Report
The first skin cancer screening day at the Italian parliament: a Euromelanoma initiative Mariano Suppa1,2, MD, Luca Neri3,4, MD, PhD, Luca Bianchi4,5, MD, Rodolfo Capizzi5,6, MD, a7, MD, Sergio Chimenti5, MD, Maria Concetta Angelo Carbone7, MD, Caterina Catrical 1 6 Fargnoli , MD, Barbara Fossati , MD, Pasquale Frascione7, MD, and Ketty Peris1,6, MD
1 Department of Dermatology, University of L’Aquila, L’Aquila, 2Department of ^pital Erasme, Universite Dermatology, Ho Libre de Bruxelles, Brussels, Belgium, 3 Dipartimento di Scienze Cliniche e di , Universita di Milano, Milan, Comunita 4 Fondazione IRCCS Ca Granda – Ospedale Maggiore Policlinico, Milan, 5 Department of Dermatology, University of Rome Tor Vergata, Rome, 6Department of Dermatology, Catholic University of the Sacred Heart, Rome, and 7Department of Oncologic Dermatology, Santa Maria and San Gallicano Institute of Dermatology – IRCCS, Rome, Italy
Correspondence Ketty Peris, MD Department of Dermatology University of L’Aquila Via Vetoio – Coppito 67100 L’Aquila Italy E-mail: [email protected]
Abstract Background The effort to decrease incidence/mortality of skin cancer should target not only the general public but also politicians and decision makers, to create a proper health policy. We report the results of the first Skin Cancer Screening Day at the Italian Parliament, organized to draw politicians’ attention on skin cancer. Methods A questionnaire was used to collect data on participants’ characteristics and suspected skin cancers. Results We screened 70 members of parliament (61.4% males, median age 54 years). Overall skin cancer suspicion rate was 14.5%. Suspicion rate, detection rate, and positive predictive values for melanoma were respectively 1.6, 1.6, and 100%, and for basal cell carcinoma 6.5, 1.6, and 25%. Highly educated, 20 sessions/year)
13. Have you ever had an outdoor occupation? No Yes 14. How often do you use sunscreen? When sunbathing: After swimming or sweating:
Never Never
Sometimes Sometimes
(*) An atypical nevus is defined by the presence of at least 3 of the following criteria: diameter >5 mm, irregular margins, ill -defined border, color variation, macular and papular components (**) BCC, basal cell carcinoma (***) AK, actinic keratosis; SCC , squamous cell carcinoma
Always Always
15. Have you spent at least 1 year in countries with higher sun irradiance than the country you currently live in? No Yes
1
2
Figure 1 Study questionnaire. The first page (completed by the participating MP) enquired about participant’s demographics and risk factors. The second page (fulfilled by the dermatologist) was about clinical findings emerged during the examination ª 2014 The International Society of Dermatology
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Table 1 Demographics of participants, motivations to participate, and previous skin checks
Sex Females Males Age, median (range) Educational level Primary/secondary school University/postgraduate Motivation to participate “I just want to be checked” “I have many moles” “I have a suspicious skin lesion” “A family member/friend had/has skin cancer” “I was previously diagnosed with a skin cancer” At least 1 previous skin check Number of previous skin checks
Overall
Males
Females
Pa
5 mm, irregular margins, ill-defined border, color variation, and macular and papular components) were present, as previously described.25,26 All visits were dermatoscopically aided. If a suspicious lesion was found, the screenees received advice for further diagnostics or treatment. Continuous variables were compared using the two-sample Wilcoxon rank-sum (Mann–Whitney) test. For categorical variables, different groups were compared using Pearson’s chisquared test. Comparisons were performed within different sex, age, education, and phenotypic groups. Three parameters were used to evaluate the efficacy of the screening: (i) the suspicion rate, defined as the number of participants with a suspicious skin cancer divided by the total number of participants; (ii) the detection rate, defined as the proportion of histologically confirmed skin cancers among all screenees; and (iii) the positive predictive value (PPV), defined as the proportion of histologically confirmed skin cancers among all patients suspected of having a skin cancer. All statistical tests were twotailed and considered significant at the arbitrary 5% level. The statistical analysis was carried out using the STATA version 10 (2007; StataCorp., College Station, TX, USA).
