Nonmelanoma skin cancer in Australia
Authors: Rodney Sinclair
Journal: British Journal of Dermatology (2012)

Nonmelanoma skin cancer (NMSC) is extremely common in both Australia and the U.K., though exactly how common is difficult to gauge as NMSC is not recorded on the cancer registries. As NMSC is managed in both specialist and primary care settings and treatment does not always generate histology, these data are not readily obtained by other means. Furthermore, NMSC is a chronic disease and most affected individuals will develop multiple primary lesions, often within the same year. Incidence data only record an individual's first episode of skin cancer in a calendar year and underestimate the full burden of disease. Medicare Australia is a Commonwealth government-funded universal health insurance scheme. Each service provided by a medical practitioner in a community or private hospital setting is itemized and patients claim a refund on their medical bill based on the item numbers listed on their account. For the past 15 years, all item numbers pertaining to the excision of skin cancer have required histological confirmation of the diagnosis. Item numbers for curettage, cryotherapy and laser treatments of NMSC require either biopsy diagnosis or clinical diagnosis by a specialist dermatologist. Services provided in public hospitals are funded by state governments and recorded separately. In Australia, <2% of NMSC is currently treated in a public hospital setting, and Medicare Australia captures data on over 98% of all skin cancer treatments in Australia. A comprehensive evaluation of Medicare Australia data for NMSC treated using excision, curettage, laser or cryotherapy was published in November 2012 in the Medical Journal of Australia.1 We identified over 8 million NMSC treatments between 1 January 1997 and 31 December 2010 among a population of 22·6 million. The total number of NMSC treatments increased from 412 493 in 1997 to 767 347 in 2010. By 2015 this is forecast to rise to 938 991. The total cost to the Australian government, which includes costs for diagnosis, treatment and pathology, was calculated at A$511 million in 2010. This is set to increase by a further 37% to A$703 million in 2015. The greatest increase in NMSC treatments is among the elderly. From 1997 to 2015, NMSC treatments provided to those aged 65–74 years and ≥75 years will have increased by 171% and 215%, respectively. These increases are far in excess of the population growth in these age groups of 57% among those aged 65–74 and 68% for those aged ≥75 years. In contrast, treatments provided to people aged <45 years will show only a modest increase of 3% from 1997 to 2015, far less than the 15% population growth in this age group over this time. One possible explanation for the relative decrease in treatments for those younger than 45 years is the high profile, public education campaigns conducted by the Australian Cancer Councils since the 1980s. As described in the paper by Makin et al.2 published in this edition of BJD, these programmes have led to a significant impact on sun-protective behaviour and sunburn in Australia. The importance of maintaining these programmes in Australia in view of the significant burden of disease and cost to the Government is as great as ever, with NMSC now accounting for seven out of every eight cancers diagnosed in Australia and being the most costly cancer to treat. So what is the burden of NMSC in the U.K. and how important are public education campaigns? In the U.K. there were only 99 549 cases of NMSC registered in 2010 among a population of 62·6 million, but this figure is considered to be an underestimate because the recording of NMSC is known to be incomplete.3 One indication of the magnitude of this underestimation would be to compare melanoma rates in the U.K. and Australia, as melanoma is a prescribed cancer with data more likely to be recorded accurately on cancer registries. In 2010 it is estimated there were 11 900 melanomas in Australia4 and 12 818 new cases of malignant melanoma in the U.K.3 If we assume that climate and population differences between Australia and the U.K. are unlikely meaningfully to affect the ratio of melanoma to NMSC, then I would expect the number of NMSC treated in the U.K. in 2010 to be more like the 767 347 NMSC that were treated in Australia. In view of the significant public health impact of NMSC, I support the call for a pilot registry of NMSC in the U.K. and adoption of a public education campaign along the lines of the Australian SunSmart programme.5 None declared.