Occupational UV Radiation Claims – 2018 Update

INTRODUCTION

Occupational diseases, resulting from exposure to UV radiation, pose an emerging risk to UK workforces. Across editions 148 (here) and 149 (here), we presented a 2-part series on UV radiation risks associated with outdoor work. This week’s feature provides a review of the latest UV radiation-related developments, published in 2018.

In this article, we cover:

  • An Information Note from the Industrial Injuries Advisory Council;
  • Action taken by the Institution of Occupational Safety and Health’s No Time To Lose Campaign;
  • Other campaigns and calls to action;
  • Merkel cell carcinoma as an emerging disease;
  • Recent studies, reviews and articles; and
  • Changing claimant solicitor services.

IIAC INFORMATION NOTE

Earlier this year, the Industrial Injuries Advisory Council (IIAC) released an information note on non-melanoma skin cancer (NMSC) and occupational exposure to natural ultraviolet (UV) radiation[i]. This was discussed in issue 229 of BCDN (here). A separate Note, on melanoma skin cancer, is expected to be released in due course.

Currently, skin cancer, caused by occupational UV radiation, does not appear on the list of prescribed diseases eligible for Industrial Injuries Disablement Benefit. Many basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) are diagnosed early, and are less likely to spread around the body.

The Council’s Note referred to a review of 24 high-quality, systematic studies, published in 2011, which sought to discover whether BCC is attributable to occupational UV exposure from sunlight.[ii] Research conducted at a lower latitude than the UK was only indirectly relevant to interpretations on the risks facing UK workforces.

The Information Note stated that there was some evidence of a dose-response relationship. 2 of the 24 studies, undertaken at latitudes similar to the UK, showed a doubling of risk of BCC. This requirement is a prerequisite for addition to the list of prescribed diseases. The first of these studies referred to ‘outdoor workers’, no further information was given on the type or duration of work[iii]. The second study referred to ‘frequent or sometimes’ occupational UV exposure[iv]. Again, there was no mention of the type or overall duration of the employment undertaken by test subjects.

The Council’s Note also reviewed academic literature on BCC, published after 2011. Few informative studies were found, and were limited by the methods used to assess occupational exposure. Nevertheless, a case-control study, from Southern Germany, reported an increased risk in NMSC with farming[v], and a case-control study, involving several European countries, identified an increased risk of NMSC in farming or construction work, of any duration, as well as an increased risk in participants who had worked outdoors for more than 5 years[vi].

The Council’s Note also referred to a 2011 review of SCC risk with occupational UV exposure[vii]. Similar to the findings for BCC, risk estimates varied considerably between studies, given differences in quality of exposure assessment and differences in latitude.

In a study of Finnish seafarers, the incidence of BCC and SCC was increased in those whose cancer was identified 20 or more years after first employment, and in those with 10 or more years on board a vessel[viii]. The risk was more than doubled in male deck officers, but not in male deck crew. Also, in a Swedish analysis of more than 320,000 male construction workers, no increased risk of NMSC was found[ix]. Elsewhere, in Alberta, Canada, research showed a ‘strong trend toward increasing risk’ of SCC with outdoor occupational exposure[x], and another study reported a more than doubled risk of SCC with outdoor work, but gave no further details about the work or exposure[xi]. Also, in a study of European workers, a more than doubled risk of SCC was found in farming and construction workers with five or more years of outdoor work experience[xii].

In the review on post-2011 literature, a large study from 4 Nordic countries identified an increased risk of SCC in 14 occupations, but the risk was only more than doubled in male physicians and female administrators, aged less than 50 at diagnosis[xiii]. There were some increased risk estimates in farmers and seamen, but there was no evidence of increased risk in construction workers, gardeners or forestry workers.

In summary, the Council concluded that the risk of BCC and SCC may be increased by outdoor work, such as farming, construction, or seafaring – in some cases, the risk is more than doubled. However, there is no consistent evidence of definitive causation. Evidence in support of elevated risk often focused on populations with more intense UV exposure than the UK, while studies from latitudes similar to the UK inferred that there was a less than doubling of risk. Studies also tended not to distinguish between occupational and recreational UV exposure. Consequently, the Council did not recommend that sunlight-induced SCC or BCC should be added to the IIDB list of diseases.

IOSH CAMPAIGN

In 2014, the Institution of Occupational Safety and Health (IOSH) launched its No Time To Lose (NTTL) campaign, with the objective of preventing occupational cancer.

This year, IOSH made available free resources on its website, include the following information cards and posters, which address risks of solar UV radiation:

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The NTTL materials provide information and advice on the following areas:

  • How to reduce exposure;
  • The UV Index;
  • Signs of melanoma;
  • Risk of melanoma for different skin types;
  • Risk of sunburn;
  • The effects of sunscreen use; and
  • Annual statistics on UK skin cancer diagnoses and deaths, caused by occupational sun exposure.

A video on the website also documents the suffering of a construction worker, who developed malignant melanoma and needed skin grafts to seal surgical wounds[xiv].