Results Overall, 70 MPs were screened, 43 (61.4%) men and 27 (38.6%) women, with median age 54 years (range 30– 74 years). The women were significantly younger than the men were (median age 49 vs. 57 years, P = 0.02) (Table 1). The main reason to participate was the simple desire to have the skin checked (48.5%), followed by the perceived presence of many moles (32.3%), a recently changed or somehow suspicious lesion (12.1%), a family International Journal of Dermatology 2015, 54, 42–49
member/friend diagnosed with skin cancer (6.1%), and a previous personal diagnosis of skin cancer (4.6%). Compared to women, men reported significantly more the simple desire to have their skin checked (P = 0.04) and significantly less a previous personal diagnosis of skin cancer (P = 0.03). At least one previous skin check was reported by 43.8% of participants, with those individuals >54 years old more likely to do so (P = 0.04). The median number of previous skin checks was two (range 1–10). Risk factors for skin cancer among the screened MPs are illustrated in Table 2. The majority of participants reported skin types III (37.9%) and IV (30.3%). Males and ≥54-year-old MPs reported a significantly darker skin type than females (P = 0.04) and younger participants (P = 0.02), respectively. No participant reported a personal history of melanoma, while 6.8% of them reported a family history of melanoma and 6.1% a condition of iatrogenic immunosuppression (organ transplant recipients being treated with immunosuppressant agents). Assessment of behavioral risk factors (Table 2) showed that females were more likely than males to use a solarium (P = 0.01), and to apply sunscreen when sunbathing (P = 0.04) and reapply it after swimming or sweating (P = 0.05). Similarly, MPs aged 50. Similarly one of four suspected BCCs (PPV = 25%) was histopathologically confirmed (in a 62year-old man, with skin type III and university education), which resulted in a detection rate of 1.6%. Therefore, the overall detection rate was 3.2% (two of 62), and overall PPV was 22.2% (two of nine). A comparison of the findings of the present study with those from the first Italian Euromelanoma Day on the International Journal of Dermatology 2015, 54, 42–49
general population21 is reported in Table 4. The suspicion rate of skin cancer, melanoma detection rate, and PPV for melanoma were higher in this study as compared to the previously performed general population screening. Overall, female, younger, and higher-educated participants reported sun-seeking behaviors more frequently than their male, older, and less-educated peers in both studies. Moreover, sunscreen users reported sunburn more frequently than non-users in both investigations. Discussion This is the first report of a skin cancer screening in a national parliament. Previously, the Euromelanoma task force in conjunction with the European Academy of Dermatology and Venereology (EADV) organized a Skin Cancer Screening Day at the European Parliament in Brussels (Belgium) for three consecutive years (2011–2013), whose results are currently under evaluation.27–29 In 2006, a screening for major cardiovascular risk factors was performed in the Polish parliament to present the related epidemiological situation to political and key opinion leaders and to assess individual risk among Polish MPs.30 The Skin Cancer Screening Day at the Italian parliament produced slightly different results than those obtained from the Italian Euromelanoma screening of the general population,21 in particular in terms of overall suspicion rate of skin cancer (14.5% in this study, 4.6% in the general population screening). This is not surprising given that the majority of participants in the present study were men older than 35 years, which proved to be the most at-risk group in the Italian Euromelanoma screening but also the less adherent to that initiative.21 The differences in terms of melanoma detection rates (1.6 here, vs. 0.28%) and PPVs (100 here, vs. 21.4%) in the two studies are due to the fact that only one melanoma was suspected and confirmed in the present screening, compared to 15 (three confirmed) in the general one. The more extensive use of dermatoscopy during the skin examinations in this study (100%) as compared to the previous one (79.2%) is also likely to explain these discrepancies. As previously found, dermatoscopy can increase the odds of diagnosing a melanoma by at least nine times as compared with a naked eye examination.31 In the cardiovascular screening initiative carried out at the Polish parliament, the authors observed a higher level of awareness among MPs compared to the general population.30 Conversely, we have found no evidence that Italian MPs are more aware of skin cancers, risk factors for their occurrence, and methods of sun protection compared to the general public, either adults21 or adolescents.32 For instance, sunscreen users were more likely than non-users to report sunburns, a finding similar to ª 2014 The International Society of Dermatology
