Evaluation of the National Skin Cancer Campaign : a Swiss experience of Euromelanoma

Lieberherr Svena, Seyed Jafari S. Mortezaa, Cazzaniga Simoneab, Bianchi Enricac, Schlagenhauff Bettinad, Tscharner Gione, Hafner Jürgf, Mainetti Carlog, Lapointe Anne-Karineh, Hunger Robert E.a a Department of Dermatology, Inselspital, Bern University Hospital, Bern, Switzerland b Centro Studi GISED, Bergamo, Italy c Studio medico, Lugano, Switzerland d Dermacenter Küssnacht, Switzerland e Lindenhofspital, Bern, Switzerland f Department of Dermatology and Venerology, University Hospital Zurich, Switzerland g Department of Dermatology, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland h Private Practice, Lausanne, Switzerland


Introduction
Skin cancer is a non-negligible burden to healthcare and patients alike.Epidemiological data are collected on a regular basis to estimate the extent of the disease.Various prevention approaches have been introduced to reduce the burden of skin cancers.Primary prevention focuses on spread of information about and reduction of skin cancerrelated risk factors and behaviour, namely reducing sun exposure, avoidance of sunburn and artificial tanning or use of sunscreen when ultraviolet radiation (UV) exposure is unavoidable.Furthermore, it tries to raise awareness among the public of warning signs of skin cancer [1][2][3].Secondary prevention aims to diagnose and treat skin cancer at a potentially curable stage, to improve prognosis and thus reduce the burden of melanoma on healthcare resources and patients [1,2].Euromelanoma is a pan-European campaign for skin cancer prevention, which was initiated in 1999 and has now spread to 29 European countries.This campaign is targeted to both primary and secondary prevention of malignant melanoma (MM) and nonmelanoma skin cancers (NM-SCs) by increasing the public awareness of skin tumours via media campaigns and by providing free skin examinations to the general public once a year, at the end of May before the summer holiday season [1][2][3][4].As Switzerland has one of the highest incidences of cutaneous melanoma in Europe [5,6], a National Skin Cancer-Screening Day has been organised there since 2001, on a yearly base [5,7].In 2006, the Swiss Society for Dermatology and Venerology (SSDV), in collaboration with the Swiss Cancer League, shifted its skin cancer prevention activities towards a Euromelanoma Screening Week Campaign to promote primary prevention measures by use of media advertising to a large public and the direct education of the patient at the screening day itself [5,7].The current study aimed to evaluate the results from the Swiss skin cancer screening day 2016 and investigate the number of skin cancer diagnoses based on the suspicious lesions detected.

Material and methods
A free-of-charge skin examination was offered within the annual Euromelanoma skin cancer prevention campaign and organised by the SSDV (from 30 May 2016 to 3 June 2016).In the National Skin Cancer Campaign 2016, 93 medical centres (69 dermatological practices and 24 general practices) were involved.Participating physicians (dermatologists and general practitioners) in hospitals or in private practices conducted the screening examinations.Participating doctors chose whether they wanted to see patients by appointment or if people could turn up at their practice freely.The examination process was structured by using the standardised European questionnaire developed in 2008 [7,8] (see appendix 1).The questionnaire consists of three sections: ).All questionnaires were sent to the SSDV office.After 3 to 6 months, all screened persons participating in the study who had a suspicious lesion were contacted either by e-mail or telephone.In the case of noresponse, the patient was contacted for a second time.
Patients who gave their permission were asked whether they had followed the physician's recommendation.Final-ly, the patients were asked about the definite diagnosis.All results of the questionnaire and the follow-up data were collected in a file.

Statistical analysis
For descriptive purposes, data were presented as means with standard deviations (SDs) or numbers with percentages for continuous and categorical variables respectively.Prevalences (i.e., detection rates) of selected skin cancers and other precancerous conditions within the study sample were presented along with their exact (Clopper-Pearson) 95% confidence intervals (CIs).The ratios between study prevalences and known estimates from the general Swiss population (i.e., prevalence ratios), where available, were computed, with exact 95% CIs and p-values.Detection rate is defined here as the percentage of subjects in the overall study population who had a positive diagnosis of skin cancer or other precancerous conditions after clinical assessment.
All tests were considered statistically significant at p-value <0.05.The analysis was carried out using Matlab software, ver.7.8 (The MathWorks Inc., Natick, MA, USA).