The IOSH campaign also features a case study on the Royal Mail, which employs around 143,000 people in outdoor-based roles. Shaun Davis, Group Director of Safety, Health, Wellbeing and Sustainability (SHWS), recently carried out detailed research into sun safety at Royal Mail, including how workforce attitudes towards solar radiation correspond to everyday behaviours.[xv] The function of this research was to highlight weaknesses in the Royal Mail’s overall wellbeing and sustainability strategy.

In severe weather (sun exposure and heatwaves), Royal Mail devolves responsibility to local managers to assess the risks facing their teams and take appropriate action, e.g. by suspending a collection or delivery.

Moreover, Royal Mail Group offers British Association of Dermatologists-approved protective clothing to its employees:

  • Wide-brimmed hats;
  • Long-sleeved tops; and
  • Long trousers.

Staff are encouraged to use these items of clothing in summer months. However, Royal Mail Group does not provide sunscreen, because research has shown that offering sunscreen can increase sun risk-taking activity, such as exclusive reliance on sunscreen, often irregularly and neglecting to cover up.

In a survey among Royal Mail workers, SHWS found that greater risk awareness resulted in greater engagement with ‘sun safe behaviours’. Further, workers with fairer skin tones were more knowledgeable and proactive in protecting themselves from solar radiation.

The survey also reinforced the Royal Mail’s decision to focus on protective clothing, rather than protective sunscreen, because 55% of those questioned mistakenly believed than SPF 30 sunscreen needed to be applied only once a day.

The Royal Mail began their sun safety strategy in April, when solar radiation levels were predicted to rise.

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Royal Mail is acting as a consultant advisor to other businesses which are in the process of developing sun strategies.

The IOSH website provides a list of companies who have pledged to support the campaign[xvi].

OTHER CAMPAIGNS

NHS England’s Cover up Mate Campaign

The Cover Up, Mate campaign was launched on 19 June, 2017, and was showcased at various farm shows across the South of England last summer. Pocket cards explain how to protect the skin from sun exposure when working outdoors and advise workers to wear suitable clothing and sunglasses, use at least SPF15 sunscreen and check skin for signs of skin cancer[xvii].

According to a survey, conducted by agricultural retailer, Mole Valley, and the NHS, 80% of rural occupants, in the South of England, think that outdoor workers are at greater risk of developing skin cancer, as a result of sun exposure[xviii]. Most of the people who completed the survey were agricultural workers. While more than half of the respondents said that protection from the sun is ‘very important’, more than a quarter admitted to ‘hardly ever’ using sunscreen.

Skcin Campaign

Skcin is a UK charity that was founded in memory of Karen Clifford, after she passed away from skin cancer, in 2005.[xix]

The charity has an accreditation scheme for workplaces. This is a national, annual scheme, developed to advise employers and educate outdoor workers on the importance of sun safety. Sun Safe Workplaces is a free online tool, available to all UK companies, which provides access to a range of free resources for implementing a sun safety policy.[xx]

European Academy of Dermatology and Venerology call to action

There have been calls for NMSC to be added to the European list of occupational diseases[xxi]. At an interactive exhibition on UV radiation-induced skin cancer, organised by the European Academy of Dermatology and Venerology (EADV), participants were informed that skin cancer costs member state governments €500 million each year.[xxii] Participants were also informed that European outdoor workers twice as likely as indoor workers to develop NMSC and unaware of this fact. EADV President, Professor Luca Borradori, stated:

Despite strong evidence that outdoor workers are exposed to high levels of UV radiation from the sun, develop a much higher incidence of non-melanoma skin cancer, this link has not yet translated into a common European or national standard on UV protection. Most EU member states have no legislation to protect outdoor workers from UV radiation’.

In a global call for action, EADV are asking for[xxiii]:

  • Improvements to the legislative framework to protect outdoor workers more effectively;
  • Official recognition of UV-induced NMSC as an occupational disease;
  • The development of tools to measure workplace exposure;
  • The creation of an evidence base on occupational NMSC;
  • Multi-stakeholder collaboration to promote sun-safe working practices; and
  • Education on simple and cheap techniques of sun-safe behavior and prevention of skin cancer.

Interestingly, solar radiation was omitted from the scope of the EU’s recent directive on the protection of workers from risks associated with occupational carcinogen exposure.

MERKEL CELL CARCINOMA: AN EMERGING ISSUE?

We reported, in issue 220 of BCDN (here) that the incidence of Merkel cell carcinoma (MCC), a rare form of skin cancer, is increasing in the USA. Merkel cell cancer develops in Merkel cells, which are in the top layer of the skin[xxiv]. It is a rare form of cancer, but MCC is highly aggressive and often fatal[xxv].

The researchers used data from the Surveillance, Epidemiology, and End Results Program (SEER-18) database, which contained 6,600 cases of MCC, to determine patterns of incidence of MCC between 2000 and 2013. They also made projections for future numbers of cases by combining this data with United States census data. From 2000 to 2013, the number of MCC cases increased by 95%. By comparison, the number of solid cancer cases increased 15% and the number of melanoma cases increased 57%. In 2013, the incidence rate of MCC was 0.7 cases per 100,000 people per year, corresponding to 2,488 cases per year in the USA.