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what has been observed in previous surveys of the Italian general population; this behavior has been defined as the sunscreen paradox and described as a feeling of excessive protection when using sunscreen, which disproportionately extends sun exposure time and increases sun-seeking behaviors.33 Risk compensation is a well-known behavior previously described in different therapeutic areas and in ethology.34–36 As risk perception significantly affects risktaking decisions, it is key to ensure adequate knowledge of sunscreen use to help facilitate their correct use. Consistent with previous studies,21,23,32,37–43 we have found that females, younger participants, and those with higher education reported a stronger sun seeking behavior than their counterparts: although they seem to understand the necessity to avoid sunburn (more frequent sunscreen use), they still seek a tan (more frequent sunbed use and longer sunny holidays). This further suggests that there is no difference in the level of skin cancer awareness between the MPs and the general population in Italy.21,32 The strengths of this study are that this is the first report of a skin cancer campaign within a national parliament and that an internationally validated questionnaire was used.21,23 A limitation of the study was the restricted availability of follow-up data about suspected lesions. Indeed, only two of the nine MPs with suspicious lesions decided to refer to our departments for further diagnosis, whereas the other seven went to their own dermatologists, and it was therefore not possible to retrieve their follow-up data, in respect of their privacy. Additionally, the supposedly low participation rate could be regarded as another limitation. However, the main point of this initiative was not to determine the prevalence of skin cancer in such a selected population but to set a precedent for a new strategy to draw the attention of MPs to a very important issue, which is often forgotten or underestimated at the political/decision making level. Skin cancer represents indeed an important public health problem with striking healthcare costs. Primary and secondary prevention may potentially reduce the overall disease burden provided that sufficient resources are allocated to specific risk awareness actions and screening campaigns allowing early diagnosis. Expert medical groups and decision makers should cooperate to create a proper, integrated, longterm health policy on skin cancer. New policies should include the implementation of more awareness campaigns for the general public, as knowledge of skin cancer obviously represents the first step to its prevention. Unfortunately, though, this knowledge does not always translate into an effective change in people’s sun-related behavior32; therefore, new educational strategies should target those subgroups that seem to know more about skin cancer but behave less appropriately (i.e., females, younger, and highly educated) than their counterparts. ª 2014 The International Society of Dermatology
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In this scenario, it is vital to increase the awareness of skin cancer among politicians. We believe that the Skin Cancer Screening Day at the Italian parliament is a milestone in this direction and should be periodically repeated. This is of extreme importance, especially in view of the periodic personal rotations of politicians, determined by parliamentary elections. Drawing MP’s attention to the high prevalence of skin cancers, the feasibility of their prevention, costs of their treatment, and lack of adequate resources allocated to deal with these issues should result in a positive outcome of future parliamentary discussions and make the fight against skin cancer more successful. Acknowledgments The authors wish to thank Dr. Giuseppe Palumbo, MP and President of the Italian Parliament Health Commission, for the organizational support to this initiative. The authors are also indebted to Flavia Baldi from Leo Pharma Inc. for the conception and technical and organizational support of the project. This study has been realized thanks to an unconditional contribution from Leo Pharma, Inc. References 1 Jemal A, Siegel R, Xu J, et al. Cancer statistics, 2010. CA Cancer J Clin 2010; 60: 277–300. 