiation
through demonstrating changes in behaviours and changing the environment – increasing the use of
protective clothing and sunscreen; decreasing risk behaviours (spending time outdoors in peak UV
periods and incidence of sunburn) and increasing the amount of shade available in public places.
This Plan is consistent with the NSW Cancer Plan, which includes the same goal for skin cancer
prevention.

There are two levels of target audiences for actions under the Plan
•
priority groups
•
the wider community to ensure that all community segments maintain a basic level of
awareness of the hazards of UV exposure

1.2
Priority groups
Priority groups have been selected based on:
•
degree of risk – some community segments are at higher risk, or demonstrate higher risk
behaviours
•
incidence of skin cancer – some community segments, or populations in some locations,
have a higher incidence of skin cancer, indicating behaviours or factors which may need
attention
•
potential benefit – actions with some groups are more likely to lead to sustained benefits at a
population level

The Priority Groups for this Strategic Plan are:

•
Children aged 0 to 11
These were identified in the 2001-2005 Strategic Plan as the highest priority target group for
action and this position is unchanged, given that:
-
high exposure in childhood is more likely to lead to an individual developing skin cancer,
and lifetime cumulative exposure to UV radiation has a strong bearing on the likelihood of
an individual developing skin cancer – limiting exposure in childhood therefore confers a
lifetime benefit;
-
Children in this age group are typically in more controlled environments – there is greater
parental influence on daily activities; children may attend pre-schools where it is possible
to implement effective sun protection policies; the majority of children attend primary
schools where the duty of care in overseeing children’s health is generally understood to
include sun protection.

•
Adolescents
Raising awareness and changing behaviour of adolescents is very difficult. However, this
group also demonstrate the highest risk behaviours in terms of long periods of exposure to UV
radiation, incidence of sunburn and holding positive views about sun tanning. These attitudes
and behaviours are likely to contribute to a higher incidence of skin cancer in later life.





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•
Older people, especially older men (55+)
The incidence of skin cancer is highest in older men. Whilst exposure early in life is critical,
the incidence of skin cancer in older men is significantly higher than older women, indicating
that there are lifestyle factors that trigger skin cancers in later life. The incidence of skin
cancer in older men has tripled on an age standardised basis over the last 20 years. Whilst
older men are the higher priority group, actions and programs for this group are often directed
at both older men and women based on findings from previous programs that older men tend
to change behaviour based on advice from their partners or wives. Actions for older people
focus mostly on early detection, with a limited emphasis on prevention through reducing
exposure.

•
People living in coastal zones, particularly mid to upper North Coast
The areas covered by the current North Coast Area Health Service have the highest incidence.
Other coastal zones are also above the State average.

1.3
The wider community
The partners to the Plan also maintain an ongoing level of activity to support awareness raising across
the community overall. This includes the Cancer Helpline managed by the Cancer Council,
development and distribution of brochures and other resources and work with sectors that have a broad
impact.


2
Roles of the partner organisations
This Plan is an agreement between the three core partners – the NSW Cancer Council, Cancer Institute
NSW and NSW Health. The priority actions identify which agency is the lead for each action. The
actions of the NSW agencies are also influenced and informed by actions nationally and interstate.

The three core partners bring complementary assets and capacities to deal with skin cancer prevention:
•
Capacity and experience in mass media campaigns (Cancer Institute NSW)
•
Statewide infrastructure and reach into communities for community-based or collaborative
activities (The Cancer Council NSW and NSW Health through the Area Health Services)
•
Policy advocacy (The Cancer Council NSW)
•
Policy advice to Government (NSW Health and Cancer Institute NSW)
•
Standing relationship with other key parties, especially local Government (NSW Health and
The Cancer Council NSW) and peak bodies
•
Development and co-ordination of State Cancer Plan, including through professional
education (Cancer Institute NSW)

2.1
NSW Cancer Council
The Cancer Council NSW is an independent cancer charity with a mission to defeat cancer, by
building a cancer smart community. The Cancer Council has a broad portfolio of functions, including
providing support and information about cancer, conducting behavioural and epidemiological
research, funding research, preventing cancer and advocating for improved cancer control.

