Skin cancer in Australia

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Skin cancer prevalence by country in 2008. Australia and New Zealand have the highest rates of skin cancer, shown in red. Worldwide Melanoma of Skin Cancer Incidence - 2008 Globocan.svg
Skin cancer prevalence by country in 2008. Australia and New Zealand have the highest rates of skin cancer, shown in red.
Currumbin Beach, Queensland, Australia Currumbin Beach, Queensland, Australia.jpg
Currumbin Beach, Queensland, Australia

Skin cancer in Australia kills over 2,000 each year, with more than 750,000 diagnosed and treated. [1] Tanning became embedded in Australian culture and proved to be a controversial issue because of its popularity among teens and solarium users, [2] despite correlations between tanning and an increased risk of developing melanoma.[ citation needed ] Australia experienced relative success through skin cancer prevention campaigns started in the 1980s and continued to invest and promote awareness through government-funded mass media strategies. [3] Although Australia has one of the highest national rates of skin cancer, mortality trends in melanoma stabilized. [4]

Contents

Tanning

sun bed tanning Tanning bed in use.jpg
sun bed tanning

Australians culturally identify with the "bronzed Aussie" stereotype,[ citation needed ], viewing it as a positive body image associated with recreational sport and exercise-orientated lifestyles. With over 90% of melanomas derived through contact with the sun, [4] skin cancer preventive initiatives in Australia strived to change this perception.

Solariums and tanning salons are widely used and available throughout Australia[ citation needed ]. Tanning has been a phenomenon since the 1800s, with medical use of phototherapy, emerging popularity of sunbathing, and in the 1970s, with tanning salons and solariums becoming increasingly popular, had developed into a worldwide tanning industry. [5] Although the tanning industry in Australia is relatively small by international standards, it has quadrupled in size since 1992. [6] The tanning industry promotes tanning as a process to stimulate higher levels of vitamin D, associating it with reduced likelihood of sunburn and skin cancer, with increased well being and feelings of happiness. [5]

Solarium regulation

The solarium industry is regulated on a state by state basis. The first states to regulate solarium use (2008) were Victoria, South Australia and Western Australia following the death of skin cancer victim Clare Oliver. [7] [8] [9] [10] The 2008 regulations required solaria to obtain a license, display health warnings. In Victoria, those under 16 and people with fair skin were banned from solaria and 16-17 year olds were required to have parental consent whereas in South Australia and Western Australia, under 18s were banned. [7]

In February 2009, the Victorian Government introduced license changes, including banning under 18s, consistent with the revised Australian standard, released in January 2009. Victorian solarium legalisation was revised in late 2010, strengthening controls around citing evidence of age documents for under 18s. [11] [12] [13] [14]

The Australian standard requires that operators must: [12]

New South Wales, Queensland, ACT and Tasmania introduced legislation applying these standards in 2009 and 2010. [15] [16] [17] [18] In 2011, the New South Wales government called for public submissions in relation to a proposal to extend the age ban to those under 30. In February 2012 the New South Wales Government announced its intention to ban tanning beds, starting in 2014. [19] In October 2013, the Victorian parliament passed an official ban on solaria to take effect by 2015. [20] As of 2018, there was illegal solarium use in Australia, often advertised on Gumtree. [21]

Ultraviolet radiation and skin cancer

Melanoma, basal cell carcinomas and squamous cell carcinomas are predominantly caused by exposure to ultra violet radiation (UVR), and both UVA and UVB radiation has internationally been categorised as carcinogenic. [6] Artificial UVR primarily used in tanning salons and sunbeds, has generated concern among health officials and it was observed to considerably heighten the risk of developing cutaneous malignant melanoma. [6] A study in 2010 found strong evidence supporting association between indoor tanning salon use and increased risk of developing melanoma. [2] The study demonstrated strong correlations between increased risk of melanomas and carcinogenic ultraviolet radiation related outcomes. [2] These increased risks were specifically associated with younger participants, [2] with tanning and solarium use relatively popular among teens and young adults. An increase of 59% in risk of developing melanoma was associated with people who used sun beds before they were 35. [22]

