joint statement participating logos joint statement participating logos joint statement participating logos

Skin cancer(1) is among the most common and burdensome types of cancers in the European Union. In 2020, over 106.000 EU citizens were diagnosed with melanoma(2), making it the sixth most frequently occurring cancer and one of the twenty most frequent causes of cancer death(3). Keratinocyte Carcinomas(4) (which include basal cell and squamous cell carcinomas) are by far the most widespread of all cancers and whilst not life-threatening in most cases, can significantly impact a patient’s quality of life(5). It is of major concern that Keratinocyte Carcinomas are the most rapidly increasing cancers, with incidence expected to continue rising (by over 40% until 2040)(6), presenting a tremendous challenge to health systems. This does not have to be the case, as skin cancer is part of the 40 percent of cancers that are preventable(7) and whose incidence would be considerably reduced if more conscious and responsible behaviours were adopted.

Europe’s Beating Cancer Plan is an important opportunity to join forces towards developing an adequate EU policy and regulatory framework to address skin cancer. With a view to improving skin cancer prevention across Europe, the signatory organisations call on the European Commission to act on several areas where additional measures are needed:

1. IMPROVING UNDERSTANDING, EDUCATION AND AWARENESS ABOUT SKIN CANCER AND IMPLEMENTING EVIDENCE-BASED INTERVENTIONS FOR BEHAVIOURAL CHANGE

Educating citizens about the risks of skin cancer from excessive exposure to natural and artificial UV radiation (e.g. sunbeds) is crucial to effectively reduce the incidence of the disease. Particular attention is needed to reach vulnerable populations (children and teenagers, outdoor workers and people with high risk factors or conditions which predispose them to skin cancer). A personalised approach to prevention, whereby tailored messages are delivered to target populations at the right time for them, can improve understanding and awareness, and together with the implementation of evidence-based interventions, foster more conscious and responsible behaviours.

The co-signatories call on the European Commission to:

  • • Update the European Code Against Cancer considering the latest scientific evidence and best practices in skin cancer prevention
  • • Make skin cancer prevention information widely available to EU citizens and healthcare professionals
  • • Facilitate the uptake of scientifically-validated interventions including digital and innovative tools
  • • Encourage the setting up of EU-wide awareness-raising campaigns on skin cancer prevention, to:
    • - Promote the protection of children and teenagers during organised recreational activities (e.g. in schools, kindergartens, sport clubs etc.)
    • - Promote adequate skin protection to outdoor workers as well as to all citizens participating in outdoor pursuits (e.g. sports, tourism, sunbathing)
    • - Improve understanding of the harmful effects of sunbeds
  • • Improve understanding, importance and implementation of the HPV vaccination campaign as the long- term prevention tool of different Keratinocyte Carcinomas
  • • Allocate EU funds (e.g. through the EU4Health Programme and Horizon Europe) to support understanding, education and awareness about skin cancer and sun exposure behaviours, and in particular to address inequalities

2. INTRODUCING MEASURES TO PROTECT EU CITIZENS FROM EXCESSIVE EXPOSURE TO NATURAL AND ARTIFICIAL UV RADIATION

Excessive exposure to natural and artificial UV radiation is the main cause of skin cancer. Children and teenagers are particularly vulnerable, as their lifestyle exposes them to greater risks: they spend more time outdoors and usually are not aware of the harmful effects of UV radiation. Artificial tanning devices (e.g. sunbeds) play a significant role in the development of skin cancer: over 3,400 melanoma cases are attributable to sunbed use every year in Europe and there is evidence that sunbed use substantially increases the risk of Keratinocyte Carcinomas. Despite UV radiation being classified by the World Health Organisation International Agency for Research on Cancer (IARC) as carcinogenic to humans(8), there are still no EU harmonised rules regulating sunbed use.

The co-signatories call on the European Commission to:

  • • Develop legislative/policy measures and recommendations that improve adoption of skin cancer preventative behaviours
  • • Develop or update a set of recommendations for Member States on adequate sun protection measures for children and teenagers in institutional settings , for instance during school hours and organised outdoor activities
  • • Implement strict criteria and monitoring in the access and use of sunbeds, including banning their use by minors and a phasing out for aesthetic purposes
  • Regulate sunbeds as medical devices, not as consumer products

3. RECOGNISING SKIN CANCER AS AN OCCUPATIONAL DISEASE AND IMPLEMENTING UV PROTECTION MEASURES FOR OUTDOOR WORKERS

In the EU, 14.5 million people work outdoors for at least 75 percent of their working time(9), dramatically increasing the risk of developing skin cancer. Although skin cancer is the most common occupational cancer in Europe, it is not recognised as such within the EU regulatory framework, even though recent UV- measurements have shown that outdoor workers all over Europe are regularly exceeding the daily WHO/ ICNIRP(10) UV-exposure limits by up to five times(11).

