Preventing skin cancer

• Preventing skin cancer – fast facts
• Introduction
• Types of skin cancers
• Preventing skin cancer
  • Slip on sun protective clothing
  • Slop on sunscreen
  • Slap on a hat
  • Seek shade and extra protection when sun is intense
  • Slide on sun shades
  • Early detection
• Balancing vitamin D intake and skin cancer risk
• How to enjoy a sunburnt country safely

Preventing skin cancer – fast facts

• There are three types of skin cancer: squamous cell carcinoma, basal cell carcinoma and melanoma.
• Skin cancer is 2-3 times more common in Australia than other countries such as the United States and United Kingdom.
• Skin cancer can be prevented by minimising exposure to the sun’s ultraviolet rays in accordance with the slip, slop, slap, slide, seek principles:
  • Slip on protective clothing including long pants and a long-sleeved shirt whenever you are exposed to sunlight
  • Slop on broad-spectrum sunscreen with a sun protection factor (SPF) of at least 30 whenever you go out in the sun
  • Slap on a hat with a broad brim to protect your face, ears and neck whenever you are in the sun
  • Slide on sun shades to protect your eyes from the sun’s ultraviolet rays
  • Seek shade when outside, especially at the hottest times of day between 10am and 2pm
• Ensure you expose your skin to the sun for short periods each day so that you get enough Vitamin D to protect your health.
• Choose clothing that’s in good condition and made from dark-coloured, tightly-woven fabric as it offers better UV protection than worn, faded, light, loosely-woven fabric.

Introduction

Skin cancer is the most common form of cancer and is particularly common in Australia, where up to one million visits to GPs each year are related to skin cancer. The rate of skin cancer in Australia is 2-3 times greater than those in Canada, the United States and the United Kingdom. Sunburn, caused by ultraviolet radiation from the sun, is responsible for 95% of melanomas, the deadliest type of skin cancer.

Types of skin cancers

There are three types of skin cancer: basal cell carcinoma, squamous cell carcinoma and melanoma. Basal and squamous cell carcinoma may also be referred to collectively as non-melanoma skin cancer.

	For detailed information including statistics, risk factors and treatment, see Basal cell carcinoma.
	For detailed information including statistics, risk factors and treatment, see Squamous cell carcinoma.
	For detailed information including statistics, risk factors and treatment, see Melanoma.

Preventing skin cancer

Skin protection from birth is vital for preventing skin cancer. Exposure to the sun’s UV rays during childhood contributes significantly to a person’s skin cancer risk over their lifetime.

For more information see Preventing cancer: UV radiation.

The skin of babies and young children is sensitive to the effects of sunlight, and can burn easily. It is very important for parents to protect not only their own skin, but also the skin of their children from sunlight when UV levels are 3 or above. The slip, slop, slap, seek, slide principles provide a useful framework for remembering the different ways in which skin can be protected from the sun’s UV rays.

Slip on sun-protective clothing

Sun-protective clothing is any clothing that covers skin and prevents exposure to damaging UV radiation from the sun. Most fabrics provide a sun-protection factor (SPF) of at least 10, and 85% of fabrics provide an SPF of more than 20. While different fabrics provide different levels of protection, the greatest determining factor is the amount of fibre in the fabric. Fabrics with a higher fibre content often provide better UV protection.

People of all ages should wear protective clothing on their legs and arms each time they are exposed to sunlight for extended periods of time. A hat is essential, and long trousers and sleeves provide better sun protection than short trousers and sleeves. Clothing should be made from closely woven fabric that cannot be penetrated by the sun’s UV rays.

In Australia, employers are required to provide workers with appropriate protective clothing (as well as hats and sunglasses) while they are exposed to sunlight in the workplace. However, it is the employee’s responsibility to ensure that such clothing is worn. For Australian schools, it is recommended that uniforms be designed to provide adequate sun protection.