Awareness

Australia and New Zealand have the world's highest skin cancer rates. [23] Factors include the large percentage of the population with fair skin prone to skin cancers and the high levels of ambient UV radiation. [3] Similarly the Anglo-Celtic ancestry of many New Zealanders together with their outdoor lifestyle, is presumed to be a dominant factor in the risk, due to the effect of high UV levels on fair skin. [24] The UV Index (UVI), defined as the sun-burning strength of ultraviolet rays (UVR), in Canada ranges between 1 and 10. [25] The National Institute of Water and Atmospheric (NIWA) research recorded that New Zealand (similar latitude to Australia) the UVI exposure often exceeds 13 and is 40% more than that recorded at comparable latitudes in North America. [25] In order to maintain effective prevention and national awareness Australia used a variety of campaigns and initiatives beginning in the early 1980s. [3] The Slip, Slop, Slap campaign was initiated in 1981 introduced a seagull singing a catchy jingle “Slip on a shirt! Slop on some sunscreen! and Slap on a hat!”, promoted awareness and entered Australian culture. [3] It was so successful that it remained part of the SunSmart slogan, which was updated to read, Slip, Slop, Slap, Slide (on sun glasses), Seek (shaded areas). [26] SunSmart began in 1987, led by an Australian foundation focused on promoting skin cancer awareness. Social education, challenging societal and cultural ideals, is one of SunSmart's methods for promoting awareness and through its many successes now functions throughout all of Australia, under state Cancer Councils. [3]

The first government-funded mass media skin cancer initiative began in Australia during 2006. [3] Its skin cancer awareness message was delivered through radio, television and printed mediums. [3]

Media promotion and education remains a vital and effective tool in Australian skin cancer awareness strategy. Despite its effectiveness[ citation needed ] members of the public remain indifferent or unaware of the risks caused by inefficient sun protection and skin care. [27]

Mortality

Metastatic melanoma cells Metastatic Melanoma Cells Nci-vol-9872-300.jpg
Metastatic melanoma cells

Skin cancer has three main forms: basal cell carcinoma, squamous cell carcinoma and melanoma. The first two are the most prevalent forms. [23] Although generally non-melanoma carcinomas have lower associations with mortality than melanomas, fatalities occur, with 534 reported deaths in 2011. [28] 434,000 Australians in 2008 underwent treatment for non-melanoma carcinomas. [28] Melanomas have the highest correlation with mortality, killing 1,544 in 2011. [28] Australia shares with New Zealand, the highest diagnosis of melanoma throughout the world and also has the highest diagnosis of non-melanoma carcinomas. [23] In 2011, New Zealand surpassed the Australian rate for invasive melanoma cases [24] and now has the highest melanoma incidence in the world. [29]

Australia has recorded increased mortality rates of melanoma from the 1950s, continuing to rise until the late 1980s and beginning to steady from 1990 onwards. [4] Australia has some of the world's highest melanoma-related fatalities—double the mortality rates of south and central Europe. [4] The introduction of preventive campaigns correlate with the transition to decreases in melanoma mortality. Sun protection, other forms of primary protection, early detection and increased public awareness have had the greatest impact. [4]

Prevention

Awareness and early detection are the most efficient tools for avoiding skin cancer and are the basis of many effective prevention campaigns in Australia. Prevention initiatives such as SunSmart promote awareness by advocating effective sun protective methods, sun risk awareness and are an integral part of skin cancer prevention. SunSmart recommends wearing protective clothing, [30] hats, [31] sunscreen, [26] seeking shade [32] from the sun and wearing UV protective eyeware. [33] SunSmart also provides recommendations on how to choose the right protective products. [30] Regular skin checks are another important preventive step.