2 de Vries E, Bray FI, Coebergh JW, et al. Changing epidemiology of malignant cutaneous melanoma in Europe 1953–1997: rising trends in incidence and mortality but recent stabilizations in western Europe and decreases in Scandinavia. Int J Cancer 2003; 107: 119– 126. 3 de Vries E, Louwman M, Bastiaens M, et al. Rapid and continuous increases in incidence rates of basal cell carcinoma in the southeast Netherlands since 1973. J Invest Dermatol 2004; 123: 634–638. 4 Linos E, Swetter SM, Cockburn MG, et al. Increasing burden of melanoma in the United States. J Invest Dermatol 2009; 129: 1666–1674. 5 Lomas A, Leonardi-Bee J, Bath-Hextall F. A systematic review of worldwide incidence of nonmelanoma skin cancer. Br J Dermatol 2012; 166: 1069–1080. 6 Guy GP Jr, Ekwueme DU, Tangka FK, et al. Melanoma treatment costs: a systematic review of the literature, 1990–2011. Am J Prev Med 2012; 43: 537–545. 7 Ekwueme DU, Guy GP Jr, Li C, et al. The health burden and economic costs of cutaneous melanoma mortality by race/ethnicity – United States, 2000 to 2006. J Am Acad Dermatol 2011; 65: S133–S143. 8 AIRTUM Working Group. Italian cancer figures, report 2009: Cancer trend (1998–2005). Epidemiol Prev 2009; 33: 1–168. International Journal of Dermatology 2015, 54, 42–49
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9 Aguilar-Bernier M, Gonzalez-Carrascosa M, Padilla-Espana L, et al. Five-year economic evaluation of non-melanoma skin cancer surgery at the Costa del Sol Hospital (2006–2010). J Eur Acad Dermatol Venereol 2013; 28: 320–326. 10 Mudigonda T, Pearce DJ, Yentzer BA, et al. The economic impact of non-melanoma skin cancer: a review. J Natl Compr Canc Netw 2010; 8: 888–896. 11 El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens – part D: radiation. Lancet Oncol 2009; 10: 751–752. 12 Newton-Bishop JA, Chang YM, Elliott F, et al. Relationship between sun exposure and melanoma risk for tumours in different body sites in a large case-control study in a temperate climate. Eur J Cancer 2011; 47: 732–741. 13 Rigel DS, Russak J, Friedman R. The evolution of melanoma diagnosis: 25 years beyond the ABCDs. CA Cancer J Clin 2010; 60: 301–316. 14 Argenziano G, Soyer HP. Dermoscopy of pigmented skin lesions – a valuable tool for early diagnosis of melanoma. Lancet Oncol 2001; 2: 443–449. 15 Fargnoli MC, Kostaki D, Piccioni A, et al. Dermoscopy in the diagnosis and management of non-melanoma skin cancers. Eur J Dermatol 2012; 22: 456–463. 16 Argenziano G, Albertini G, Castagnetti F, et al. Early diagnosis of melanoma: what is the impact of dermoscopy? Dermatol Ther 2012; 25: 403–409. 17 Altamura D, Menzies SW, Argenziano G, et al. Dermatoscopy of basal cell carcinoma: morphologic variability of global and local features and accuracy of diagnosis. J Am Acad Dermatol 2010; 62: 67–75. 18 Peris K, Micantonio T, Piccolo D, et al. Dermoscopic features of actinic keratosis. J Dtsch Dermatol Ges 2007; 5: 970–976. 19 Seidenari S, Benati E, Ponti G, et al. Italian Euromelanoma Day Screening Campaign (2005–2007) and the planning of melanoma screening strategies. Eur J Cancer Prev 2012; 21: 89–95. 20 Carli P, De Giorgi V, Giannotti B, et al. Skin cancer day in Italy: method of referral to open access clinics and tumor prevalence in the examined population. Eur J Dermatol 2003; 13: 76–79. 21 Suppa M, Altomare G, Cannavo SP, et al. The Italian Euromelanoma Day: evaluation of results and implications for future prevention campaigns. Int J Dermatol 2012 [Epub ahead of print] doi:10.1111/j. 1365-4632.2012.05783.x. 22 Euromelanoma website. Prevention. Tips. Sunscreen. [WWW document] Available at: URL http://www. euromelanoma.org/italy/tips-0. Accessed March 20, 2013. 23 van der Leest RJ, de Vries E, Bulliard JL, et al. The Euromelanoma skin cancer prevention campaign in Europe: characteristics and results of 2009 and 2010. J Eur Acad Dermatol Venereol 2011; 25: 1455–1465. 24 Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol 1988; 124: 869–871.
