Key message

The incidence of melanoma skin cancer in people aged under the age of 55 years in Europe varies considerably between countries. The highest incidence rates are found in northern and western countries and the lowest in southern countries, with rates from three to eight times lower for men and women, respectively. In eastern European countries the incidence rates are low to intermediate. These variations are likely to be linked to specific behaviour (winter holidays, sun-seeking behaviour) as well as to improved diagnoses resulting from better detection of melanoma.

Figures

Presentation of data

Fig. 1 presents the variations between countries in age-standardized melanoma skin cancer incidence rates in Europe in 2002.

The data in Fig. 2 are derived from the International Agency for Research on Cancer (IARC) registries database (1). They show the trends over time in the incidence of melanoma for two Scandinavian countries, Norway and Sweden, illustrating the recent levelling off or decreasing trend in incidence among those aged under 55 years compared with older people.

Fig. 1. Age-standardized rates of melanoma incidence in people aged under 55 years, selected European countries, 2002

Source: GLOBOCAN (2).

Fig. 2. Time trends of melanoma incidence in Norway and Sweden, 1953–1997

Source: IARC (1).

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Rationale

Acute, irregular and excessive exposure to the sun, mainly during childhood, by people with fair skins is a major risk factor for melanoma, a malignant cancer of pigment cells in the skin. Considering the 20–40 year time-lag between exposure to the sun and onset of the cancer, the incidence of melanoma among people aged under 55 years and the respective time trends will be a good indicator of the final success of action against excessive exposure to ultraviolet (UV) radiation during childhood.

Health and environment context

It is estimated that in 2002, 9219 males and 12 303 females under the age of 55 years were diagnosed with a melanoma in the European Union and the accession countries (Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia). Melanoma is a malignant transformation of the pigmentation cell (melanocyte) of the skin (3). Most melanomas seem to be caused by acute, intermittent and excessive exposure to the sun, mainly during childhood, but exposure in adulthood also contributes to the risk. The phototype of fair skin (types I, II), large numbers of naevi or atypical naevi and a family history of skin cancer are the most important predictors of melanoma risk (4).

Melanomas occurring in those aged under 55 years seem to be strongly linked to exposure to UV radiation in childhood. These melanomas are often localized on the body trunk (males) and on the legs (females). The fact that melanoma in the elderly occur on the most chronically exposed parts of the body illustrates that chronic exposure is more important for melanomas occurring among elderly people. The use of sunbeds is an additional risk factor for melanoma. Melanoma is more frequent among people in the higher socioeconomic brackets and among northern European populations. This is probably due to their higher excessive intermittent exposure to UV radiation in combination with a light skin phototype.

The main way to prevent melanoma is to advise people to limit their exposure to the sun by avoiding such exposure during the hours of the day when UV radiation is most intense (approximately two hours each side of the solar noon) and to wear appropriate clothes, hats and sunglasses. Special attention needs to be paid to children. The use of sun-screen preparations may help to prevent sunburn and skin cancer but may also lead to increased exposure to the sun. Survival is strongly linked to the stage of the disease at diagnosis, which provides a rationale for considering organized screening programmes for melanoma. Since the incidence of melanoma is expected to keep increasing in the future, early detection remains an important strategy to combat the disease. Prevention campaigns carried out in north-western European countries since the 1980s have probably resulted in a decrease in the average thickness of melanomas and stabilization in melanoma mortality in young people (5).

Policy relevance and context

Melanoma is strongly linked with exposure to UV radiation during childhood and is therefore largely preventable. WHO has launched the INTERSUN Global UV Project to stress the importance of increasing awareness and knowledge about the potential negative health effects of exposure to UV radiation, especially during childhood (6). This information should be readily available through various channels such as television, radio, campaigns, meteorological websites and in schools. Representatives of the tourism industry can also play a crucial role in minimizing the risks associated with exposure to the sun by disseminating information to their customers and by taking essential measures in tourism facilities and services. A UV radiation index can help to identify appropriate action based on the measured UV radiation levels. Furthermore, the use of sunbeds by children should be strongly discouraged, if not forbidden. The INTERSUN Project recommendations can serve as a framework for a European action plan to reduce exposure to UV radiation.

Nevertheless, there are at present few official regulations in most European countries (see ENHIS-2 fact sheet No. 4.8 of April 2007 on policies to reduce excessive exposure of children to UV radiation (7)). There are thus major opportunities for developing policy as well as for harmonizing and strengthening efforts to reduce such exposure. National policies to reduce exposure to artificial UV radiation - including regulations for the use of sunbeds by children and teenagers – should be implemented in more countries in the WHO European Region. Excessive exposure to solar UV radiation can best be prevented by regional and local awareness-raising and information campaigns, especially in educational institutions. The aim is to encourage schoolchildren to take measures to protect themselves against the sun.