UV and Vis Sunscreen.jpg

The standard for skin cancer screening in Australia is self-assessment and occasional clinic screening. [34] Consistent with Australian guidelines for public skin cancer screening, Cancer Council Australia does not recommend annual or regular skin assessment because low national melanoma occurrences do not financially justify national public screening. A 2003 study analysing the effectiveness of skin cancer screening was implemented in northern Germany. Study doctors received 8 hours of training and over a year screened 19% of Schleswig-Holstein’s population. [34] Initially melanoma detection increased 34%. After 5 years the population experienced over 50% decrease in melanoma mortality. [34]

Economic implications of prevention campaigns

Australia spends more than $2 billion annually treating cancer, [35] with skin cancer the most costly. From 2005-15 over $300 million was spent annually on diagnosis, treatment and pathology-related costs of skin cancer. With $512.3 million spent in 2010 on melanoma carcinomas, [22] costs continued to rise. The number of life-years lost and loss of productivity both have a bearing on the financial cost of the disease. The direct and indirect expenses of skin cancer in the Australian state of New South Wales (NSW) have been investigated. [36] Direct costs included those resources related to skin cancer management, and indirect costs were concerned with premature mortality and morbidity. [36] Review of 150 000 skin cancer patients in NSW (2010) revealed a total lifetime cost estimation of AU$536 million, with 72% of this cost related to direct costs, and the remaining 28% to indirect costs; the direct costs were higher in females and indirect costs higher in males. [36] Prevention initiatives make up an important part of financial expenditure for skin cancer funding and investments. Prevention programs are a productive tool, as they beneficially influence attitudes and behaviours towards skin cancer, but also deliver positive financial returns. [3] A 2009 study analysed the economic impact of prevention programs such as SunSmart. SunSmart demonstrated positive health impacts, was cost effective. The Victoria-based program returned $3.60 for every $1 invested. It concluded that SunSmart prevented 103,000 skin cancers and more than 1,000 related fatalities from 1988-2003. The study found strong evidence that continued investment and support for SunSmart was economically sound and presented beneficial outcomes for Australia. [37]

See also

Related Research Articles

Skin cancer A medical condition involving uncontrolled growth of skin cells

Skin cancers are cancers that arise from the skin. They are due to the development of abnormal cells that have the ability to invade or spread to other parts of the body. There are three main types of skin cancers: basal-cell skin cancer (BCC), squamous-cell skin cancer (SCC) and melanoma. The first two, along with a number of less common skin cancers, are known as nonmelanoma skin cancer (NMSC). Basal-cell cancer grows slowly and can damage the tissue around it but is unlikely to spread to distant areas or result in death. It often appears as a painless raised area of skin that may be shiny with small blood vessels running over it or may present as a raised area with an ulcer. Squamous-cell skin cancer is more likely to spread. It usually presents as a hard lump with a scaly top but may also form an ulcer. Melanomas are the most aggressive. Signs include a mole that has changed in size, shape, color, has irregular edges, has more than one color, is itchy or bleeds.

Sunscreen Topical skin product that helps protect against sunburn

Sunscreen, also known as sunblock or suntan lotion, is a lotion, spray, gel, foam, stick or other topical product that absorbs or reflects some of the sun's ultraviolet (UV) radiation and thus helps protect against sunburn. Diligent use of sunscreen can also help to slow or temporarily prevent the development of wrinkles, dark spots and sagging skin.

Squamous cell skin cancer

Squamous-cell skin cancer, also known as cutaneous squamous-cell carcinoma (cSCC), is one of the main types of skin cancer along with basal cell cancer, and melanoma. It usually presents as a hard lump with a scaly top but can also form an ulcer. Onset is often over months. Squamous-cell skin cancer is more likely to spread to distant areas than basal cell cancer. When confined to the outermost layer of the skin, a precancerous or in situ form of cSCC is known as Bowen's disease.

