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Melanoma in The Northern Beaches
Melanoma in The Northern Beaches
Introduction
Community nurses (CNs) work in a variety of non-hospital settings and have an important
role in managing patients with a myriad of health conditions (Australian College of Nursing
[ACN], 2015). In order to meaningfully address the healthcare needs of a particular
community, it is essential for CNs to first understand the characteristics of that community
(Adib-Hajbaghery, 2013). By taking into consideration various community characteristics (for
example, geography, ancestry, and socioeconomic status), CNs are better able to develop
and implement relevant care services, as well as health promotion, illness prevention, and
community development strategies (ACN, 2015).
The main aim of this paper is to discuss melanoma in the context of the Northern Beaches
(NB), a Local Government Area (LGA) within New South Wales (NSW). The paper will begin
with a description of melanoma regarding its aetiology, pathophysiology, and risk factors.
An outline of the epidemiology of melanoma, including incidence and mortality will then be
presented, with specific reference to the NB. Following, an analysis will be undertaken to
determine if there are any relationships between characteristics of the NBs and its
melanoma incidence and mortality. To conclude, the paper will discuss the potential role for
community nurses within the NB to implement primary, secondary, and tertiary prevention
and health promotion strategies for melanoma.
Overall, Australia and New Zealand have the highest incidence of melanoma (Jiang,
Rambhatla, & Eide, 2015). Australian statistics from 2015 reveal that melanoma was the
third most commonly diagnosed cancer in both men and women, with an age standardised
ratio (ASR [per 100,000]) of 63.1 for males and 42.0 for females (Australian Institute of
Health and Welfare [AIHW], 2019). Further, 2016 data showed that melanoma was the
eleventh and twelfth most common cause of mortality for Australian men and women, with
an ASR of 6.6 and 2.7 respectively (AIHW, 2019). Contrastingly, incidence, and to an extent
mortality rates, are much lower in the United States and Europe (Ferlay et al., 2013; Guy et
al., 2015). In the United States, 2011 data revealed the ASR incidence for melanoma to be
25.3 for men and 15.6 for women, and ASR mortality to be 4.0 for men and 1.7 for women
(Guy et al., 2015). In Europe, 2012 data from forty countries found the ASR incidence of
melanoma to be 11.4 for men and 11.0 for women, and ASR mortality to be 2.8 for men and
1.8 for women (Ferlay et al., 2013).
Compounded with potential increased exposure, the impact of UVR on the NB population
may be further heightened due to the region’s ancestry. The most common ancestries are
Caucasian; including, English, Australian, Irish and Scottish, totalling 68.2% of the NB
population (ABS, 2019a). This is marginally higher than the broader Australian population,
where the same top four ancestries represent 62.3% of the population (ABS, 2019a). All four
of these ancestries are associated with features linked to a two to four-fold increased risk of
melanoma; namely, light skin, red hair, blue eye colour, and high freckle density (Gandini,
Sera, Cattaruzza, Pasquini, Zanetti, et al., 2005). As described above, UV light penetrates
light skin more easily; thus, people with light skin are more susceptible to developing
melanomas (Gilchrest et al., 1999). Thus, the increased proportion of Caucasian residents
within the NB may be a contributing factor to the increased incidence of melanoma within
the LGA.
Interestingly, a systematic review by Jiang et al. (2015) found that the incidence of
melanoma was greater in populations with a higher socioeconomic status (SES), and
particularly so in those who are highly educated. As per the Socioeconomic Indexes for
Australia, the NB is in the tenth decile (lowest = 1st, highest = 10th) for all socioeconomic
index categories, including relative socioeconomic advantage and disadvantage, economic
resources, as well as education and occupation (ABS, 2019b). Specifically, compared to
16.4% of Australian households, 34.1% of NB households have a gross weekly income over
$3,000, and compared with 20.0% of Australian households, only 12.6% of NB households
have a gross weekly income of less than $650. In terms of highest level of education
achieved, 32.3% of the NB’s population have a bachelor’s degree or higher, compared to
22.0% of the wider Australian population (ABS, 2019a). Thus, the higher incidence of
melanoma in the NB is consistent with its high level of SES. One reason for this association
may be that a higher SES affords people increased access to recreational activities that
involve short-term, but high-intensity exposure to UVR, for example boating trips and
vacations to high-altitude or low-latitude destinations where there is greater UVR exposure
(Temowetsky, 1983, as cited in zk ). Other reasons may be a cultural desire for tanned skin
(Dellavalle, Schilling, Chen, & Hester, 2003) or the fact that people from a high-SES
background may have more time to engage in outdoor leisure activities such as sports and
gardening (Lindstrom, Hanson, & Ostergren, 2001). Compared to the wider Australian
population, residents in the NB have a marginally higher proportion of people working 40
hours or more (ABS, 2019a). Despite this statistic, it is possible they may have more free
time overall as a result of having the financial means to utilise various time-saving services
such as dry-cleaning and eating out.
An association between melanoma incidence and outdoor occupations has also been found
(Jiang et al., 2015). However, compared to the general population, a greater number of NB’s
residents have indoor occupations as professionals and managers (ABS, 2019a). Thus, it is
unlikely that this characteristic contributes to the increased melanoma incidence in the NB.
