What is Non-Melanoma Skin Cancer?
Non-Melanoma Skin Cancer (NMSC) refers to all types of cancer of the skin that are not melanoma. An estimated 2-3 million cases are recorded in the world every year, with the number of diagnosed cases increasing by 3-8 percent annually. Europe is particularly impacted by NMSC, which accounts for approximately 90 percent of all skin cancers.
Despite the threat it constitutes to outdoor workers, very few European countries recognize UVR-inflicted occupational skin cancer, including NMSC, as an occupational disease. Solar radiation remains remarkably absent from the EU directive on occupational carcinogens and mutagens. While there is solid evidence that outdoor workers in various workplaces across Europe are exposed to elevated levels of UVR and are consequently at a significantly increased risk of developing NMSC, this has yet not been translated into a common European regulatory approach. The lack of official recognition of occupational skin cancer hinders the implementation of effective prevention and treatment measures.
Exposure to ultraviolet radiation (UVR) is the most important external risk factor for the development of skin cancer, and outdoor workers, who are exposed to high ambient UV radiation levels during most of their work hours, are at increased risk. In fact, with five years or more of outdoor work, the likelihood of suffering from NMSC can increase three-fold.
Outdoor workers have an increased risk of developing CSCC and actinic keratosis by 77%, and for BCC by 43% respectively, compared with the general population. Considering that Europe has more than 14.5 million active workers who spend at least 75% of their working time outdoor, special attention should be paid to this kind of occupational exposure. The workers exposed to UV radiation the most are in the agriculture, hunting and construction sectors. The level of their exposure vastly exceeds the WHO recommended limits of 1.3 Standard Erythemal Doses (SED). 1.3 SED is sufficient to cause sunburn in fair-skinned individuals of skin type 1 (Blond or redhaired, freckles, always burns, never tans), when working eight hours outdoors). More recent European studies reveal that the risk for long-time outdoor work for CSCC and BCC is doubled compared to average population. (1)
The economic burden of skin cancer due to UVR has continuously put national governments and their healthcare systems under significant economic strain. In
Europe, the annual direct cost for the treatment of patients with advanced melanoma, is estimated to a range from €2,916 in Italy all the way up to €22,671 in Sweden,
which remains three times higher than the next highest costs which are to be found in France (€7,005) and the UK (€6,887). In addition, mortality costs in England are six
times greater than those in Sweden (€ 20,408 vs € 3,511 respectively). Morbidity costs in England (€ 4550) are found to be seven times over costs in Denmark (€ 658) and
forty times over the costs in Sweden (€ 103). Danish Data also showed that the direct yearly costs of malignant melanoma and NMSC were more than €30 million in
the 3 years after diagnosis, corresponding to 0.2% of the total Danish health budget (€14.3 billion), and approximately to 5% of the hospital budget for cancer patients.
These figures also reflect the costs of inactivity regarding prevention. (2)
Unregistered (informal) employment
Unregistered employment in many sectors with an elevated level of UV radiation exposure (agriculture, hunting and construction)(9) should be taken into consideration
by European policy makers and legislative authorities. Recent data shows that although 1 to 25 in Europe work in the Agriculture sector, 15% of the agricultural workforce and 32% of all employees in the agricultural sector have no formal employment contract, while in the construction sector the unregistered employment is set at 19%. (3)
Quality of life and prevention
Reduction of quality of life is also an important issue to consider for NMSC patients as they potentially undergo repeated rounds of surgery and, as a result, can suffer significant consequences for their appearance, self-esteem, and well-being. NMSC frequently results in chronic illness due to recurring lesions in sun-exposed skin, requiring almost continuous treatment efforts.
Preventive measures such as primary prevention, early detection, treatment and regular follow-up, targeting outdoor workers could reduce the costs, be beneficial from a health economic perspective and also increased quality-of-life, functional ability and overall health. (4)
Policy and Legislation
Despite the solid evidence that outdoor workers in various workplaces across Europe are exposed to elevated levels of UVR and are consequently at a significantly increased risk of developing NMSC, this evidence has yet not been translated into a common European regulatory approach.