Sun tanning The darkening of skin in response to ultraviolet light

Sun tanning or simply tanning is the process whereby skin color is darkened or tanned. It is most often a result of exposure to ultraviolet (UV) radiation from sunlight or from artificial sources, such as a tanning lamp found in indoor tanning beds. People who deliberately tan their skin by exposure to the sun engage in a passive recreational activity of sun bathing. Some people use chemical products which can produce a tanning effect without exposure to ultraviolet radiation, known as sunless tanning.

Indoor tanning Tanning using an artificial source of ultraviolet light

Indoor tanning involves using a device that emits ultraviolet radiation to produce a cosmetic tan. Typically found in tanning salons, gyms, spas, hotels, and sporting facilities, and less often in private residences, the most common device is a horizontal tanning bed, also known as a sunbed or solarium. Vertical devices are known as tanning booths or stand-up sunbeds.

Basal-cell carcinoma Most common type of skin cancer

Basal-cell carcinoma (BCC), also known as basal-cell cancer, is the most common type of skin cancer. It often appears as a painless raised area of skin, which may be shiny with small blood vessels running over it. It may also present as a raised area with ulceration. Basal-cell cancer grows slowly and can damage the tissue around it, but it is unlikely to spread to distant areas or result in death.

Melanoma Cancer originating in melanocytes

Melanoma, also redundantly known as malignant melanoma, is a type of skin cancer that develops from the pigment-producing cells known as melanocytes. Melanomas typically occur in the skin but may rarely occur in the mouth, intestines or eye. In women, they most commonly occur on the legs, while in men they most commonly occur on the back. About 25% of melanomas develop from moles. Changes in a mole that can indicate melanoma include an increase in size, irregular edges, change in color, itchiness or skin breakdown.

Preventive healthcare Prevent and minimize the occurrence of diseases

Preventive healthcare, or prophylaxis, consists of measures taken for disease prevention. Disease and disability are affected by environmental factors, genetic predisposition, disease agents, and lifestyle choices and are dynamic processes which begin before individuals realize they are affected. Disease prevention relies on anticipatory actions that can be categorized as primal, primary, secondary, and tertiary prevention.

Slip-Slop-Slap

Slip-Slop-Slap was the iconic and internationally recognised sun protection campaign prominent in Australia and New Zealand during the 1980s. Launched by Cancer Council Victoria in 1981, the Slip! Slop! Slap! campaign featured a seagull named Sid the Seagull, who was singing and dancing to encourage people to reduce sun exposure and protect themselves against an increased risk of skin cancer. Sid had Australians slipping on long-sleeved clothing, slopping on sunscreen and slapping on a hat. This successful program was funded by public donations.

Clare Oliver was an Australian woman whose own health crisis prompted her to become an activist, garnering wide media coverage for her campaign to raise awareness about the risks of using solariums excessively. She had wanted to become a journalist and wrote a story before her death that was published in newspapers all over the country. Oliver's melanoma was first discovered as part of a health check-up shortly after she had been employed by SBS Television upon completion of a media degree. She went to Melbourne Girls' College and Presentation College Windsor in her high school years.

Tanning dependence

Tanning dependence or Tanorexia is a syndrome where an individual appears to have a physical or psychological dependence on sunbathing or the use of ultraviolet (UV) tanning beds. Compulsive tanning may satisfy the definition of a behavioral addiction as well.

Tanning activators are chemicals that increase the effect of UV-radiation on the human skin.

Sunburn burning of the skin by the suns radiation

Sunburn is a form of radiation burn that affects living tissue, such as skin, that results from an overexposure to ultraviolet (UV) radiation, usually from the Sun. Common symptoms in humans and other animals include: red or reddish skin that is hot to the touch or painful, general fatigue, and mild dizziness. Excessive UV radiation can be life-threatening in extreme cases. Excessive UV radiation is the leading cause of, primarily, non-malignant skin tumors. Sunburn is an inflammatory response in the tissue triggered by direct DNA damage by UV radiation. When the cells' DNA is overly damaged by UV radiation, type I cell-death is triggered and the tissue is replaced. Sun protective measures including sunscreen and sun protective clothing are widely accepted to prevent sunburn and some types of skin cancer. Special populations, including children, are especially susceptible to sunburn and protective measures should be used to prevent damage.