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25 Garbe C, Buttner P, Weiss J, et al. Risk factors for developing cutaneous melanoma and criteria for identifying persons at risk: multicenter case-control study of the Central Malignant Melanoma Registry of the German Dermatological Society. J Invest Dermatol 1994; 102: 695–699. 26 Garbe C, Buttner P, Weiss J, et al. Associated factors in the prevalence of more than 50 common melanocytic nevi, atypical melanocytic nevi, and actinic lentigines: multicenter case-control study of the Central Malignant Melanoma Registry of the German Dermatological Society. J Invest Dermatol 1994; 102: 700–705. 27 European Academy of Dermatology and Venereology (EADV) website. Prevention is better than cure - EADV and Euromelanoma at the European Parliament 08 September 2011. [WWW document] http://www.eadv. org/fileadmin/user_upload/documents/Press_Corner_ press_releases/Press_release_-_Web.pdf. [accessed on April 23, 2014]. 28 Association of European Cancer Leagues (ECL) website. Sunbed Use and Skin Cancer Prevention, 04 December 2012. [www document] http://www.europeancancerleagues. org/mac/mac-events/309-sunbed-use-and-skin-cancerprevention-04-december-2012.html [accessed on April 23, 2014]. 29 European Academy of Dermatology and Venereology (EADV) website. Skin Cancer Awareness Day 2013. [WWW document] URL http://www.eadv.org/presscorner/skin-awareness-day [accessed on April 23, 2014]. 30 Rutkowski M, Zdrojewski T, Bandosz P, et al. Screening for major cardiovascular risk factors among Members of Polish Parliament as a continuation of health marketing for effective cardiovascular prevention in Poland, Warsaw, May 2006. Kardiol Pol 2007; 65: 486–492 discussion 493–484. 31 Vestergaard ME, Macaskill P, Holt PE, et al. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol 2008; 159: 669–676. 32 Suppa M, Cazzaniga S, Fargnoli MC, et al. Knowledge, perceptions and behaviours about skin cancer and sun protection among secondary school students from Central Italy. J Eur Acad Dermatol Venereol 2013; 27: 571–579. 33 Autier P, Dore JF, Negrier S, et al. Sunscreen use and duration of sun exposure: a double-blind, randomized trial. J Natl Cancer Inst 1999; 91: 1304–1309. 34 Walker I. Drivers overtaking bicyclists: objective data on the effects of riding position, helmet use, vehicle type and apparent gender. Accid Anal Prev 2007; 39: 417–425. 35 Cassell MM, Halperin DT, Shelton JD, et al. Risk compensation: the Achilles heel of innovations in HIV prevention? BMJ 2006; 332: 605–607. 36 Kajubi P, Kamya MR, Kamya S, et al. Increasing condom use without reducing HIV risk: results of a controlled
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community trial in Uganda. J Acquir Immune Defic Syndr 2005; 40: 77–82. Coelho SG, Hearing VJ. UVA tanning is involved in the increased incidence of skin cancers in fair-skinned young women. Pigment Cell Melanoma Res 2010; 23: 57–63. Brooks K, Brooks D, Dajani Z, et al. Use of artificial tanning products among young adults. J Am Acad Dermatol 2006; 54: 1060–1066. Olson AL, Starr P. The challenge of intentional tanning in teens and young adults. Dermatol Clin 2006; 24: 131– 136, v. Stanton WR, Janda M, Baade PD, et al. Primary prevention of skin cancer: a review of sun protection in Australia and internationally. Health Promot Int 2004; 19: 369–378.
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41 McCarthy EM, Ethridge KP, Wagner RF Jr. Beach holiday sunburn: the sunscreen paradox and gender differences. Cutis 1999; 64: 37–42. 42 Dobbinson S, Wakefield M, Hill D, et al. Prevalence and determinants of Australian adolescents and adults weekend sun protection and sunburn, summer 2003–2004. J Am Acad Dermatol 2008; 59: 602–614. 43 Andreeva VA, Cockburn MG, Yaroch AL, et al. Preliminary evidence for mediation of the association between acculturation and sun-safe behaviors. Arch Dermatol 2011; 147: 814–819.