Slop on sunscreen

For areas of skin which cannot be covered with clothing like the face and hands, it is important to apply plenty of broad-spectrum, water-resistant sunscreen. Broad-spectrum means that the sunscreen provides protection against both UVA and UVB rays from the sun. Using sunscreen with an SPF of at least 30 is essential to help avoid damaging UV exposure. However, be aware that there is still no conclusive evidence that sunscreen prevents melanoma (the deadliest form of skin cancer) or basal cell carcinoma, although its role in preventing squamous cell carcinoma is well established. Remember that sunscreen is designed for use in conjunction with protective clothing and a hat, not for use alone. It should be used for protection while in the sun, but not to prolong sun exposure.

Most people do not use enough sunscreen. Because they apply only a fraction of the amount of sunscreen they need, they receive only 50-80% of the protection stated on sunscreen product labels. To ensure adequate protection from the sun, use at least a teaspoon of sunscreen for each arm and leg, another teaspoon each for the front and back of the body, and a teaspoon for the face, neck and ears. Sunscreen should be applied 20 minutes before going out into the sun, and again every two hours while in the sun. It should be applied to clean, dry skin.

Parents can safely use sunscreen on babies and children, though protective clothing is preferable, and widespread use of sunscreen on babies under six months is not recommended. If sunscreen is used, one suitable for babies should be chosen. Typically, sunscreens designed for babies use reflecting ingredients such as zinc, and avoid using ingredients and preservatives that may cause a reaction. A patch test should always be performed first, even if the same brand has been used before.

Slap on a hat

A hat is essential for protection from the sun’s UV rays. Hats protect the face and many provide excellent sun protection for the face, neck and ears. They may also reduce UV radiation to the eyes by up to 50%. The broader the hat brim, the better the protection. A hat with a 7cm brim will reduce the face’s  exposure to sun by a factor of five. Caps and visors do not provide adequate sun protection as they leave the ears, neck and cheeks exposed. Several hat types can provide adequate sun protection:

• Broad brimmed hats with a brim width of 7.5cm for adults and 6cm for children. The brim should shade the entire face, ears and back of the neck.
• Bucket or surfer style hats with a deep crown that allows them to sit tightly on the head and a brim of at least 6cm (adults) or 5cm (children), to ensure the face, ears and neck are protected.
• Legionnaire style hats are caps with a back flap to protect the neck. The back flap should meet the front brim, protecting the ears and cheeks.

Regardless of style, the hat should be made of closely woven fabric which is not penetrated by sunlight. Some hats come with an ultraviolet protection rating, which is a rating of the extent to which the fabric blocks sunlight. A dark lining can reduce reflection of sunlight onto the face. Make sure that straps and cords do not present risks (e.g. cannot get caught on things during children’s play).

Australian schools are encouraged to implement policies to prevent children from playing in the sun if they are not wearing an appropriate hat, and to further encourage teachers and visiting parents to wear such hats.

Seek shade and extra protection when sun is intense

Seeking shade when the UV index is ≥3 is important for protecting your skin. In Australia, a high UV index is most likely to occur in the middle of the day (10am-2pm regular time, 11am-3pm daylight savings time). The UV index may be high even on cool and cloudy days, even in winter. During summer, depending on your location, the UV index may be high for most of the day.

See the Australian Radiation Protection and Nuclear Safety UV Radiation index chart for more information about the UV index in your area.

One important way to reduce UV exposure is to plan your day so that you avoid going out in the sun at the hottest times. This is particularly important if you will be going out with a baby or young child, or if you have a condition which makes you more sensitive to sunlight (e.g. immunosuppression). Babies should not be exposed to any sunlight when the UV index is ≥3. If you cannot avoid being in the sun, make sure you use rigorous sun protection – that is, protective clothing, sunscreen and sun shades. Teachers, students and visitors to schools are encouraged to seek shade any time when the UV index is ≥3.

While people are not exposed to the same amount of heat on a cloudy day, UV rays are able to penetrate clouds. Therefore, sun protection is important even on cloudy days. Be aware that the usual warning sign of over-exposure to sunlight (i.e. heat) is largely absent on cool and cloudy days, but you can still get sunburn.

Shaded areas provide protection from UV exposure. Try to walk or rest in the shade, particularly between 10am and 2pm. Special provisions should be made to ensure there are shaded areas in outdoor workplaces. For example, construction scaffolding can be erected with an overhead shade, and the cabins of farm and earth moving equipment can be enclosed or covered with a canopy to provide additional sun protection. Australian schools are encouraged to provide shaded areas for breaks and meals.