Discussion
Skin cancer is one of the most common cancers in Switzerland [11].In this study, data collected during the Swiss Euromelanoma screening day 2016 were analysed to provide a current picture of the impact of the campaign and a basis for future measures to improve the screening event.
The detection rates of melanoma in Euromelanoma programmes varied substantially across participating countries (from 0.1 to 1.9%) [3].The results of the 2016 Swiss Euromelanoma Day showed a detection rate for melanoma of 0.21%, which is compatible to similar European and American studies [1-3, 12, 13].However, compared with the Swiss Euromelanoma evaluation conducted in 2008 with the same methodology and public awareness strategy on 1312 screened individuals [7], the melanoma detection rate was found to be lower (0.21 vs 0.30%).
Although the main focus of the Euromelanoma Day is the early diagnosis of melanoma [14], our campaign also detected some patients with NMSC; the BCC detection rate was higher and SCC detection rate lower in 2016 compared with 2008(0.75vs 0.38% and 0.07 vs 0.15%, respectively) [7].Furthermore, comparisons of prevalence estimates of skin cancers and other precancerous conditions between the current study and the general population showed that 6 patients in the sampling population had a diagnosis of MM with an estimated prevalence of 21.5 × 10 000.The observed prevalence was significantly higher than in the general population (prevalence ratio 6.4; p <0.001).Regarding NMSC, the observed prevalence of BCC was 75.1 × 10 000, and the prevalence of SCC was 10.7 × 10 000.Compared with general population estimates, the prevalence of BCC was significantly higher (prevalence ratio 9.4; p <0.001) [9].For other precancerous conditions, the estimated prevalence of actinic keratosis in our sample was 157.4 × 10 000, similarly to previous estimates from another study [10], while the prevalence of dysplastic naevus was 10.7 × 10 000.
In 2016, 70.7% of the persons screened had a skin phototype III or higher, which was similar to data reported by individual Euromelanoma countries in previous years [3].Additionally, in concordance with Euromelanoma Day campaigns in other countries, women were more likely than men to participate in the Swiss screenings [3,14].
Women are probably more conscious about the risk factors and more accustomed to attending cancer screening campaigns [14].Sun exposure is a known risk factor of skin cancers.Three quarters of all participants go on vacation to destinations with high solar radiation on a yearly basis.This behaviour results in elevated intermittent sun exposure.Awareness of the need for adequate sun protection while sunbathing seems to be high.The impact of unin-tended sun exposure appears to be taken less seriously, however.Twenty percent fewer screened persons used sun screen when exposed to sunlight for one hour than sunbathers.The elevated numbers of BCCs and MMs could be explained by widespread intermittent sun exposure.These findings reveal a continuing need of public education about UV radiation as a risk factor, not only when sunbathing but also when exposure is not intended.Skin cancer screening of an unselected population is controversial: the Cancer Council Australia does not recommend routine skin screening for average-risk individuals, whereas the American Cancer Society supports this type of regular screening [15].Skin cancer screening could be accompanied by psychosocial harms, cosmetic harms, or overdiagnosis [16].However, it was shown that skin cancer screening might be able to reduce disease-specific mortality [17][18][19][20][21][22].
The success of the Euromelanoma days depends on many factors, including the number of dermatologists who participate, as well as the costs of the screening and information campaigns.Furthermore, the characteristics of the   population screened during Euromelanoma were influenced by the message broadcasted and local rules of participation [3].
Our current study was certainly not without limitations, because the individuals screened were relatively older than the Swiss population, with a predominance of women.Another possible limitation of the study is that not all of the subjects with suspect lesions were followed up, because they did not give permission to be contacted for further evaluation.This might have lowered our detection rate estimates.Nevertheless, the observed rates are significantly higher, at least for MM and BCC, than the reference general population, showing a positive impact of a national campaign of screening on detection rates.All in all, skin cancer prevention initiatives are highly costeffective and may also be cost-saving [23].Although the direct benefits of skin cancer screening may be greatest among subgroups most likely to develop fatal melanoma [16], indirect consequences of screening campaigns should not be underestimated.The impact of skin cancer diag-noses on the awareness of the social circle of a patient can hardly be measured.This spread of consciousness of skin cancer might influence the risk factor-related behaviour and secondary prevention can thus reinforce primary prevention efforts.Therefore, considering the morbidity, mortality and financial and social impact of skin cancer, the capacity to raise awareness of risk factors, skin cancer prevention methods and educating high-risk and at-risk individuals, we may assume that a National Screening Day does have a crucial impact on the public health system.
Original articleticipants (47.8%) attended the screening for a general skin examination; 40.1% gave a high number of naevi as a reason to participate in the campaign and about one fifth of the patients (21.7%) were concerned about a specific or newly appeared lesion.(table2) presents the entire workflow.A total 2215 (79.3%) screened individuals required no further treatment.Suspicious lesions were found in 580 (20.7%) patients.Out of these 580 patients, 243 (41.lesion who underwent a referral to a dermatologist.The majority of the 157 patients were female (58.0%) and the mean age was 58.8 years for both genders.The skin phototypes I, II, III or IV were reported for 8.9%, 15.9%, 47.1% and 23.6% of the patients, respectively.Overall, 69.4% had never had a skin cancer screening before.Most of the par-PrevalencePrevalence estimates of skin cancers and other precancerous conditions, in detail, and comparisons with known estimates from the general population are reported in table 4. Overall.6 patients in the sampling population had a diagnosis of MM with an estimated prevalence of 21.5 × 10 000 (95% CI 7.9-46.7).Regarding NMSC, the observed prevalence of BCC was 75.1 × 10 000 (95% CI 46.6-114.6),and the prevalence of SCC was 10.

Table 1 :
Distribution of diagnosis, biopsies and detection rate during Swiss Euromelanoma 2016 † .BCC = basal cell carcinoma; MM = malignant melanoma; NMSC = non-melanoma skin cancer; SCC = squamous cell carcinoma † based on recorded data of 157 patients * Detection rate can be defined here as the percentage of subjects in the overall study population who had a positive diagnosis of skin cancer or other precancerous conditions after clinical assessment.‡ Detection rates of MM, SCC and BCC in the Swiss National Skin Cancer Campaign in 2008 were 0.3, 0.15 and 0.38%, respectively.

Table 2 :
Reasons for participation in the campaign and previous skin cancer screenings † .

Table 3 :
Distribution of the risk factors family history of skin cancer, sunburn in childhood, use of sunscreen and vacation in areas with high sun exposure † .

Table 4 :
Prevalence estimates of skin cancers and other pre-cancerous conditions, in detail, and comparisons with known estimates from the general population † .