Assessment 3 – 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.

Melanoma – aetiology, pathophysiology and risk factors

Melanoma is a malignant skin cancer that results from unregulated proliferation of pigment-
producing cells called melanocytes (Abdel-Malek et al., 1995). Current thinking implicates an
interplay between genetic susceptibility and environmental exposures (Rastrelli, Tropea,
Rossi, & Alaibac, 2014). The most important modifiable risk factor is sun exposure (Curiel-
Lewandrowski, 2019; Gandini, Sera, Cattaruzza, Pasquini, Picconi, et al., 2005). In particular,
for areas infrequently exposed to the sun (for example, the backs of men), melanomas are
generally associated with intense, intermittent sun exposure as well as sunburns (Zanetti et
al., 2006). Whereas other body sites may be associated with extended high sun exposure
(Ghiasvand et al., 2019). Two separate pathogenic pathways have been postulated for
melanoma development; in both, ultraviolet A (UVA) and ultraviolet B (UVB) radiation are
involved in causing direct and indirect damage to melanocyte DNA, which can then result in
unregulated cell division (Noonan et al., 2012; Premi et al., 2015). In terms of genetic
susceptibility, a meta-analysis by Gandini, Sera, Cattaruzza, Pasquini, Zanetti, et al. (2005)
found that people with light skin, red hair, blue eye colour, and high freckle density had a
two to four-fold increase in melanoma risk. UV light is more able to penetrate lighter skin;
thus, people with naturally light skin or skin that does not tans readily upon sun exposure
are more susceptible to developing melanoma (Gilchrest, Eller, Geller, & Yaar, 1999).

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).

Melanoma in the Northern Beaches LGA

Compared to NSW, the 2011–2015 standardised incidence ratio (SIR) and standardised
mortality ratio (SMR) for melanoma in the NB was 1.25 and 0.84, respectively (Cancer
Institute of NSW [CIN], 2019). Further, since the melanoma age-standardised rates (ASRs)
for incidence and mortality are very similar between NSW and Australia as a whole (in 2014
the difference was 0.2 for incidence and 0.1 for mortality) (AIHW, 2019), it can be
extrapolated that the NB melanoma SIR and SMR hold true as compared to national figures.
The following paragraphs aim to analyse various characteristics of the NB and explain how
they may contribute to these incidence and mortality figures.

With a population of 252,878 (Australian Bureau of Statistics [ABS], 2019a), the NB is a

metropolitan LGA located on the Eastern Seaboard of Australia (Kiem et al., 2016), bounded
by the Hawkesbury River and Broken Bay in the North, and Middle Harbour and North
Harbour in the South (.idcommunity, 2016). Due to its proximity to numerous beaches and
extensive walking trails (Northern Beaches Council, n.d.), it could be inferred that residents
of the NB may participate in high levels of outdoor recreational activity. This is supported by
data which shows that out of all the NSW Local Health Districts (LHD), the Northern Sydney
LHD (of which the NB LGA is part) has the lowest percentage of people with an insufficient
level of physical activity (HealthStats NSW, 2019). Thus, NB’s increased incidence of
melanoma may be partly explained by ample availability of outdoor recreational activities
that result in higher levels of UV-exposing physical activity. This theory is supported by
Moore et al. (2016), who found a statistically significant association between higher
melanoma incidence and leisure-time physical activity in US regions with higher levels of
solar UVR (hazard ratio, 1.26 [ 95% CI, 1.14-1.38]).

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).

Roles for the community nurse

By utilising a community-specific approach, CNs are more able to tailor appropriate
prevention and health promotion (PHP) strategies for any health condition (Jiang et al.,
2015). The following paragraphs will describe the potential roles of the CN in PHP for
melanoma in the NB LGA.