The Cancer Council has played a significant ongoing role in raising the community awareness of the
risks of UV exposure and strategies for reducing that exposure. The Cancer Council’s key activities in
skin cancer prevention include:
•
Raising awareness of individuals to encourage behaviour change
•
Development of resources and information to support increased community awareness



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•
Working with and through key organisations (local councils, schools, child care centres) to
improve their capacity to prevent skin cancer, particularly through the adoption of good sun
protection policies and practices
•
Working with health professionals to support increased awareness of sun protection and skin
cancer issues
•
Liaison with an expert reference group on skin cancer to provide professional advice on key
issues
•
Commissioning or undertaking research into sun protection knowledge, attitudes and
behaviour; and funding research relevant to skin cancer
•
Increasing the availability of high quality, sun protective clothing and products through
Cancer Council retail stores and other outlets.
The Cancer Council has a statewide community presence through its network of regional offices that
implement Cancer Council programs in their areas. The Cancer Council’s local infrastructure
provides the community with a key point of contact for cancer issues, including skin cancer
prevention. The local staff of The Cancer Council are well-established in regional communities, and
deliver a range of skin cancer prevention programs and messages to priority target groups and settings.

2.2
Cancer Institute NSW
The Cancer Institute NSW was established in July 2003 through the Cancer Institute (NSW) Act 2003
as a direct response to the need to decrease the burden of cancer. The Cancer Institute NSW has the
statutory mandate to substantially improve cancer control in NSW by increasing cancer survival,
reducing cancer incidence, improving the quality of life of cancer patients and their carers and
providing expert advice to patients, the public health care professionals and the Government.

The NSW Cancer Plan 2007-2010 notes that the Cancer Institute NSW has a collaborative and key
role in cancer prevention, including skin cancer and melanoma. The Cancer Institute NSW has
identified that its primary role in skin cancer prevention is through a population approach, using mass
media social marketing campaigns to increase awareness of melanoma and the importance of sun
protection.

The Cancer Institute NSW will explore opportunities to work with health professionals to promote
melanoma awareness and promote local activity in skin cancer prevention with the Cancer Council,
NSW Health and Area Health Services.

The Cancer Institute NSW also contributes to improved understanding of cancer and cancer
management through:
•
the cancer registry, including reporting on incidence and mortality
•
research funding, including a melanoma program grant
•
co-ordination of an expert Melanoma NSW Oncology Group.

2.3
NSW Health
Within the NSW Department of Health, the primary interest in skin cancer prevention rests with the
Centre for Chronic Disease Prevention and Health Advancement which focuses on health promotion.
The Centre is represented on the Skin Cancer Prevention Working Group, although it does not
currently have programs relating directly to skin cancer. The Centre provides a direct connection to
the Health Promotion units in each Area Health Service, some of which are working in skin cancer
prevention where there is a high local need or opportunity (e.g. good working relationship with Cancer
Council regional staff). The Centre maintains a strong connection to public health programs in Local
Government, particularly through a close relationship with the Local Government & Shires
Association of NSW, and is therefore well placed to provide a conduit for the promotion of skin
cancer prevention messages and programs to local councils.

The Department contributes to better knowledge of skin cancer and management through regular



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studies of attitudes and behaviour (e.g. Health Behaviours of Secondary School students survey, NSW
Health survey and solarium operators compliance to voluntary standards).

2.4
National and interstate agencies
It is important to recognise that the actions taken by NSW agencies are informed by, and in turn
inform, the broader context of actions and activity underway nationally and in other States.

The Cancer Council Australia
This is a national body comprising the Cancer Councils from each State and Territory (eight in
total). This body auspices a National Skin Cancer Committee, which has issued ‘position
statements’ on key issues relating to sun protection e.g. sun protection for 0-1 yr olds; solaria;
risks and benefits of sun exposure. These are de facto policy statements and are endorsed by
medical experts such as the Australian Council of Dermatologists. The National Working Group
includes a NSW representative from the Cancer Council to ensure that NSW approaches and
concerns are both informed by and inform the national processes.

Australian Department of Ageing and Health
The Department is currently funding a national mass-marketing campaign focusing on prevention
and targeting 13 to 17 year olds. The campaign is anticipated to be launched in November 2006.
The Cancer Institute NSW is represented on the advisory committee for the campaign. The
Department does not significantly contribute to other ongoing skin cancer prevention programs.