The incidence of MCC in the USA increases dramatically with age, rising 10-fold (from 0.1 to 1.0 cases per 100,000 per year) between the age brackets of ‘40-44’ years and ‘60-64’ years. Incidence also rose to 9.8 cases per 100,000 per year in the ‘85 years and over’ age group. Due to the increasing numbers within elderly populations, total incidence rates are predicted to increase to 3,284 cases per year by 2025.

According to Dr Paul Nghiem, one of the senior researchers, ‘Compared to melanoma, MCC is much more likely to be fatal, so it’s important for people to be aware of it’[xxvi]. Like other skin cancers, MCC is associated with cumulative exposure to ultraviolet radiation from the sun. It is also associated with a virus, known as the Merkel cell polyomavirus, which is common. However, the vast majority of people exposed to the virus do not develop MCC. Those most likely to be affected by MCC are people with a prior history of skin cancer, men, Caucasians, and those aged over 50. Age is a particularly significant risk factor, and an ageing population is the main reason for the recent increases and predicted future increases in case numbers reported in this study.

MCC is most commonly found on sun-exposed areas of the body in older Caucasians, who may also have other sun-induced skin cancers[xxvii]. Mayo Clinic lists exposure to ultraviolet light as a risk factor and lists sun protection actions as preventative methods[xxviii]. Cancer Research UK provides the following information about MCC[xxix]:

  • It is rare.
  • Risk factors are UV light from sunlight, artificial UV light e.g. in treatment of psoriasis, immune conditions.
  • MCC usually appears as a 1-5 cm bluish-red lump on the skin, in an area that gets a lot of sun.
  • It can easily spread to lymph nodes and to other parts of the body.
  • Treatment is surgery to remove the affected area, carried out at a specialist skin cancer centre, often followed by radiotherapy to kill any remaining cancer cells.
  • Chemotherapy can be used to treat cancers that have spread.

Like other cancers, MCC is staged when it is diagnosed. The stages relate to the size of the tumour and, if it has spread, by how much?[xxx] Many cases are diagnosed at the later stages when the cancer has already spread. This means that 5-year survival rates are poor.

Merkel Cell Carcinoma Cases in the UK

In England, there were 1,515 merkel cell carcinoma (MCC) cases entered to the National Cancer Data Repository, between 1999 and 2008. There are many other types of rare skin cancer, of which a few hundred or fewer cases are reported each year. Thus, MCC is the most prevalent of the rare skin cancer types. When all rare skin cancers were grouped together, there was an increase in the annual number of cases from 1999 to 2008[xxxi].

A paper by Goon and colleagues, published in 2016, reported that MCC incidence is on the rise in the East of England[xxxii]. The paper reports that there is controversy over actual incidence rates, which vary considerably between developed countries with fair-skinned populations.

In their study, the researchers recorded data on all cases of MCC, diagnosed by cell testing, between January 2004 and December 2013. This information was made available on the databases of the Eastern Office, National Cancer Registration Service, Public Health England, and the Pathology department of the Norfolk and Norwich University Hospital.

MCC incidence rates were 0.7 and 1.08 cases per 100,000 people per year respectively, and the total number of cases in the region over this time period was 73. Incidence rates increased 3-fold during the study period. It is estimated that there will be 17 cases in the region in 2020 and 22 in 2025. Estimated cases UK-wide are 920 in the year 2020, and 1,134 in the year 2025 (compare these estimates with the above study which found 1,515 cases over the 10 year period between 1999 to 2008, in England only). The rates reported in this study are 12 times greater than previous UK estimates.

It is worth noting that even though MCC is not a form of melanoma, the commonly used term, ‘non-melanoma skin cancer’, usually refers to basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) and excludes MCC.

RECENT OCCUPATIONAL SKIN CANCER STUDIES, REVIEWS AND ARTICLES

Burden of Occupational Melanoma in Britain Due to Solar Radiation

A paper, published in 2017 by Lesley Rushton and Sally Hutchings, reported on occupational exposure to UV and malignant melanoma of the skin in Britain[xxxiii].

Using risk estimates from published papers and national data sources to determine the numbers of workers exposed, they estimated that the proportion of melanoma attributable to occupational UV exposure is 2.0%, which corresponds to 48 deaths in 2012 and 241 registrations in 2011.

Of these risks, the largest burden is in the construction industry, which is responsible for 44% of these deaths and 42% of the registrations.

The statistical analysis took into account the age distribution of exposed workers.

There were higher numbers of attributable cases in males than females, because there were more exposed males, and exposed males tend to have higher exposures. The industries of main concern are construction (21 deaths, 101 registrations), agriculture (11 deaths, 55 registrations), public administration and defence (5 deaths, 26 registrations) and land transport (4 deaths, 21 registrations).

The burden may have been over or under-estimated, due to assumptions made during the analysis and uncertainties in the data. Uncertainties were caused by errors in the risk estimates used (due to limitations of studies from which risk estimates were taken), inaccurate estimations of numbers of people exposed, and inaccuracy in the estimation of the latency period. The researchers also note that there was no good quality study of workplace exposure to solar radiation in Britain. The study they used may not have comprehensively reflected exposure in Britain, and its use of death certificate information for residence and occupation might reflect recent exposure but not lifetime exposure.

The article reports that evidence of a causal role of occupational sunlight exposure in the development of cutaneous malignant melanoma is equivocal.