Assessment

Melanoma is one of the cancers with the fastest rates of increase among white people in Europe. Trends in rates differ between regions: in northern Europe where the rates are high, they appear to have levelled off since the 1990s, particularly among people aged under 55 years (Fig. 2). This seems to be the result of a change in sun-seeking and protective behaviour against UV radiation among the younger generations. In contrast, in southern and eastern Europe, the rates are generally still increasing steeply in all age groups (8,9).

Currently, in almost all European countries the incidence is higher in women than in men. Estimates of the age-standardized (world standard population) rate for women vary from under 2/100 000 to over 16/100 000. There is a strong geographical correlation between the European regions and the incidence of melanoma in people aged under 55 years. The highest incidences are found in northern (Denmark, Norway and Sweden) and western European countries (France, the Netherlands and the United Kingdom), with incidences of 6–9 per 100 000 for males and 8–16 per 100 000 for females. Austria and Switzerland have among the highest incidence rates for both sexes: around 6 per 100 000 for men and around 10 per 100 000 for women. The lowest incidence rates are found in southern Europe (Greece, Italy, Portugal and Spain) with incidence rates of 2–4 per 100 000 for both men and women. In eastern Europe the rates vary from low (<2 per 100 000 in Bulgaria, Latvia and Romania) and intermediate (to 6 per 100 000 in Lithuania and Slovenia).

The main way to prevent melanoma is to advise people to limit their exposure to the sun. National and European policies should, therefore, pay more attention to preventing excess exposure to UV radiation during childhood (following the INTERSUN Project recommendations). The levelling off since the 1990s of the previously rising trends in northern Europe among people aged under 55 years supports the notion that specific UV protection activities are being effective in these countries.

Metadata

Name: Incidence of melanoma in people aged under 55 years

Definition: Incidence of melanoma as defined by ICD-10 codes C43, D03 in the population aged under 55 years

Code: RPG4_UVrd_E1

Data source

The main source of data used for this report is the European Globocan 2002 web site (2). The IARC data from C15 (Cancer incidence in five continents) (IARC C15) (10) are used to illustrate time trends in incidence in Scandinavia, with estimates based on the registers.

Description of data

The methodology sheet proposed the reporting of incidences as the number of cases per 100 000 person-years in people aged between 0 and 49 years. The Globocan data only allow estimations between 0 and 54 years of age. Data for this age group have been used since they allow more countries to be included in the comparisons. Most of the registries in Europe have data available from the beginning of the 1980s and allow the investigation of time trends. Cancer registration is a continuous procedure and summary reports are usually produced annually. However, owing to the time required for data management and production of reports, there is often a time lag of 1–2 years until the data are publicly available.

The IARC C15 data allow world-standardized estimates to be made of the incidence of melanoma by age for six periods between 1953–1957 and 1993–1997.

Method for indicator calculation

Incidence in people aged under 55 years is the number of cases during the period of consideration divided by the number of person-years of the population targeted. It is given in the number of new cases per 100 000 person-years. The incidence is given by calculating the number of cases on the mean population size during the period considered. The age-standardized rate (ASR, world standard) is calculated using the age groups. The age group considered here are those aged 0–54 years.

Geographical coverage

Melanoma national incidence estimates of 26 European countries (see Data quality below).

Period of coverage

The disease rates are not those for 2002 but are taken from the most recent data available, generally two to five years earlier, derived from IARC data.

Frequency of update

Every five years.

Data quality

Globocan data have been chosen because they give the best estimates of national incidence in the European countries. At the time of writing, Bulgaria, Greece, Hungary and Romania did not have good quality population-based cancer registries and the incidence rates are, therefore, based on those of neighbouring countries combined with information from mortality statistics. Some other countries do not have nationwide cancer registries so the information is based on regional incidence information (the figures in brackets are the number of registries, none of which cover the whole country): Austria (2), France (10), Germany (1), Italy (16), Poland (4), Portugal (1), Spain (11) and Switzerland (9). Because the sources of data are continually improving in quality and extent, estimates may not be truly comparable over time and care should be taken when comparing these estimates with those published earlier. The differences observed may be the result of a change in the methodology and should not be interpreted completely as a time-trend effect. The IARC C15 data appear to be more reliable since they rely on registers. They are, however, subject to the possibility of error concerning classification and data collection considerations. Unfortunately most of the registers are local rather than national, which impedes the use of these data for European comparisons.