Health effects of sunlight exposure

The ultraviolet radiation in sunlight has both positive and negative health effects, as it is required for the synthesis of vitamin D3 and is a mutagen. A dietary supplement can supply vitamin D without this mutagenic effect. Vitamin D has been suggested as having a wide range of positive health effects, which include strengthening bones and possibly inhibiting the growth of some cancers. UV exposure also has positive effects for endorphin levels, and possibly for protection against multiple sclerosis. Visible sunlight to the eyes gives health benefits through its association with the timing of melatonin synthesis, maintenance of normal and robust circadian rhythms, and reduced risk of seasonal affective disorder.

Skin Cancer Foundation Non-profit organisation in the United States

Since its founding in 1979, The Skin Cancer Foundation (SCF) has aimed to “empower people to take a proactive approach to daily sun protection and the early detection and treatment of skin cancer.” The organization has developed a mix of programs and resources that serve the needs of a diverse audience. SCF disseminates information via its digital resources, public service campaigns and community programs, including Destination: Healthy Skin. The foundation's professional membership includes dermatologists, Mohs surgeons, plastic surgeons and other medical professionals working to fight skin cancer. Headquartered in New York City, the foundation is a 501(c)(3) public charity.

Dark skin Human skin color

Dark skin is a type of human skin color that are rich in melanin pigments, especially eumelanin. People with very dark skin are often referred to as "black people", although this usage can be ambiguous in some countries where it is also used to specifically refer to different ethnic groups or populations.

Sunscreen Innovation Act

The Sunscreen Innovation Act is a 2014 law that amended the Federal Food, Drug, and Cosmetic Act to establish an expedited process for the review and approval of over-the-counter (OTC) sunscreens. The US Food and Drug Administration (FDA) had not approved a new active ingredient in sunscreen since 1999, despite some sunscreens having been approved and used overseas for a decade. The new law gave the FDA one year to respond to the existing backlog of sunscreen ingredient approval requests, and then 18 months to reply to any future applications.

Adele Chandler Green is an Australian epidemiological senior scientist at the QIMR Berghofer Medical Research Institute in Brisbane and is the institute's Head of Cancer and Population Studies Group.

The Public Access to Sunscreens Coalition, or PASS Coalition, is a coalition of public health organizations, dermatologists and sunscreen product companies whose mission is to help prevent skin cancer and improve public health by ensuring Americans have access to safe and effective sunscreens and evidence-based education on sun-safe practices. It accomplishes these goals by lobbying for an efficient and transparent regulatory pathway to market for new sunscreens and advocating against proposals that limit access to FDA-approved sunscreens.

June K. Robinson is an American dermatologist, academic and researcher. She is a Research Professor of Dermatology at Northwestern University’s Feinberg School of Medicine.