For example, studies have found that having more moles is associated with melanoma on body sites not usually exposed to the sun. What is more, skin type, hair colour type and sunburn are associated with melanomas at all sites. Intermittent, relatively high exposure has also been associated with melanoma. Some studies have found an increased risk of melanoma in outdoor work or farming, but other studies have found reduced risks in these groups. It has been suggested that recreational sun exposure increases the risk of melanoma on the trunk and limbs, whereas occupational sun exposure tends to increase the risk of head and neck melanoma, especially at low latitudes.

An Australian study found no increased risk of melanoma with occupational sun exposure, either overall, or at particular body sites. There was a reduced risk of head and neck melanoma with increased exposure.

In a large European study, which compared indoor and outdoor workers, higher risks of BCC and SCC was identified in farmers, construction workers and other outdoor workers, but increased risk of melanoma was non-significant.

The 2017 study authors opine that, although the evidence for a link between occupational UV exposure is not entirely convincing, it is suggestive of a potential causal relationship, and it is possible that occupational exposure contributes to the burden of melanoma.

The findings from this study are included in the IOSH No Time To Lose campaign materials[xxxiv].

Commentary Article on Occupational Skin Cancer Prevention

The skin is the most common cancer site in Caucasian populations, and also the site at which cancer is most easily preventable through education, exposure reduction, early detection and treatment. Despite this, occupational skin cancer cases go unnoticed, un(der)reported, unscreened, uncared for at early stages and uncompensated.

A commentary article, published in the Journal of Occupational Medicine in July 2017, discusses the need for occupational skin cancer prevention[xxxv]. The article reflects on the history of occupational skin cancer, specifically how occupational cancer among young chimney sweeps was eradicated by enforced legislation on hygiene and working conditions. The authors express concern over the ‘lack of specific legislation for preventing exposure to a group 1 carcinogen amongst outdoor workers’ and note that risk reduction starts with ‘proper legislation’. Further, the authors opine that a lack of specific legislation to protect outdoor workers is the result of difficulties in measuring lifetime UV exposure, in differentiating occupational from recreational exposure, and also in under-reporting occupational skin cancer.

In addition, the authors report that ‘the real burden is significantly higher than revealed by official statistics in many countries, which may explain the higher rate of patients treated for skin cancer in the claims data than the cases recorded by the registries’, and that 90% of the medical costs related to skin cancer are spent on treatment, while less than 10% are invested in prevention.

In 2016, dermatologists from 11 European countries completed a survey on occupational skin cancer. 7 countries recognised SCC in outdoor workers as occupational skin cancer, 6 recognised BCC, 5 recognised actinic keratoses, and 5 recognised malignant melanoma[xxxvi].

Non-Melanoma Skin Cancer in Different Occupations

A new study has found that workers in different industries have different risks of NMSC[xxxvii]. This study was discussed in issue 233 of BCDN (here).

348 farmers, gardeners and mountain guides and 215 office workers participated in the study; office workers formed the control group. The participants completed a questionnaire, in which they provided information about their UV exposure and how they protected themselves against UV. Participants underwent a skin examination, conducted by a dermatologist.

NMSC, or actinic keratosis (damage to the skin caused by the sun), was diagnosed in 33.3% of mountain guides, 27.4% of farmers, 19.5% of gardeners and 5.6% of office workers. The NMSC risk associated with different outdoor occupations was statistically significant; mountain guides had a 2.6-fold risk, compared to farmers. There were also differences in protective behavior between the groups; 61.4% of indoor workers attended skin cancer screening, compared with 57.8% of mountain guides, 31.9% of farmers and 27.6% of gardeners. In addition, daily UV exposure dose varied between the groups.

The authors of the study concluded that different outdoor professions have significantly different risks of NMSC and exhibit different protective behaviours. Efforts to prevent NMSC could be tailored to different occupational groups, based on their particular needs. Lead author, Dr. Alexander Zink, of the Technical University of Munich, said:                                                                                              

‘Altitude and number of hours working outside seem to make the difference’.[xxxviii]

Italian Study on Cases of Occupational Skin Cancer Recognition

This study compared predicted numbers of skin cancers in outdoor workers with the number of recognized occupational skin cancers in the Italian National Compensation Authority[xxxix]. The researchers used data on annual incidence of melanoma to predict incidence in agriculture, fishery and construction workers and compared these figures with reported skin cancer prevalence in those industries. The numbers of cases recognized as occupational skin cancer were around 2% of the estimated numbers of cases in these workers. The researchers concluded that there is large under-estimation of occupational skin cancer in Italy, but the credibility of the study was hindered by limitations.

IARC Global Burden of Melanoma

The International Agency for Research on Cancer (IARC) has published a study into the global burden of melanoma of the skin, attributable to UV radiation, in 2012[xl]. The information is also presented on a website, on which users may generate their own representations of modifiable data on melanoma attributable to UV[xli]. This was discussed in issue 230 of BCDN (here).

In the IARC study, the researchers quantified the number of melanomas of the skin that are attributable to UV radiation. Figures were calculated (separated by age and gender) for 153 countries. Current numbers of melanoma cases were compared with cases in a population with minimal exposure to UV and were also compared with cases among dark-skinned African populations, with low susceptibility to effects from UV.