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The first skin cancer screening day at the Italian parliament: a Euromelanoma initiative Mariano Suppa1,2, MD, Luca Neri3,4, MD, PhD, Luca Bianchi4,5, MD, Rodolfo Capizzi5,6, MD, a7, MD, Sergio Chimenti5, MD, Maria Concetta Angelo Carbone7, MD, Caterina Catrical 1 6 Fargnoli , MD, Barbara Fossati , MD, Pasquale Frascione7, MD, and Ketty Peris1,6, MD
1 Department of Dermatology, University of L’Aquila, L’Aquila, 2Department of ^pital Erasme, Universite Dermatology, Ho Libre de Bruxelles, Brussels, Belgium, 3 Dipartimento di Scienze Cliniche e di , Universita di Milano, Milan, Comunita 4 Fondazione IRCCS Ca Granda – Ospedale Maggiore Policlinico, Milan, 5 Department of Dermatology, University of Rome Tor Vergata, Rome, 6Department of Dermatology, Catholic University of the Sacred Heart, Rome, and 7Department of Oncologic Dermatology, Santa Maria and San Gallicano Institute of Dermatology – IRCCS, Rome, Italy
Correspondence Ketty Peris, MD Department of Dermatology University of L’Aquila Via Vetoio – Coppito 67100 L’Aquila Italy E-mail: [email protected]
Abstract Background The effort to decrease incidence/mortality of skin cancer should target not only the general public but also politicians and decision makers, to create a proper health policy. We report the results of the first Skin Cancer Screening Day at the Italian Parliament, organized to draw politicians’ attention on skin cancer. Methods A questionnaire was used to collect data on participants’ characteristics and suspected skin cancers. Results We screened 70 members of parliament (61.4% males, median age 54 years). Overall skin cancer suspicion rate was 14.5%. Suspicion rate, detection rate, and positive predictive values for melanoma were respectively 1.6, 1.6, and 100%, and for basal cell carcinoma 6.5, 1.6, and 25%. Highly educated, 20 sessions/year)
13. Have you ever had an outdoor occupation? No Yes 14. How often do you use sunscreen? When sunbathing: After swimming or sweating:
Never Never
Sometimes Sometimes
(*) An atypical nevus is defined by the presence of at least 3 of the following criteria: diameter >5 mm, irregular margins, ill -defined border, color variation, macular and papular components (**) BCC, basal cell carcinoma (***) AK, actinic keratosis; SCC , squamous cell carcinoma
Always Always
15. Have you spent at least 1 year in countries with higher sun irradiance than the country you currently live in? No Yes
1
2
Figure 1 Study questionnaire. The first page (completed by the participating MP) enquired about participant’s demographics and risk factors. The second page (fulfilled by the dermatologist) was about clinical findings emerged during the examination ª 2014 The International Society of Dermatology
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Table 1 Demographics of participants, motivations to participate, and previous skin checks
Sex Females Males Age, median (range) Educational level Primary/secondary school University/postgraduate Motivation to participate “I just want to be checked” “I have many moles” “I have a suspicious skin lesion” “A family member/friend had/has skin cancer” “I was previously diagnosed with a skin cancer” At least 1 previous skin check Number of previous skin checks
Overall
Males
Females
Pa
5 mm, irregular margins, ill-defined border, color variation, and macular and papular components) were present, as previously described.25,26 All visits were dermatoscopically aided. If a suspicious lesion was found, the screenees received advice for further diagnostics or treatment. Continuous variables were compared using the two-sample Wilcoxon rank-sum (Mann–Whitney) test. For categorical variables, different groups were compared using Pearson’s chisquared test. Comparisons were performed within different sex, age, education, and phenotypic groups. Three parameters were used to evaluate the efficacy of the screening: (i) the suspicion rate, defined as the number of participants with a suspicious skin cancer divided by the total number of participants; (ii) the detection rate, defined as the proportion of histologically confirmed skin cancers among all screenees; and (iii) the positive predictive value (PPV), defined as the proportion of histologically confirmed skin cancers among all patients suspected of having a skin cancer. All statistical tests were twotailed and considered significant at the arbitrary 5% level. The statistical analysis was carried out using the STATA version 10 (2007; StataCorp., College Station, TX, USA).