SunSmart
The Cancer Council Victoria has played a significant role in promoting skin cancer prevention
over the last twenty years, including the development of the SunSmart program as an umbrella for
all sun protection activity in Victoria. This has been a very effective program in many areas,
including: recognising settings as SunSmart when they meet the criteria for best practice for sun
protection policies and practices; work with sports organisations; social marketing campaigns;
work with local government and shade awards for local councils.

Peak bodies and community groups
There are a range of peak bodies which are active in the public debate around prevention,
detection and treatment of skin cancer. These include professional groups (e.g. the Melanoma
Group as part of the Clinical Oncology Society of Australia) and foundations (e.g. the Melanoma
Foundation). Each of these groups has some links to the core partners, ranging from formal links
– e.g. through representation on expert panels, to informal links through personal contacts.



3
Implementing the Plan
The implementation of the Plan will be coordinated by the Skin Cancer Prevention Working Group,
made up of the three core partners. The Working Group will be responsible for monitoring progress
and preparing an annual progress report.

3.1
Core partners
The core partners have agreed to work together cooperatively by:
•
jointly managing the implementation of the Strategic Plan through annual progress reviews at
the end of each calendar year, and outlining forward plans at the beginning of each new
calendar year
•
jointly planning projects and campaigns where more than one partner is involved – the Cancer
Council and the Cancer Institute NSW agreement on the design and implementation of the
‘Tattoo’ social marketing campaign in Summer 2006/7 which provides a working example
•
providing advance notice (where possible) of projects and campaigns to maximise the
opportunities for coordinating programs and notifying staff implementing programs



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(particularly staff in Cancer Council Regional offices and Area Health Service Health
Promotion Units)
•
recognising that whilst the Plan aims to coordinate action between the three parties, any one of
the partners may undertake other skin cancer prevention activities additional to those outlined
in this Plan.

3.2
Other sectors
In working with other sectors, the core partners recognise that:
•
strategies that integrate sun protection messages and programs into the core business of the
other sectors will be more successful, and
•
there is limited capacity (both in available funding and staff expertise) in most sectors and
strategies and actions will be developed to suit the available resources

3.3
Priority actions
In considering actions, priority has been given to actions or projects which:
•
apply to a priority group
•
apply in a relevant setting to that priority group
•
use an intervention which addresses the factors contributing to the risks for that group, and
•
have a reasonable chance of success with the available resources (this does not preclude
exploration of new interventions e.g. trialing a new approach for raising awareness in
adolescents).

The Plan is a dynamic document and the partners recognise that it may be modified during its lifetime
in response to new knowledge or emerging priorities. New actions or projects which may arise in the
life of the Plan will also be assessed against these criteria.


4
Results logic for the strategic plan
The 2007-2009 Strategic Plan aims to achieve results through feasible strategies that reflect priorities
and opportunities to make effective reductions in sun exposure for at–risk groups. It represents the
ways the three core partners will contribute to the ultimate outcomes of reduced incidence of skin
cancers for the people of NSW.

These strategies and their intended results are outlined in the results logic for the plan (Figure 1). It
shows in general terms how the three partners intend to produce a set of intermediate results that in
turn contribute to the ultimate outcomes. While terminologies vary (eg program logic, logic models,
outcomes hierarchy), results logic is the approach used by NSW Treasury and is appropriate for this
plan. It has three broad levels of services/ intermediate results/ ultimate results. The main distinction
is that the core partners are directly responsible for the services (the bottom level), have a reasonable
degree of control and responsibility for the intermediate results, but have far less control over the
ultimate results which occur in the longer term and are increasingly influenced by range of external
factors.

The foundation of the results logic is the services delivered by the three core partners – the creation
and implementation of an appropriate and feasible strategic plan, represented as the bottom levels in
Figure 1. A key element in achieving the plan is up-to-date research on the scope of the problem, on
the effectiveness of interventions, and on the opportunities to take action in the current institutional
and policy context. The other key element is agreement by the three partners on priorities, strategies
and resources, so that the plan will have a strategic and coordinated approach.






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