Worldwide, there were at least 168,000 cases of melanoma attributable to UV radiation in 2012. This corresponds to 75.7% of all new melanoma cases and 1.2% of all new cancer cases. Melanoma cases were concentrated in highly developed countries and was most pronounced in Oceana, where 96% of all melanomas were attributed to UV radiation. If incidence rates in every population were equivalent to those in low-risk (dark skinned, skin with lots of pigment) populations, there would be approximately 151,000 fewer melanoma cases each year.

The IARC concluded that the study findings underline a need for public health action, an increasing risk of melanoma and its risk factors, and the need to promote changes in behaviour to reduce sun exposure to people of all ages.

Costs of NMSC In Canada

A new study estimated the total costs and the costs per case of newly diagnosed non-melanoma skin cancer (NMSC), attributable to workplace sun exposure, in Canada, in 2011[xlii]. This was discussed in issue 230 of BCDN (here). An estimated 2,846 (5.3%) cases of basal cell carcinoma (BCC) and 1,710 (9.2%) cases of squamous cell carcinoma (SCC) were attributable to occupational solar radiation.

Canada sits at a similar latitude to the UK, which means that outdoor workers in both countries have similar amounts of sun exposure: Fort McMurray and Dundee are both 56° F, Calgary and Winchester are both at 51° F, and Plymouth and Winnipeg are both close to 50° F. Some major Canadian cities are slightly further South, with Ottawa at 45° F and Toronto at 43° F.

Roughly 1 in 10 workers in Canada are exposed to solar radiation at work, and the majority of these spend 6 hours or more outdoors each day.[xliii]

The researchers investigated direct costs and indirect costs of NMSC. Direct costs included healthcare costs, out-of-pocket costs (travel to healthcare appointments, medicines, vitamins and supplements, and hotel costs) and informal caregiver costs. Indirect costs included loss of income and home production costs (the cost of domestic tasks that the patient would not be able to do). The researchers also considered intangible costs, which was the monetary value of the loss of health-related quality of life.

The combined total for direct and indirect costs of occupational NMSC cases was $28.9 million, of which $15.9 million was for BCC and $13.0 million was for SCC. The total for intangible costs was $5.7 million, of which $0.6 million was for BCC and $5.1 million was for SCC.

When the costs were broken down into the costs per case, the average cost of a BCC case was $5,670 and the average cost of a SCC case was $10,555. The costs are higher for SCC because SCC has a lower survival rate, which results in higher indirect and intangible costs.

The study’s main investigator, Dr. Emile Tompa, said:

‘The findings suggest that policy-makers might give greater priority to reducing sun exposure at work by allocating occupational cancer prevention resources accordingly’.[xliv]

Study of Occupational Melanoma Risk In Nordic Countries

A very large study, in which participants across 5 Nordic countries were followed for 45 years, found that those with the highest socioeconomic status and male indoors workers had the highest relative risk of cutaneous melanoma[xlv]. Standardised incidence ratios were estimated for 53 occupational categories (indoor, outdoor and mixed work) and also took into account socioeconomic status. The study collected data for 385 million person-years (total participants multiplied by years of follow up) and 83,898 new cases of melanoma developed. Statistically significant standardized incidence ratios for cutaneous melanoma were found among occupational categories with indoor work for males, and the highest socioeconomic status for men and women. The lowest SIRs were found in occupational categories with outdoor work for both men and women, and the lowest socioeconomic status categories for both sexes.

Study Of Melanoma In The US Military

A study of melanoma in the US military, lasting 15 years, reported 2,233 new cases of melanoma diagnoses[xlvi].

The highest incidence rates were in the fixed wing pilot/crew group, and the lowest incidence rates were in the infantry, special operations, combat engineer groups.

During the 15 years of follow-up, rates of melanoma diagnosis increased exponentially with relation to years of active service. After several years of service, rates of melanoma diagnoses increased relatively rapidly among pilots and crews of fixed-wing aircraft, and those in occupations inherently conducted outdoors.

By contrast, melanoma rates increased relatively slowly among healthcare providers and those in ‘other’ military operations. In each occupational group and overall, rates of melanoma diagnoses were very low during the first few years of service. However, after 12 years of service, diagnoses rates in those with combat-related occupations with repeated exposure of long duration to UV radiation began to increase rapidly.

In addition to solar UV radiation, cosmic ionizing radiation may have contributed to these findings, as those on board aircraft are exposed to small amounts.

Criticism of Recent Reports on Sunbeds

In recent years, both the World Health Organisation (WHO)[xlvii] and European Commission’s Scientific Committee on Health, Environmental and Emerging Risks (SCHEER)[xlviii], have published reports on the link between sunbed use and melanoma. Both reports concluded that a large proportion of melanoma and non-melanoma skin cancer is attributable to sunbed use, and that there is no safe exposure limit for UV radiation from sunbeds. However, a paper, published early in 2018, offers the view that:

‘… these assessments appear to be based on an incomplete, unbalanced and non-critical evaluation of the literature’.

The paper goes on to argue that current scientific knowledge does not support the conclusion that sunbed use increases melanoma risk[xlix].