The co-signatories call on the European Commission to:

  • • Ensure official recognition of UV-induced Keratinocyte Carcinomas, including actinic keratosis, as an occupational disease
  • Update EU Directives to recognise natural UV radiation as an occupational risk factor and the risk of skin cancer as an occupational disease, namely:
    • - Annex I, Part 5 of Commission Recommendation (2003/670/EC) on the European schedule of occupational disease to reflect the direct link between outdoor work and skin cancer caused by solar UV radiation
    • - Directive 2006/25/EC on artificial UV radiation, which must be expanded for solar UV
  • • Provide guidance to Member States on UV protection measures for outdoor workers, such as:
    • - Schedules avoiding workers exposure during sun peak hours (also to avoid heat stroke)
    • - Facilitating access to regular screening and monitoring for outdoor workers
    • - Implementing education of the risks of UV exposure for both employers and employees

4. IMPROVING REGISTRATION OF SKIN CANCER CASES ACROSS EUROPE TO DETECT RISK GROUPS

Cancer registries provide the epidemiological data needed to estimate cancer burden in a given population and to inform decision-making on resource allocation according to public health priorities and needs. Inadequate registration of melanoma cases in several European countries means that disease burden is under- estimated. Furthermore, Keratinocyte Carcinomas are not reported in most population-based cancer registries and when they are, they are grouped under a single coding, preventing differentiation between tumour types.

The lack of effective and harmonised registration of melanoma and Keratinocyte Carcinomas across Europe prevents adequate data collection and constitutes an obstacle for the development of targeted skin cancer control measures.

The co-signatories call on the European Commission to:

  • • Take measures to facilitate improved registration of melanoma cases across the EU, particularly in South- East Europe
  • • Promote the inclusion of Keratinocyte Carcinomas reporting in population-based cancer registries with clearly distinguished datasets for separate diseases according to international cancer classification systems

5. ENHANCING EARLY DETECTION OF SKIN CANCER BY TARGETED SCREENING OF HIGH RISK GROUPS

Targeted cancer screening programmes help identify cases amongst high-risk population groups, helping to tackle the disease promptly and cost-effectively. Therefore, the Commission’s plans to update the Council Recommendation on cancer screening and to widen the scope of targeted cancer screenings to additional types of cancers other than cervical, breast and colorectal cancers, are of utmost importance.

The co-signatories call on the European Commission to:

  • Expand the scope of EU-wide cancer screening to include melanoma and Keratinocyte Carcinomas, targeting high-risk groups , including individuals aged above 60 years, patients with a history of melanoma or Keratinocyte Carcinomas, individuals with multiple nevi and/or fair skin, immunosuppressed patients and individuals with cumulative burden of UV exposure, such as outdoor workers
  • • Support research into and the development of skin cancer screening methods, particularly with new technologies

NOTES:
1 Includes all cancers that appear on the skin and mucosa
2 Most recent estimates from the European Cancer Information System (ECIS) for the EU-27 countries on melanoma skin cancer incidence and mortality
3 European Cancer Information System (ECIS) Melanoma Factsheet, 2021
4 The term non melanoma skin cancer (NMSC) covers all cutaneous cancers that do not involve melanocytes. This term is widely (and inconve- niently) used to refer to basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Keratinocyte Carcinomas (KC), named from the cell of origin (similarly to melanoma) is a more correct term for grouping BCC and SCC, the most frequent skin cancers
5 Other skin cancers exist, including Merkel cell carcinoma, skin lymphomas, adnexal carcinomas etc. and while rare, can have high mortality
6 Girvalaki C et al, Non-melanoma skin cancer as an occupational disease. What is the impact on the society and the welfare system? Journal of Health Inequalities (2020); 6(2) 153-159
7 Communication from the Commission to the European Parliament and the Council: Europe’s Beating Cancer Plan (2021)
8 www.who.int
9 Girvalaki C et al, Non-melanoma skin cancer as an occupational disease. What is the impact on the society and the welfare system? Journal of Health Inequalities (2020); 6(2) 153-159
10 International Commission on Non-Ionising Radiation Protection
11 John SM, Garbe C, French LE, Takala J, Yared W, Cardone A, Gehring R, Spahn A, Stratigos A. Improved protection of outdoor workers from solar ultraviolet radiation: position statement. J Eur Acad Dermatol Venereol. 2021 Jun;35(6):1278-1284. doi: 10.1111/jdv.17011. Epub 2020 Nov 21. PMID: 33222341

This joint statement is an initiative driven and funded by the European Academy of Dermatology and Venereology as part of its EU Advocacy programme of activities.
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