References

  1. ↑ "Skin cancer facts & stats - SunSmart". Skin cancer facts & stats - SunSmart. Archived from the original on 5 September 2015. Retrieved 30 August 2015.
  2. 1 2 3 4 .Cust, Anne E.; Armstrong, Bruce K.; Goumas, Chris; Jenkins, Mark A.; Schmid, Helen; Hopper, John L.; Kefford, Richard F.; Giles, Graham G.; Aitken, Joanne F. (1 January 2010). "Sunbed use during adolescence and early adulthood is associated with increased risk of early-onset melanoma". International Journal of Cancer. 128 (10): 2425–2435. doi:10.1002/ijc.25576. PMC   2993823 . PMID   20669232.{{|date=May 2018 |bot=InternetArchiveBot |fix-attempted=yes }}
  3. 1 2 3 4 5 6 7 8 Sinclair, C.; Foley, P. (1 November 2009). "Skin cancer prevention in Australia". British Journal of Dermatology. 161: 116–123. doi:10.1111/j.1365-2133.2009.09459.x. ISSN   1365-2133. PMID   19775367. S2CID   35387726.
  4. 1 2 3 4 5 Baade, Peter; Coory, Michael (1 August 2005). "Trends in melanoma mortality in Australia: 1950–2002 and their implications for melanoma control". Australian and New Zealand Journal of Public Health. 29 (4): 383–386. doi: 10.1111/j.1467-842X.2005.tb00211.x . ISSN   1753-6405. PMID   16222938.
  5. 1 2 Levine, Jody A.; Sorace, Michael; Spencer, James; Siegel, Daniel M. (1 January 2005). "The indoor UV tanning industry: A review of skin cancer risk, health benefit claims, and regulation". Journal of the American Academy of Dermatology. 53 (6): 1038–1044. doi:10.1016/j.jaad.2005.07.066. PMID   16310065.
  6. 1 2 3 Hirst, Nicholas; Gordon, Louisa; Gies, Peter; Green, Adèle C. (1 January 2009). "Estimation of avoidable skin cancers and cost-savings to government associated with regulation of the solarium industry in Australia". Health Policy. 89 (3): 303–311. doi:10.1016/j.healthpol.2008.07.003. PMID   18760857.
  7. 1 2 Victorian Government. Radiation (Tanning Units Amendment) interim regulations 2007 Under section 139 of the Radiation Act 2005. Vol. STATUTORY RULE No. 148/2007, 2007.
  8. ↑ South Australia. Radiation protection and control (cosmetic tanning units) regulations 2008 under the Radiation protection and control act 1982, 2008.
  9. ↑ Radiation Safety Act 1975 Radiation Safety (General) Regulations 1983. Western Australia, 2008.
  10. ↑ Makin J, Dobbinson SJ. Changes in solarium numbers in Australia following negative media and legislation. Australian & New Zealand Journal of Public Health 2009; 33 (5): 491-494.
  11. ↑ Victorian Government. Radiation Amendment (Tanning Units and Fees) Regulations 2008 Under section 139 of the Radiation Act 2005. Vol. STATUTORY RULE No. 167/2008, 2008.
  12. 1 2 Standards Australia/Standards New Zealand. Australian/New Zealand Standard AS/NZS 2635 (Solaria for cosmetic purposes): Standards Australia/Standards New Zealand, 2008.
  13. ↑ Gies P, Javorniczky J, Henderson S, McLennan A, Roy C, Lock J, Lynga C, Melbourne A, Gordon L. UVR emissions from solaria in Australia and implications for the regulation process Photochemistry and Photobiology 2011; 87 (1): 184-190.
  14. ↑ Department of Health. Management licence conditions for the possession of a commercial tanning unit. Melbourne: Victorian Government, 2011.
  15. ↑ New South Wales Government. Radiation control regulation 2003 made under the Radiation Control Act 1990, as at 29 May 2009. Reg 615 of 2003. Part 4A - Tanning units, 2009.
  16. ↑ Queensland Health. Section 47A, Radiation Safety Act 1999, 2009.
  17. ↑ Australian Capital Territory. Radiation Protection (Tanning Units) Amendment Regulation 2010 (No 1) made under Radiation Protection Act 2006. Subordinate Law SL2010-29, 2010.