Results Overall, 70 MPs were screened, 43 (61.4%) men and 27 (38.6%) women, with median age 54 years (range 30– 74 years). The women were significantly younger than the men were (median age 49 vs. 57 years, P = 0.02) (Table 1). The main reason to participate was the simple desire to have the skin checked (48.5%), followed by the perceived presence of many moles (32.3%), a recently changed or somehow suspicious lesion (12.1%), a family International Journal of Dermatology 2015, 54, 42–49
member/friend diagnosed with skin cancer (6.1%), and a previous personal diagnosis of skin cancer (4.6%). Compared to women, men reported significantly more the simple desire to have their skin checked (P = 0.04) and significantly less a previous personal diagnosis of skin cancer (P = 0.03). At least one previous skin check was reported by 43.8% of participants, with those individuals >54 years old more likely to do so (P = 0.04). The median number of previous skin checks was two (range 1–10). Risk factors for skin cancer among the screened MPs are illustrated in Table 2. The majority of participants reported skin types III (37.9%) and IV (30.3%). Males and ≥54-year-old MPs reported a significantly darker skin type than females (P = 0.04) and younger participants (P = 0.02), respectively. No participant reported a personal history of melanoma, while 6.8% of them reported a family history of melanoma and 6.1% a condition of iatrogenic immunosuppression (organ transplant recipients being treated with immunosuppressant agents). Assessment of behavioral risk factors (Table 2) showed that females were more likely than males to use a solarium (P = 0.01), and to apply sunscreen when sunbathing (P = 0.04) and reapply it after swimming or sweating (P = 0.05). Similarly, MPs aged 50. Similarly one of four suspected BCCs (PPV = 25%) was histopathologically confirmed (in a 62year-old man, with skin type III and university education), which resulted in a detection rate of 1.6%. Therefore, the overall detection rate was 3.2% (two of 62), and overall PPV was 22.2% (two of nine). A comparison of the findings of the present study with those from the first Italian Euromelanoma Day on the International Journal of Dermatology 2015, 54, 42–49
general population21 is reported in Table 4. The suspicion rate of skin cancer, melanoma detection rate, and PPV for melanoma were higher in this study as compared to the previously performed general population screening. Overall, female, younger, and higher-educated participants reported sun-seeking behaviors more frequently than their male, older, and less-educated peers in both studies. Moreover, sunscreen users reported sunburn more frequently than non-users in both investigations. Discussion This is the first report of a skin cancer screening in a national parliament. Previously, the Euromelanoma task force in conjunction with the European Academy of Dermatology and Venereology (EADV) organized a Skin Cancer Screening Day at the European Parliament in Brussels (Belgium) for three consecutive years (2011–2013), whose results are currently under evaluation.27–29 In 2006, a screening for major cardiovascular risk factors was performed in the Polish parliament to present the related epidemiological situation to political and key opinion leaders and to assess individual risk among Polish MPs.30 The Skin Cancer Screening Day at the Italian parliament produced slightly different results than those obtained from the Italian Euromelanoma screening of the general population,21 in particular in terms of overall suspicion rate of skin cancer (14.5% in this study, 4.6% in the general population screening). This is not surprising given that the majority of participants in the present study were men older than 35 years, which proved to be the most at-risk group in the Italian Euromelanoma screening but also the less adherent to that initiative.21 The differences in terms of melanoma detection rates (1.6 here, vs. 0.28%) and PPVs (100 here, vs. 21.4%) in the two studies are due to the fact that only one melanoma was suspected and confirmed in the present screening, compared to 15 (three confirmed) in the general one. The more extensive use of dermatoscopy during the skin examinations in this study (100%) as compared to the previous one (79.2%) is also likely to explain these discrepancies. As previously found, dermatoscopy can increase the odds of diagnosing a melanoma by at least nine times as compared with a naked eye examination.31 In the cardiovascular screening initiative carried out at the Polish parliament, the authors observed a higher level of awareness among MPs compared to the general population.30 Conversely, we have found no evidence that Italian MPs are more aware of skin cancers, risk factors for their occurrence, and methods of sun protection compared to the general public, either adults21 or adolescents.32 For instance, sunscreen users were more likely than non-users to report sunburns, a finding similar to ª 2014 The International Society of Dermatology