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. de Vries E, Tyczynski JE, Parkin DM. Cutaneous malignant melanoma in Europe. Lyons, International Agency for Research on Cancer, 2003 (European Network of Cancer Registries fact sheet No. 4; http://www.encr.com.fr/melanoma-factsheets.pdf, accessed 23 March 2007).
2. GLOBOCAN 2002 database [online database]. Lyons, International Agency for Research on Cancer, 2002 (http://www-dep.iarc.fr/globocan/database.htm, accessed 23 March 2007).
3. Amstrong BK, Heenan P. A theory of the aetiology and pathogenesis of human coetaneous malignant melanoma. Journal of the National Cancer Institute, 1983, 71:651–656.
4. Tucker MA, Goldstein AM. Melanoma etiology: where are we? Oncogene, 2003, 22:3042–3052.
5. Mansson-Brahme E et al. Trends in incidence of coetaneous malignant melanoma in a Swedish population 1976–1994. Acta Oncologica, 2002, 41:138–146.
6. INTERSUN – The Global UV Project: A guide and compendium. Geneva, World Health Organization, 2003 (http://www.who.int/uv/publications/intersunguide/en/index.html, accessed 23 March 2007).
7. WHO European Centre for Environment and Health. Policies to reduce the excessive exposure of children to ultraviolet radiation. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 4.8).
8. de Vries E et al. Changing epidemiology of malignant cutaneous melanoma in Europe 1953–1997: rising trends in incidence and mortality but recent stabilizations in western Europe and decreases in Scandinavia. International Journal of Cancer, 2003, 107:119–126.
9. de Vries E, Coebergh JW. Cutaneous malignant melanoma in Europe. European Journal of Cancer, 2004, 40:2355–2366.
10. Parkin DM et al., eds. Cancer incidence in five continents. Vol. I to VIII. Lyons, International Agency for Research on Cancer, 2005 (IARC Scientific Publications No. 155; http://www-dep.iarc.fr/, accessed 23 March 2007).

WHO-IARC mortality database [online database]. Lyons, International Agency for Research on Cancer, 2007 (http://www-dep.iarc.fr/, accessed 30 March 2007).

Suggestions for further monitoring

Comparable methods of collection, classification, description and registration of information are important to allow comparisons of melanoma incidence and mortality. The increasing quality and population coverage of European cancer registries are good bases for future monitoring efforts. Complete national data registries for melanoma are of crucial importance. Estimates of mortality from melanoma are an important co-indicator, since melanoma prognosis is strongly correlated with the thickness of the tumour at diagnosis.

Further information about the control and use of sunbeds

UV-radiation of sun beds. Common public health advice from Nordic radiation protection and health authorities. Danish National Board of Health (Sundhedsstyrelsen), Finnish Radiation and Nuclear Safety Authority (Säteilyturvakeskus, STUK), Icelandic Radiation Protection Institute (Geislavarnir Rikisins), Norwegian Radiation Protection Authority (Statens strålevern), Swedish Radiation Protection Authority (Statens strålskyddsinstitut) (http://www.sst.dk/upload/forebyggelse/cff/sol_hudkraeft/nordic_sunbed_position.pdf, accessed 23 March 2007).

Sunbeds, tanning and UV exposure. Geneva, World Health Organization, 2005 (Fact sheet No. 287; http://www.who.int/mediacentre/factsheets/fs287/en/index.html, accessed 23 March 2007).

Further information about recommendations on exposure of children to UV radiation

Protecting children from ultraviolet radiation. Geneva, World Health Organization, 2001 (Fact sheet No. 261; http://www.who.int/mediacentre/factsheets/fs261/en/, accessed 24 March 2007).

Towards the promotion and harmonization of skin cancer prevention. Recommendations from an International Conference held in Hamburg, Germany, 2–5 May 2000. The European Society of Skin Cancer Prevention – EUROSKIN (http://www.who.int/uv/resources/recommendations/en/1stEuroskinrec.pdf, accessed 23 March 2007).

SunWise Program [web site]. Washington, U.S. Environmental Protection Agency, 2007 (http://www.epa.gov/sunwise/summary.html, accessed 23 March 2007)

Authors: Philippe Pirard, National Institute of Public Health Surveillance, Paris, France; E. de Vries, Department of Public Health, Erasmus MC, Rotterdam, Netherlands.