  18. ↑ Department of Health and Human Services Tasmania. Guidelines for the operation of solaria in Tasmania. Public Health Act 1997. Population Health, ed. Hobart, Australia: Department of Health and Human Services Tasmania, 2009.
  19. ↑ "Solariums banned across NSW". ABC News (Australia). 4 February 2012. Archived from the original on 4 February 2012. Retrieved 4 February 2012.
  20. ↑ "Tan ban passes Vic parliament". News.com.au. 15 October 2013. Archived from the original on 19 October 2013. Retrieved 15 October 2013.
  21. ↑ "'It's criminal, it should be stopped': Melanoma survivor issues warning on illegal solariums". ABC News. 6 March 2018. Archived from the original on 6 March 2018. Retrieved 10 April 2018.
  22. 1 2 "Skin cancer facts & stats - SunSmart". Skin cancer facts & stats - SunSmart. Archived from the original on 5 September 2015. Retrieved 29 August 2015.
  23. 1 2 3 Girschik, J.; Fritschi, Lin; Threlfall, T.; Slevin, T. (2 April 2008). "Deaths from non-melanoma skin cancer in Western Australia". Cancer Causes & Control. 19 (8): 879–885. doi:10.1007/s10552-008-9150-9. ISSN   0957-5243. PMID   18386140. S2CID   8523244.
  24. 1 2 Whiteman, David C.; Green, Adele C.; Olsen, Catherine M. (June 2016). "The Growing Burden of Invasive Melanoma: Projections of Incidence Rates and Numbers of New Cases in Six Susceptible Populations through 2031". The Journal of Investigative Dermatology. 136 (6): 1161–1171. doi: 10.1016/j.jid.2016.01.035 . ISSN   1523-1747. PMID   26902923.
  25. 1 2 "New Zealand Skin Cancer Primary Prevention and Early Detection Steering Committee" (PDF). www.sunsmart.org.nz. May 2017. Archived (PDF) from the original on 14 June 2018.
  26. 1 2 "Sunscreen - SunSmart". Sunscreen - SunSmart. Retrieved 30 August 2015.
  27. ↑ Turner, Jessica. "Despite one of the worst skin-cancer rates in the world, and a beach bag full of awareness campaigns over the years, [online]".
  28. 1 2 3 Australia, Cancer Council. "Non-melanoma - Cancer Council Australia". www.cancer.org.au. Archived from the original on 10 September 2015. Retrieved 27 August 2015.
  29. ↑ "Funding". Ministry of Health NZ. Archived from the original on 14 June 2018. Retrieved 14 June 2018.
  30. 1 2 "Sun protective clothing - SunSmart". Sun protective clothing - SunSmart. Archived from the original on 29 August 2015. Retrieved 30 August 2015.
  31. ↑ "Sun protective hats - SunSmart". Sun protective hats - SunSmart. Archived from the original on 29 August 2015. Retrieved 30 August 2015.
  32. ↑ "Shade - SunSmart". Shade - SunSmart. Archived from the original on 6 September 2015. Retrieved 30 August 2015.
  33. ↑ "Sunglasses - SunSmart". Sunglasses - SunSmart. Archived from the original on 6 September 2015. Retrieved 30 August 2015.
  34. 1 2 3 Sinclair, Rodney (2012). "Skin Checks". Australian Family Physician.
  35. ↑ "Cancer Statistics Australia | ACRF". ACRF. Retrieved 29 August 2015.
  36. 1 2 3 Doran, Christopher M.; Ling, Rod; Byrnes, Joshua; Crane, Melanie; Searles, Andrew; Perez, Donna; Shakeshaft, Anthony (23 September 2015). "Estimating the economic costs of skin cancer in New South Wales, Australia". BMC Public Health. 15 (1): 952. doi:10.1186/s12889-015-2267-3. PMC   4581089 . PMID   26400024.
  37. ↑ Shih, Sophy Ting-Fang; Carter, Rob; Sinclair, Craig; Mihalopoulos, Cathrine; Vos, Theo (1 January 2009). "Economic evaluation of skin cancer prevention in Australia". Preventive Medicine. 49 (5): 449–453. doi:10.1016/j.ypmed.2009.09.008. PMID   19747936.
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