The World Health Organization (WHO) and the International Labour Organization (ILO) prioritized this topic and they are currently developing a methodology to assess the global disease burden of work-related skin cancer by solar UVR.
In addition, the nine co-hosting organizations of the Multi-Stakeholder Summit on Occupational Skin Cancer in 2019, representing patient advocacy groups, trade unions, occupational safety and health professionals, social security representatives, dermatologists and oncologists, called for the implementation of a systematic approach to address the Non-Melanoma Skin Cancer Epidemic.
Finally, Europe’s Beating Cancer Plan, calls for: further legislative and soft measures to reduce exposure to carcinogenic substances in the workplace, in products and in the environment, and to UV and ionising radiations from natural and artificial sources.
Scientific work from across the EU and worldwide provides solid evidence to put prevention of UVR exposure for outdoor workers as priority to the European agenda and highlights the importance and necessity for new policies and legislation adaption. Policymakers should improve the legislative framework to protect outdoor workers more effectively and build accessibility for regular screenings and thus earlier treatments. In the European Union, NMSC should be officially recognized as an occupational disease within the next legislative period. The latest WHO World Cancer Report also highlights the need for protective measures against hazardous exposure to sunlight, such as avoiding unnecessary sun exposure, using protective measures when in the sun, and avoiding tanning devices.
This report is a call for action to increase awareness among policymakers and protection for those who work outdoors by establishing the necessary legislation on the European
level and preventive measures to prevent the numbers of the disease from rapidly growing in the coming years. (5)
”Non-melanoma Skin Cancer is the most frequent cancer of all cancer in women and men. It is very easy to be diagnosed, you just have to look at the skin and you just have to have an expert who knows about skin cancer”
Dr Swen Malte John, Institue of Multidisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrueck
What ECPC does
In 2019, together with the European Academy of Dermatology and Venereology (EADV), ECPC launched the first-ever Global NMSC Awareness Day to raise awareness and highlight the disproportionate impact of the disease on outdoor workers. ECPC also contributed to the White Paper on Improved Protection of Outdoor Workers from Solar Ultraviolet Radiation.
Last year, we launched an awareness campaign on NMSC and developed a community-building toolkit together with an action brief on Occupational Skin Cancer. Furthermore, an article on ”Non-melanoma skin cancer as an occupational disease. What is the impact on the society and the welfare system?” was published in the Journal of Health Inequalities in 2020. ECPC also co-hosted the 2020 Follow-up workshops of the Multi-stakeholder Summit on Occupation Skin Cancer that took place in October 2020.
For this year, we have developed this web hub that includes all relevant information on Non-melanoma Skin Cancer. Likewise, we will host a webinar on the 15th of June. It will aim to identify the main barriers that prevent health professionals and other relevant stakeholders from reporting or taking measures to prevent occupational skin cancer, and in particular NMSC.
List of relevant External Resources
- Global evidence on occupational sun exposure and keratinocyte cancers: a systematic review
- Information on Non-Melanoma Skin Cancer from the Australian Cancer Council
- German information portal on Skin Cancer – National Health Care Conference Skin Cancer (NVKH e.V.).
- BG BAU, the professional association for the construction industry report, Germany (in German)
- BG BAU, the professional association for the construction industry UV-protection day 15 April 2021, Germany (in German)
- Non-Melanoma Skin Cancer Report (Melanoma UK)
- Euromelanoma 2021 campaign leaflet
- Euromelanoma and The Global Coalition for Melanoma Patient Advocacy – 2O2O Melanoma Skin Cancer Report
- Fondation contre le Cancer (in French):
- Irish Cancer Society
- British Association of Dermatologists: Know the facts about common skin cancers
- ECL Sun Safety Recommendations
- What You Didn’t Know About Advanced Basal Cell Carcinoma
- Non-Melanoma Skin Cancer or the unknown relative of Melanoma
- Macmillan Cancer Support:
- Your Guide to skin cancer
- How to check your skin for skin cancer
- Skin cancer what do you need to know
- Understanding Skin Cancer: A guide for people with cancer, their families and friends
- Skin cancer: How to diet, nutrition and physical activity affect the risk of skin cancer?