Australian Annual Report

The 2017 Skin Health Report Card (SHARC) reported that 28% of Australian employees (2 million people) who work outdoors, are provided with sun protection by their employers[l]. By contrast, 43% of outdoor workers reported that their employers supply them with sunscreen, 34% supply protective clothing and 20% provide sunglasses. Some commentators have suggested that businesses have now accepted that occupational skin cancer claims are inevitable[li].

CLAIMANT LAW FIRM MARKETING

Towards the end of 2017, it was noticeable that numerous claimant law firms added or updated content on their websites, in respect of occupational skin cancer. For example,

  • SB Claims: encourages claimants to seek compensation for loss of earning, medical expenses, pain and suffering and financial provision for dependents if the illness is terminal[lii];
  • Simpson Millar: provides information about occupational skin cancer, how workers can protect themselves, and indicates that skin cancer claims are possible[liii];
  • SAH Solicitors: reports on the NHS and IOSH campaigns to tackle occupational skin cancer[liv].

 

[i] Non-melanoma skin cancer and occupational exposure to (natural) UV radiation: IIAC information note. Industrial Injuries Advisory Council. 25 April 2018. https://www.gov.uk/government/publications/non-melanoma-skin-cancer-and-occupational-exposure-to-natural-uv-radiation-iiac-information-note/non-melanoma-skin-cancer-and-occupational-exposure-to-natural-uv-radiation-iiac-information-note (Accessed 30 April 2018)

[ii] Bauer A, Diepgen TL, Schmitt J. Is occupational solar ultraviolet irradiation a relevant risk factor for basal cell carcinoma? A systematic review and meta-analysis of the epidemiological literature. Br J Dermatol. 2011;165(3):612-25 https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2133.2011.10425.x (Accessed 2 May 2018)

[iii] Radespiel-Troger M, Meyer M, Pfahlberg A, Lausen B, Uter W, Gefeller O. Outdoor work and skin cancer incidence: a registry-based study in Bavaria. International archives of occupational and environmental health. 2009;82(3):357-63. https://www.ncbi.nlm.nih.gov/pubmed/18649084 (Accessed 2 May 2018)

[iv] Walther U, Kron M, Sander S, Sebastian G, Sander R, Peter RU, et al. Risk and protective factors for sporadic basal cell carcinoma: results of a two-centre case-control study in southern Germany. Clinical actinic elastosis may be a protective factor. Br J Dermatol. 2004;151(1):170-8 https://www.ncbi.nlm.nih.gov/pubmed/15270887 (Accessed 2 May 2018)

[v] Kaskel P, Lange U, Sander S, Huber MA, Utikal J, Leiter U, et al. Ultraviolet exposure and risk of melanoma and basal cell carcinoma in Ulm and Dresden, Germany. J Eur Acad Dermatol Venereol. 2015;29(1):134-42 https://onlinelibrary.wiley.com/doi/full/10.1111/jdv.12488 (Accessed 2 May 2018)

[vi] Trakatelli M, Barkitzi K, Apap C, Majewski S, De Vries E. Skin cancer risk in outdoor workers: a European multicenter case-control study. J Eur Acad Dermatol Venereol. 2016;30 Suppl 3:5-11 https://onlinelibrary.wiley.com/doi/abs/10.1111/jdv.13603 (Accessed 2 May 2018)

[vii] Schmitt J, Seidler A, Diepgen TL, Bauer A. Occupational ultraviolet light exposure increases the risk for the development of cutaneous squamous cell carcinoma: a systematic review and meta-analysis. Br J Dermatol. 2011;164(2):291-307. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2133.2010.10118.x (Accessed 2 May 2018)

[viii] Pukkala E, Saarni H. Cancer incidence among Finnish seafarers, 1967-92. Cancer Causes Control. 1996;7(2):231-9 https://link.springer.com/article/10.1007/BF00051299 (Accessed 2 May 2018)

[ix] Hakansson N, Floderus B, Gustavsson P, Feychting M, Hallin N. Occupational sunlight exposure and cancer incidence among Swedish construction workers. Epidemiology (Cambridge, Mass). 2001;12(5):552-7. https://journals.lww.com/epidem/Fulltext/2001/09000/Occupational_Sunlight_Exposure_and_Cancer.15.aspx (Accessed 2 May 2018)

[x] Gallagher RP, Hill GB, Bajdik CD, Coldman AJ, Fincham S, McLean DI, et al. Sunlight exposure, pigmentation factors, and risk of nonmelanocytic skin cancer. II. Squamous cell carcinoma. Arch Dermatol. 1995;131(2):164-9 https://jamanetwork.com/journals/jamadermatology/article-abstract/556368 (Accessed 2 May 2018)

[xi] Radespiel-Troger M, Meyer M, Pfahlberg A, Lausen B, Uter W, Gefeller O. Outdoor work and skin cancer incidence: a registry-based study in Bavaria. International archives of occupational and environmental health. 2009;82(3):357-63. https://link.springer.com/article/10.1007/s00420-008-0342-0 (Accessed 2 May 2018)