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.
References
Abdel-Malek, Z., Swope, V. B., Suzuki, I., Akcali, C., Harriger, M. D., Boyce, S. T., … Hearing, V.
J. (1995). Mitogenic and melanogenic stimulation of normal human melanocytes by
melanotropic peptides. Proceedings of the National Academy of Sciences of the United
States of America, 92(5), 1789–1793. https://doi.org/10.1073/pnas.92.5.1789
Adib-Hajbaghery, M. (2013). Nurses role in the community. Nursing and Midwifery Studies,
2(2), 169–170. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25414853
AIM at Melanoma Foundation. (n.d.) Welcome to the Care Step Pathways. Retrieved
September 1, 2019, from https://themelanomanurse.org/care-step-pathways/
Australian Bureau of Statistics. (2019a). 2016 Census QuickStats – Northern Beaches (A).
Retrieved September 1, 2019, from
https://quickstats.censusdata.abs.gov.au/census_services/getproduct/census/2016/q
uickstat/LGA15990
Australian Bureau of Statistics. (2019b). SEIFA by Local Government Area (LGA). Retrieved
September 1, 2019, from http://stat.data.abs.gov.au/Index.aspx?
DataSetCode=ABS_SEIFA_LGA
Australian College of Nursing. (2015). Community & Primary Health Care Nursing: Position
Statement. Retrieved September 1, 2019, from https://www.acn.edu.au/wp-
content/uploads/2018/03/community_and_primary_health_care_postition_statemen
t_c3.pdf
Australian Institute of Health and Welfare. (2018). Cancer Data in Australia. Cat. no. CAN
122. Retrieved from https://www.aihw.gov.au/reports/cancer/cancer-data-in-
australia
Brunssen, A., Waldmann, A., Eisemann, N., & Katalinic, A. (2017). Impact of skin cancer
screening and secondary prevention campaigns on skin cancer incidence and
mortality: A systematic review. Journal of the American Academy of Dermatology,
76(1), 129-139.e10. https://doi.org/10.1016/j.jaad.2016.07.045
Cancer Council of Australia. (2018). National Cancer Control Policy: Position statement –
Early detection of skin cancer. Retrieved September 1, 2019, from
https://wiki.cancer.org.au/policy/Position_statement_-
_Screening_and_early_detection_of_skin_cancer
Cancer Council Victoria. (2019). SunSmart – Protect your skin. Retrieved September 1, 2019,
 from https://www.sunsmart.com.au/protect-your-skin
Cancer Institute of NSW. (2019). Cancer statistics NSW. Retrieved September 1, 2019, from
https://www.cancer.nsw.gov.au/cancer-statistics-nsw#//
Curiel-Lewandrowski, C. (2019). Risk factors for the development of melanoma. In R. Corona
(Ed.), UpToDate. Retrieved September 1, 2019, from https://www-uptodate-
com.ezproxy-so.library.usyd.edu.au/contents/risk-factors-for-the-development-of-
melanoma
Dellavalle, R. P., Schilling, L. M., Chen, A. K., & Hester, E. J. (2003, September). Teenagers in
the UV tanning booth? Tax the tan. Archives of Pediatrics & Adolescent Medicine, Vol.
157, pp. 845–846. https://doi.org/10.1001/archpedi.157.9.845
Erkin, O., & Temel, A. B. (2017). A Nurse-Led School-Based Sun Protection Programme in
Turkey. Central European Journal of Public Health, 25(4), 287–292.
https://doi.org/10.21101/cejph.a4975
Ferlay, J., Steliarova-Foucher, E., Lortet-Tieulent, J., Rosso, S., Coebergh, J. W. W., Comber,
H., … Bray, F. (2013). Cancer incidence and mortality patterns in Europe: estimates for
40 countries in 2012. European Journal of Cancer (Oxford, England : 1990), 49(6),
1374–1403. https://doi.org/10.1016/j.ejca.2012.12.027
Gandini, S., Sera, F., Cattaruzza, M. S., Pasquini, P., Picconi, O., Boyle, P., & Melchi, C. F.
(2005). Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure.
European Journal of Cancer (Oxford, England : 1990), 41(1), 45–60.
https://doi.org/10.1016/j.ejca.2004.10.016
Gandini, S., Sera, F., Cattaruzza, M. S., Pasquini, P., Zanetti, R., Masini, C., … Melchi, C. F.
(2005). Meta-analysis of risk factors for cutaneous melanoma: III. Family history,
actinic damage and phenotypic factors. European Journal of Cancer (Oxford, England :
1990), 41(14), 2040–2059. https://doi.org/10.1016/j.ejca.2005.03.034
Ghiasvand, R., Robsahm, T. E., Green, A. C., Rueegg, C. S., Weiderpass, E., Lund, E., &
Veierod, M. B. (2019). Association of Phenotypic Characteristics and UV Radiation
Exposure With Risk of Melanoma on Different Body Sites. JAMA Dermatology, 155(1),
39–49. https://doi.org/10.1001/jamadermatol.2018.3964
Gilchrest, B. A., Eller, M. S., Geller, A. C., & Yaar, M. (1999). The pathogenesis of melanoma
induced by ultraviolet radiation. The New England Journal of Medicine, 340(17), 1341–
1348. https://doi.org/10.1056/NEJM199904293401707
Guy, G. P. J., Thomas, C. C., Thompson, T., Watson, M., Massetti, G. M., & Richardson, L. C.
(2015). Vital signs: melanoma incidence and mortality trends and projections - United
States, 1982-2030. MMWR. Morbidity and Mortality Weekly Report, 64(21), 591–596.
HealthStats NSW. (2019). Physical activity in adults. Retrieved September 1, 2019, from