In terms of mortality, higher SES populations are noted to have lower mortality rates (Jiang
et al., 2015). One possible reason for this is that those with higher education levels have
greater risk perception and thus increased vigilance and self-screening behaviours (Pollitt,
Swetter, Johnson, Patil, & Geller, 2012). Together with this, an increased SES affords greater
access to general practice and dermatology services, leading to earlier diagnosis and
treatment (Jiang et al., 2015). Importantly, early diagnosis is associated with thinner
tumours at diagnosis (Brunssen, Waldmann, Eisemann, & Katalinic, 2017; Jiang et al., 2015).
This confers a significant mortality advantage as outlined in a retrospective cohort study by
Perez-Aldrete et al. (2019), which demonstrated the inverse relationship between
melanoma thickness at diagnosis (using the Breslow classification) and survival rates
(p<0.0001).
In regards to primary PHP, Australian public health programs advocating for decreased sun
exposure have been highly successful in shifting knowledge, attitudes, beliefs, and
behaviours regarding sun exposure, suntans, and protective measures (Marks, 1999). Given
their potential for increased recreational sun exposure and higher Caucasian population
(ABS, 2019a), residents of the NB need to be extra vigilant in their approach to minimising
sun exposure. A paper by Henrikson et al. (2018) found that education and behavioural
counselling can increase sun protection behaviours in all ages, though more consistently in
adolescents and children. Thus, during any patient encounters, CNs should ascertain
whether a patient is at high risk for developing melanoma; in the case of the NB for example
this would include Caucasian residents and residents who engage in extensive outdoor
recreation. If deemed high risk, the CN should then educate the patient about the dangers
of excessive sun exposure (Curiel-Lewandrowski, 2019) and methods of protection (Cancer
Council Victoria, 2019). Utilising the traditional ‘Slip, Slop! Slap!’ framework is a good
starting point and is especially memorable for children (Marks, 1999).
Education must also address the link found between melanoma and sun exposure early in
life (Curiel-Lewandrowski, 2019). As noted by Wu, Han, Laden, & Qureshi (2014), there is a
twofold risk for melanoma development in individuals who have experienced five or more
severe sunburns during childhood and adolescence. Thus, CNs have a role in educating
parents and their children about this fact. A randomised control trial by Erkin & Temel
(2017) demonstrated the benefit of a school-based, nurse-led sun protection program;
children who participated in the program had significantly increased sun protection
behaviours (p<0.001) and self-efficacy (p<0.001). Thus, CNs in the NB area should develop
and implement a similar, ongoing school-based sun safety program.
The main role for CNs in terms of secondary PHP involves promoting and performing skin
checks. As outlined above, earlier detection of melanomas is associated with thinner lesions
on diagnosis (Brunssen et al., 2017), which is turn is associated with decreased mortality
(Perez-Aldrete et al., 2019). Overall, melanomas detected by doctors are generally thinner,
however, majority of melanomas are self-detected or detected by a partner (Cancer Council
of Australia [CCA], 2018). Thus, skin self-examination (SSE) is an important aspect of early
detection and is recommended in a position statement by the CCA (CCA, 2018). A paper by
Phelan, Oliveria, Christos, Dusza, & Halpern (2003) found that patients who received nurse-
provided education developed increased SSE knowledge, awareness, and confidence. Thus,
CNs in the NB have a role in educating their patients about current screening
recommendations from the CCA. Specifically, CNs should encourage patients to become
familiar with their skin and consult a doctor if they develop any new lesions, or notice any
change in the size, shape, or colour of an existing lesion (CCA, 2018). Moreover, CNs should
recommend high-risk individuals to undergo a full skin examination, supported by
dermoscopy and total body photography, every 6 months (CCA, 2018). Because of the
regularity of contact, there is ample opportunity for CNs to carry out basic skin checks for
high risk patients and refer them to a general practitioner or dermatologist as necessary
(Watkins, 2010).
At a tertiary level of PHP, CNs are involved with preventing and managing adverse effects
(AEs) associated with numerous novel targeted and immunological therapies developed to
treat high-risk and advanced melanomas (Rubin, 2017). The AEs of these therapies are vastly
different to those of chemotherapy and require a different approach (Kirkwood & Ribas,
2017). Developed by a multidisciplinary group, the Melanoma Nursing Initiative (MNI) aims
to provide community-based oncology nurses with the tools to address these AEs, promote
adherence to therapy, as well as support patients and their families throughout the process
(Kirkwood & Ribas, 2017). Any CN looking after a patient receiving one of the novel
therapies should orient themselves with the resources provided by the MNI, especially the
relevant (therapy-specific) Care Step Pathways which outline a comprehensive approach to
nursing assessment and management strategies for various AEs (AIM at Melanoma
Foundation, n.d.).
Conclusion
Compared to the broader Australian population, the NB has a high incidence and low
mortality of melanoma. This paper has analysed various characteristics of the NB LGA and
related them to these incidence and mortality rates. In particular, characteristics that may
be contributing to the high incidence include high physical activity and increased outdoor
recreational activity secondary to the availability of numerous beaches and walking trails,
high proportion of Caucasian residents, and high SES. Contrastingly, the NB’s high SES may
also be the reason for its low mortality rate. As described, CNs in the NB have a role for
engaging with melanoma PHP at all levels, through education, screening, and symptom
management.
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