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what has been observed in previous surveys of the Italian general population; this behavior has been defined as the sunscreen paradox and described as a feeling of excessive protection when using sunscreen, which disproportionately extends sun exposure time and increases sun-seeking behaviors.33 Risk compensation is a well-known behavior previously described in different therapeutic areas and in ethology.34–36 As risk perception significantly affects risktaking decisions, it is key to ensure adequate knowledge of sunscreen use to help facilitate their correct use. Consistent with previous studies,21,23,32,37–43 we have found that females, younger participants, and those with higher education reported a stronger sun seeking behavior than their counterparts: although they seem to understand the necessity to avoid sunburn (more frequent sunscreen use), they still seek a tan (more frequent sunbed use and longer sunny holidays). This further suggests that there is no difference in the level of skin cancer awareness between the MPs and the general population in Italy.21,32 The strengths of this study are that this is the first report of a skin cancer campaign within a national parliament and that an internationally validated questionnaire was used.21,23 A limitation of the study was the restricted availability of follow-up data about suspected lesions. Indeed, only two of the nine MPs with suspicious lesions decided to refer to our departments for further diagnosis, whereas the other seven went to their own dermatologists, and it was therefore not possible to retrieve their follow-up data, in respect of their privacy. Additionally, the supposedly low participation rate could be regarded as another limitation. However, the main point of this initiative was not to determine the prevalence of skin cancer in such a selected population but to set a precedent for a new strategy to draw the attention of MPs to a very important issue, which is often forgotten or underestimated at the political/decision making level. Skin cancer represents indeed an important public health problem with striking healthcare costs. Primary and secondary prevention may potentially reduce the overall disease burden provided that sufficient resources are allocated to specific risk awareness actions and screening campaigns allowing early diagnosis. Expert medical groups and decision makers should cooperate to create a proper, integrated, longterm health policy on skin cancer. New policies should include the implementation of more awareness campaigns for the general public, as knowledge of skin cancer obviously represents the first step to its prevention. Unfortunately, though, this knowledge does not always translate into an effective change in people’s sun-related behavior32; therefore, new educational strategies should target those subgroups that seem to know more about skin cancer but behave less appropriately (i.e., females, younger, and highly educated) than their counterparts. ª 2014 The International Society of Dermatology
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In this scenario, it is vital to increase the awareness of skin cancer among politicians. We believe that the Skin Cancer Screening Day at the Italian parliament is a milestone in this direction and should be periodically repeated. This is of extreme importance, especially in view of the periodic personal rotations of politicians, determined by parliamentary elections. Drawing MP’s attention to the high prevalence of skin cancers, the feasibility of their prevention, costs of their treatment, and lack of adequate resources allocated to deal with these issues should result in a positive outcome of future parliamentary discussions and make the fight against skin cancer more successful. Acknowledgments The authors wish to thank Dr. Giuseppe Palumbo, MP and President of the Italian Parliament Health Commission, for the organizational support to this initiative. The authors are also indebted to Flavia Baldi from Leo Pharma Inc. for the conception and technical and organizational support of the project. This study has been realized thanks to an unconditional contribution from Leo Pharma, Inc. References 1 Jemal A, Siegel R, Xu J, et al. Cancer statistics, 2010. CA Cancer J Clin 2010; 60: 277–300. 2 de Vries E, Bray FI, Coebergh JW, et al. Changing epidemiology of malignant cutaneous melanoma in Europe 1953–1997: rising trends in incidence and mortality but recent stabilizations in western Europe and decreases in Scandinavia. Int J Cancer 2003; 107: 119– 126. 3 de Vries E, Louwman M, Bastiaens M, et al. Rapid and continuous increases in incidence rates of basal cell carcinoma in the southeast Netherlands since 1973. J Invest Dermatol 2004; 123: 634–638. 4 Linos E, Swetter SM, Cockburn MG, et al. Increasing burden of melanoma in the United States. J Invest Dermatol 2009; 129: 1666–1674. 5 Lomas A, Leonardi-Bee J, Bath-Hextall F. A systematic review of worldwide incidence of nonmelanoma skin cancer. Br J Dermatol 2012; 166: 1069–1080. 6 Guy GP Jr, Ekwueme DU, Tangka FK, et al. Melanoma treatment costs: a systematic review of the literature, 1990–2011. Am J Prev Med 2012; 43: 537–545. 7 Ekwueme DU, Guy GP Jr, Li C, et al. The health burden and economic costs of cutaneous melanoma mortality by race/ethnicity – United States, 2000 to 2006. J Am Acad Dermatol 2011; 65: S133–S143. 8 AIRTUM Working Group. Italian cancer figures, report 2009: Cancer trend (1998–2005). Epidemiol Prev 2009; 33: 1–168. International Journal of Dermatology 2015, 54, 42–49
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