http://www.healthstats.nsw.gov.au/Indicator/beh_phys_age/beh_phys_lhn_snap
Henrikson, N. B., Morrison, C. C., Blasi, P. R., Nguyen, M., Shibuya, K. C., & Patnode, C. D.
(2018). Behavioral Counseling for Skin Cancer Prevention: Evidence Report and
Systematic Review for the US Preventive Services Task Force. JAMA, 319(11), 1143–
1157. https://doi.org/10.1001/jama.2017.21630
.idcommunity. (2016). Northern Beaches Council social atlas. Retrieved September 1, 2019,
from https://atlas.id.com.au/northern-beaches
Jiang, A. J., Rambhatla, P. V, & Eide, M. J. (2015). Socioeconomic and lifestyle factors and
melanoma: a systematic review. The British Journal of Dermatology, 172(4), 885–915.
https://doi.org/10.1111/bjd.13500
Kiem, A., Twomey, C., Lockart, N., Willgoose, G., Kuczera, G., Chowdhury, A. F. M. K., …
Zhang, L. (2016). Links between East Coast Lows and the spatial and temporal
variability of rainfall along the eastern seaboard of Australia. Journal of Southern
Hemisphere Earth System Science, 66, 162–176. https://doi.org/10.22499/3.6002.006
Kirkwood, J. M., & Ribas, A. (2017). Collaborative Care in Melanoma: The Essential Role of
the Nurse. Clinical Journal of Oncology Nursing, 21(4 Suppl), 4–6.
https://doi.org/10.1188/17.CJON.S4.4-6
Lindstrom, M., Hanson, B. S., & Ostergren, P. O. (2001). Socioeconomic differences in
leisure-time physical activity: the role of social participation and social capital in
shaping health related behaviour. Social Science & Medicine (1982), 52(3), 441–451.
https://doi.org/10.1016/s0277-9536(00)00153-2
Marks, R. (1999). Two decades of the public health approach to skin cancer control in
Australia: why, how and where are we now? The Australasian Journal of Dermatology,
40(1), 1–5.
Moore, S. C., Lee, I.-M., Weiderpass, E., Campbell, P. T., Sampson, J. N., Kitahara, C. M., …
Patel, A. V. (2016). Association of Leisure-Time Physical Activity With Risk of 26 Types
of Cancer in 1.44 Million Adults. JAMA Internal Medicine, 176(6), 816–825.
https://doi.org/10.1001/jamainternmed.2016.1548
Noonan, F. P., Zaidi, M. R., Wolnicka-Glubisz, A., Anver, M. R., Bahn, J., Wielgus, A., … De
Fabo, E. C. (2012). Melanoma induction by ultraviolet A but not ultraviolet B radiation
requires melanin pigment. Nature Communications, 3, 884.
https://doi.org/10.1038/ncomms1893
Northern Beaches Council. (n.d.) Things To Do. Retrieved September 1, 2019, from
https://www.northernbeaches.nsw.gov.au/things-to-do
Perez-Aldrete, B. M., Matildes-Mariscal, J. B., Gomez-Padilla, F., Guevara-Gutierrez, E.,
Barrientos-Garcia, J. G., Hernandez-Peralta, S. L., & Tlacuilo-Parra, A. (2019).
Cutaneous melanoma in patients from western Mexico: Clinical pathology
characteristics and their relationship to prognosis. The Australasian Journal of
Dermatology. https://doi.org/10.1111/ajd.13054
Phelan, D. L., Oliveria, S. A., Christos, P. J., Dusza, S. W., & Halpern, A. C. (2003). Skin self-
examination in patients at high risk for melanoma: a pilot study. Oncology Nursing
Forum, 30(6), 1029–1036. https://doi.org/10.1188/03.ONF.1029-1036
Pollitt, R. A., Swetter, S. M., Johnson, T. M., Patil, P., & Geller, A. C. (2012). Examining the
pathways linking lower socioeconomic status and advanced melanoma. Cancer,
118(16), 4004–4013. https://doi.org/10.1002/cncr.26706
Premi, S., Wallisch, S., Mano, C. M., Weiner, A. B., Bacchiocchi, A., Wakamatsu, K., … Brash,
D. E. (2015). Photochemistry. Chemiexcitation of melanin derivatives induces DNA
photoproducts long after UV exposure. Science (New York, N.Y.), 347(6224), 842–847.
https://doi.org/10.1126/science.1256022
Rastrelli, M., Tropea, S., Rossi, C. R., & Alaibac, M. (2014). Melanoma: epidemiology, risk
factors, pathogenesis, diagnosis and classification. In Vivo (Athens, Greece), 28(6),
1005–1011.
Rubin, K. M. (2017). Advances in Melanoma: The Rationale for the Melanoma Nursing
Initiative. Clinical Journal of Oncology Nursing, 21(4 Suppl), 7–10.
https://doi.org/10.1188/17.CJON.S4.7-10
Watkins, J. (2010). Dermatology and the community nurse: actinic (solar) keratosis. British
Journal of Community Nursing, 15(1), 6,8,10-11.
https://doi.org/10.12968/bjcn.2010.15.Sup7.81203
Wu, S., Han, J., Laden, F., & Qureshi, A. A. (2014). Long-term ultraviolet flux, other potential
risk factors, and skin cancer risk: a cohort study. Cancer Epidemiology, Biomarkers &
 Prevention : A Publication of the American Association for Cancer Research,
Cosponsored by the American Society of Preventive Oncology, 23(6), 1080–1089.
https://doi.org/10.1158/1055-9965.EPI-13-0821
Zanetti, R., Rosso, S., Martinez, C., Nieto, A., Miranda, A., Mercier, M., … Mossotti, R. (2006).
Comparison of risk patterns in carcinoma and melanoma of the skin in men: a multi-
centre case-case-control study. British Journal of Cancer, 94(5), 743–751.
https://doi.org/10.1038/sj.bjc.6602982