[xii] Ibid Trakatelli

[xiii] Alfonso JH, Martinsen JI, Pukkala E, Weiderpass E, Tryggvadottir L, Nordby KC, et al. Occupation and relative risk of cutaneous squamous cell carcinoma (cSCC): A 45-year follow-up study in 4 Nordic countries. J Am Acad Dermatol. 2016;75(3):548-55 https://www.jaad.org/article/S0190-9622(16)30018-4/fulltext (Accessed 2 May 2018)

[xiv] My Story: David. YouTube IOSH channel, May 2018 https://www.youtube.com/watch?v=Ye-edeABeFI (Accessed 12 June 2018)

[xv] Royal Mail – Delivering a new sun safety strategy. IOSH NTTL. https://www.notimetolose.org.uk/about-the-campaign/good-practice-case-studies/royal-mail-delivering-new-sun-safety-strategy/ (Accessed 12 June 2018)

[xvi] Supporters. IOSH NTTL https://www.iosh.co.uk/NTTL/Home/Get-involved/Supporters-A-to-I.aspx (Accessed 13 June 2018)

[xvii] Farmers risk of skin cancer highlighted in Farm Safety Week. IOSH, 27 July 2017 https://www.iosh.co.uk/News/Farmers-risk-of-skin-cancer-highlighted-in-Farm-Safety-Week.aspx (Accessed 30 May 2018)

[xviii] People involved in country life say outdoor workers at greater risk of skin cancer. IOSH, 18 August 2017 https://www.iosh.co.uk/News/Outdoor-workers-are-at-greater-risk-of-skin-cancer.aspx (Accessed 30 May 2018)

[xix] Skcin. http://www.skcin.org/aboutSkcin/ (Accessed 12 June 2018)

[xx] Skcin Sun Safe Workplaces. https://www.sunsafeworkplaces.co.uk/ (Accessed 12 June 2018)

[xxi] Occupational Skin Cancer: Outdoor Workers’ number one enemy. The Parliament Magazine, 26 June 2017. https://www.theparliamentmagazine.eu/articles/news/occupational-skin-cancer-outdoor-workers%E2%80%99-number-one-enemy (Accessed 8 June 2018)

[xxii] EADV Event at the European Parliament. EADV, 20 May 2017. https://www.eadv.org/article/167 (Accessed 8 June 2018)

[xxiii] Protect Outdoor Workers from Solar UV Radiation: Global Call to Action. EADV. https://eadv.org/cms-admin/showfile/EADV%20Call%20to%20Action_Skin%20Cancer_04-12-2018-10-07-53.pdf (Accessed10 June 2018)

[xxiv] Merkel cell skin cancer. Cancer Research UK. http://www.cancerresearchuk.org/about-cancer/neuroendocrine-tumours-nets/merkel-cell-skin-cancer (Accessed 22 February 2018)

[xxv] American Academy of Dermatology. "Increasing incidence of rare skin cancer." ScienceDaily. ScienceDaily, 16 February 2018. www.sciencedaily.com/releases/2018/02/180216174658.htm. (Accessed 22 February 2018)

[xxvi] Ibid

[xxvii] Causes of merkel cell carcinoma. Merkelcell.org   https://www.merkelcell.org/about-mcc/causes-of-merkel-cell-carcinoma/ (Accessed 13 June 2018)

[xxviii] Merkel cell carcinoma. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/merkel-cell-carcinoma/symptoms-causes/syc-20351030 (Accessed 13 June 2018)

[xxix] Merkel cell skin cancer. Cancer Research UK. http://www.cancerresearchuk.org/about-cancer/neuroendocrine-tumours-nets/merkel-cell-skin-cancer (Accessed 13 June 2018)

[xxx] Merkel cell carcinoma treatment. National Cancer Institute. https://www.cancer.gov/types/skin/patient/merkel-cell-treatment-pdq (Accessed 13 June 2018)

[xxxi] Rare Skin Cancer in England. National Cancer Intelligence Network. http://www.ncin.org.uk/publications/data_briefings/rareskincancer (Accessed 13 June 2018)

[xxxii] Goon, P. K. C., Greenberg, D. C., Igali, L. & Levell, N. J. Merkel Cell Carcinoma: rising incidence in the East of England. J Eur Acad Dermatol Venereol 30, 2052–2055 (2016). https://www.ncbi.nlm.nih.gov/pubmed/27515234 (Accessed 13 June 2018)

[xxxiii] Rushton, L. & Hutchings, S. J. The burden of occupationally-related cutaneous malignant melanoma in Britain due to solar radiation. British Journal of Cancer 116, 536–539 (2017). https://www.nature.com/articles/bjc2016437 (Accessed 7 June 2018)

[xxxiv] Occupational cancer: malignant melanoma. IOSH, 2015 https://www.notimetolose.org.uk/wp-content/uploads/2018/04/POL2756-malignant-melanoma-130415-WEB.pdf (Accessed 12 June 2018)

[xxxv] Alfonso, J. H., Sandvik, A. & John, S. M. Occupational skin cancer: sweeping the path to prevention. Occup Med (Lond) 67, 328–330 (2017). https://academic.oup.com/occmed/article/67/5/328/3975234 (Accessed 5 June 2018)

[xxxvi] Ulrich, C. et al. The European Status Quo in legal recognition and patient-care services of occupational skin cancer. Journal of the European Academy of Dermatology and Venereology 30, 46–51. https://onlinelibrary.wiley.com/doi/full/10.1111/jdv.13609 (Accessed 5 June 2018)