Slide on sun shades

Sunglasses provide a barrier between UV radiation and the eyes and thus prevent the harmful effects of UV radiation from damaging the eyes. Close-fitting sunglasses with lenses that meet the Australian Standard for sun protection help protect the eyes and surrounding skin from sun damage. The Australian Cancer Council recommends sunglasses with wrap around (i.e. side) protection which comply with the Australian/New Zealand Standard for Sunglasses and Fashion Spectacles AS/NZS 1067. All sunglasses sold in Australia should be labelled with their compliance with AS/NZS 1067 and the lens category number.

Early detection

Detecting skin cancer early is an important way of reducing associated illness, disfigurement from surgery and death due to the cancer. For example, with melanoma, early treatment while cancer remains localised in the skin (and before it spreads to the bloodstream or other body organs) improves survival. 96% of people who are diagnosed and treated before melanoma spreads survive for at least five years after their treatment, compared to 63% of those who are diagnosed when their cancer has spread to surrounding areas, and only 34% of those whose cancer has spread to the bloodstream (known as metastasis). Regularly checking your skin, either self-checks at home or checks by a doctor at a clinic, are the best way to identify cancerous skin changes, which are usually painless.

For more information about identifying cancerous skin changes, see Identifying a Suspicious Mole.

Balancing vitamin D intake and skin cancer risk

Vitamin D is important for maintaining muscles and bone health. There is also a growing body of evidence suggesting that adequate levels of vitamin D play a role in preventing some internal cancers, improving the function of the innate immune system and reducing the risk of autoimmune disease and other conditions (e.g. hypertension). Further research is needed to examine the role of vitamin D in melanoma mortality, but evidence is emerging that adequate vitamin D protects against death from melanoma.

In humans, more than 90% of vitamin D is obtained from sun exposure. While over-exposure to sunlight can have damaging effects on the skin, some exposure is essential for healthy vitamin D production. Inadequate vitamin D levels are a health problem for people with limited sun exposure, including those who are housebound (e.g. because they are very old or ill), people with dark skin, and people who avoid sun exposure either by staying indoors, applying sunscreen or covering their skin with clothing.

The degree of sun exposure needed depends on the level of skin pigmentation (how dark the skin is) and the intensity of sunlight. In summer, fair-skinned people can get enough vitamin D by exposing their arms to the sun for 6-7 minutes on most days. In winter, exposing as much skin as is comfortable to midday sun for up to 40 minutes provides enough vitamin D for most fair-skinned people.

Most people can get enough vitamin D with regular, short-term exposure of the skin to ultraviolet radiation from the sun. Dietary supplementation of vitamin D may be needed if you cannot expose your skin to sunlight for social or cultural reasons, or health reasons such as increased cancer risk (e.g. due to cancer history or immunosuppression).

How to enjoy a sunburnt country safely

Balancing your exposure to sunlight for optimal vitamin D production and minimal cancer risk is the key to enjoying a sunburnt country like Australia. To do that, you should:

• Avoid long periods of sun exposure, or apply sun protection (slip, slop, slap) rigorously when staying in the sun for a long time.
• Avoid being out in the sun at the hottest times of day.
• Expose unprotected skin to sunlight for a short period each day. A general guideline is:
  • In summer, one third of the skin surface area to mid-morning or afternoon sun for about 7 minutes each day, if you have fair skin. If you have dark skin, expose your skin for 20-45 minutes.
  • In winter, as much as possible of the skin surface area to midday sun for up to 40 minutes if you have fair skin, or longer if you have dark skin.
• Consider dietary vitamin D supplements if you find it difficult to get enough sun exposure. For example, if you:
  • Have an increased cancer risk, making sun exposure too dangerous
  • Work indoors all day
  • Are housebound due to age or illness
  • Habitually cover most of your skin with clothing.

References

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13. Australian Radiation Protection and Nuclear Safety Agency. Sun protection using sunglasses [online]. 2015 (cited 24 August 2017). Available from: [URL link]
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