[xxxvii]  Zink, A. et al. Different outdoor professions have different risks – a cross-sectional study comparing non-melanoma skin cancer risk among farmers, gardeners and mountain guides. Journal of the European Academy of Dermatology and Venereology 0, https://onlinelibrary.wiley.com/doi/abs/10.1111/jdv.15052 (Accessed 7 June 2018)

[xxxviii] Different outdoor professions carry different risks for skin cancer. ScienceDaily, 6 June 2018. https://www.sciencedaily.com/releases/2018/06/180606082306.htm (Accessed 7 June 2018)

[xxxix] Modenese, A., Korpinen, L. & Gobba, F. 931 Occupational skin cancer in outdoor workers in italy: expected number vs cases recognised by the italian national compensation authority (inail). Occup Environ Med 75, A430–A430 (2018). http://oem.bmj.com/content/75/Suppl_2/A430.1 (Accessed 11 June 2018)

[xl] Arnold, M. et al. Global burden of cutaneous melanoma attributable to ultraviolet radiation in 2012. International Journal of Cancer 0, https://onlinelibrary.wiley.com/doi/abs/10.1002/ijc.31527 (Accessed 17 May 2018)

[xli] https://gco.iarc.fr/causes/uv/home (Accessed 17 May 2018)

[xlii]  Mofidi, A. et al. The economic burden of occupational non-melanoma skin cancer due to solar radiation. Journal of Occupational and Environmental Hygiene 0, 1–11 (2018). https://www.tandfonline.com/doi/full/10.1080/15459624.2018.1447118 (Accessed 16 May 2018)

[xliii] Hidden costs of skin cancer caused by workplace sun exposure revealed. ScienceDaily. 26 April 2018. https://www.sciencedaily.com/releases/2018/04/180426085524.htm (Accessed 16 May 2018)

[xliv] Ibid

[xlv] Alfonso, J. H. et al. 844 Occupation and relative risk of cutaneous melanoma: a 45-year follow-up study of 15 million people in five nordic countries. Occup Environ Med 75, A393–A393 (2018). http://oem.bmj.com/content/75/Suppl_2/A393.1 (Accessed 7 June 2018)

[xlvi] Brundage, J. F., Williams, V. F., Stahlman, S. & McNellis, M. G. Incidence rates of malignant melanoma in relation to years of military service, overall and in selected military occupational groups, active component, U.S. Armed Forces, 2001-2015. MSMR 24, 8–14 (2017). https://www.researchgate.net/profile/John_Brundage2/publication/314206345_Incidence_rates_of_malignant_melanoma_in_relation_to_years_of_military_service_overall_and_in_selected_military_occupational_groups_active_component_US_Armed_Forces_2001-2015/links/58b9a0d345851591c5db70c0/Incidence-rates-of-malignant-melanoma-in-relation-to-years-of-military-service-overall-and-in-selected-military-occupational-groups-active-component-US-Armed-Forces-2001-2015.pdf  (Accessed 7 June 2018)

[xlvii] Artificial tanning devices Public health interventions to manage sunbeds. WHO, 2017 http://apps.who.int/iris/bitstream/handle/10665/255695/9789241512596-eng.pdf;jsessionid=898E58507DD7B8CEBDAC2B951169CC68?sequence=1 (Accessed 10 June 2018)

[xlviii] Opinion on Biological effects of ultraviolet radiation relevant to health with particular reference to sunbeds for cosmetic purposes. SCHEER, 2016 https://ec.europa.eu/health/sites/health/files/scientific_committees/scheer/docs/scheer_o_003.pdf (Accessed 10 June 2018)

[xlix] Reichrath, J. et al. A Critical Appraisal of the Recent Reports on Sunbeds from the European Commission’s Scientific Committee on Health, Environmental and Emerging Risks and from the World Health Organization. Anticancer Res 38, 1111–1120 (2018). http://ar.iiarjournals.org/content/38/2/1111.full (Accessed 8 June 2018)

[l] Skin Health Australia Report Card 2017. Skin & Cancer Foundation, 2017. https://skincancer.blob.core.windows.net/assets/uploads/files/SHARC%20REPORT/2017.SHARC/2017.SHARC.Report_s2.pdf (Accessed 6 June 2018)

[li] Provide workers sun protection or risk litigation. Prochoice, data unknown. http://blog.prochoice.com.au/sunscreen/provide-workers-sun-protection-risk-litigation/ (Accessed 6 June 2018)

[lii] Can I claim compensation for occupational skin cancer? SB claims, 3 October 2017 http://www.sbclaims.co.uk/legal-articles/occupational-skin-cancer (Accessed 5 June 2018)

[liii] Occupational Skin Cancer: The Facts. Simpson Millar, 5 December 2017 https://www.simpsonmillar.co.uk/news/occupational-skin-cancer-the-facts-4337 (Accessed 5 June 2018)

[liv] NHS Campaign to Tackle Occupational Skin Cancer. SAH Solicitors Blog, 26 June 2017 https://www.simonaholt.co.uk/News/Tackle-occupational-skin-cancer.html (Accessed 5 June 2018)