Modifiable Risk-factors for Keratinocyte Cancers in Australia: A Case-control Study.

Keratinocyte cancer is the most common malignancy in Caucasians. The aim of this study was to investigate risk-factors responsible for development of keratinocyte cancer in Australia. A case-control study was conducted, including 112 cases of squamous cell carcinoma (SCC), 95 cases of basal cell carcinoma (BCC) and 122 controls. Freckling during adolescence (SCC: odds ratio (OR) 1.04, p < 0.01; BCC: OR 1.05, p < 0.01), propensity to sunburn (SCC: OR 2.75, p = 0.01, BCC: OR 2.68 p = 0.01) and high cumulative sun-exposure (SCC: OR 2.43, p = 0.04; BCC: OR 2.36 p = 0.04) were independent risk-factors for both SCC and BCC. This study provides further evidence that a sun-sensitive phenotype and excessive sun-exposure during adulthood contribute to the risk of developing keratinocyte cancer. Wearing a hat, long-sleeved shirts, and sunscreen did not significantly reduce the risk of keratinocyte cancer in this study.

Knowledge and perceptions about sunburn and solar keratoses in Australia.

An omnibus telephone survey of 1200 adult Australians determined self-reported prevalence of and attitudes to sunburn and sunspots, knowledge of the term solar keratosis and prevalence of skin checks. Half reported they had been sunburnt in the previous year. Seventy-eight per cent considered sunburn to be extremely or very serious, while 73% considered sunspots as serious or very serious. While 29% reported currently having sunspots, 69% had never heard of the term solar keratosis, 30% had never had a skin check and 28% had their last skin check more than 12 months ago. Respondents 18-29 years old (odds ration [OR] = 2.6; P = 0.002) and men (OR = 2.4; P < 0.001) were most likely to experience multiple sunburn. Persons living in capital cities (OR = 0.63; P = 0.006) and having a university degree (OR = 0.52; P = 0.001) had reduced OR for multiple sunburns. Men (OR = 0.45; P < 0.001) were less likely to consider sunburn serious or extremely serious than women. Compared with respondents 18-29 years old, those 55 years or older were 7.4-fold more likely to have had a skin check (P < 0.001). Sun-protection campaigns need to continue using evidence-based interventions targeting younger people and men to reduce sunburn. The terms used in health promotion need to be understood by the target audience.

Workplace sun protection policies and employees' sun-related skin damage.

OBJECTIVES: To investigate whether mandatory sun protection for outdoor workers in tropical regions is associated with reduced sun damage. METHODS: Survey of 26 employees working under mandatory sun protection policy was compared to survey of 21 employees working under voluntary sun protection policy. RESULTS: Voluntary sun protection associated with employees having more solar keratoses on dorsum of right hand (P=0.006) and more previously excised self-reported skin cancers (P=0.008). CONCLUSIONS: Employees working under mandatory sun protection policy had reduced sun damage, a likely consequence of less sun exposure.

Telomerase activity of basal cell carcinoma in patients living in North Queensland, Australia.

Basal cell carcinoma (BCC) is the most common skin cancer in North Queensland, Australia. The role of telomerase in BCC has not been investigated in this region. The objective of the study was to investigate the expression levels of human telomerase reverse transcriptase (hTERT) and telomerase activity in nodular BCCs and superficial BCCs from patients living in North Queensland. Matched tumor and adjacent nontumorous mucosa samples from 12 BCCs (7 nodular and 5 superficial) among 11 male patients were collected. In these samples, RNA was extracted and then transcribed to complementary DNA. Real-time polymerase chain reaction (PCR) was used to quantify the expression levels of hTERT messenger RNA (mRNA). In addition, telomeric repeat amplification protocol assay, a PCR-based method, was performed to detect telomerase activity in tissue extracts from these samples. The findings were correlated with the clinicopathologic features of patients with these tumors. All BCC samples expressed telomerase hTERT mRNA, and 75% (9/12) of the BCC samples showed telomerase activity. The mean level of expression among BCC samples was higher than that among matched nontumor samples (mean, 0.468 versus 0.140; P < .0001). Nodular BCC samples showed higher expression levels of hTERT mRNA as compared with superficial BCC samples (mean, 0.584 versus 0.305; P < .05). There was no significant association between expression of hTERT mRNA and tumor size. In conclusion, this study is the first on telomerase expression in BCC in Queensland as well as the first to analyze telomerase in BCC by quantitative PCR. The results indicate that telomerase alterations have an important role in the pathogenesis of BCCs. A unique finding is that the telomerase expression level in nodular BCCs is different from that in superficial BCCs.

Management of primary superficial basal cell carcinoma.

BACKGROUND: Superficial basal cell carcinoma (SBCC) is a skin cancer commonly treated by general practitioners. Little is known about how GPs choose from the available treatment options. METHOD: A cross sectional survey was conducted by self administered questionnaire. RESULTS: Of 257 GPs surveyed, 107 responded (adjusted response rate 59%). Sixty-three percent reported treating more than two SBCC per month, managing 90% themselves, mostly by surgery (57%), and imiquimod 5% cream (19%). Forty percent of SBCC patients were referred to a plastic surgeon, and 26% (IQR 0-50%) to a general surgeon. Contraindications to surgery included lesion site (14%), and size (12%). Sixty-two percent of GPs reported never using curettage and cautery, and 23% never cryotherapy. If the cost of imiquimod 5% cream were to be subsidised through the Pharmaceutical Benefits Scheme, GPs predicted its use for SBCC would increase from 34 to 58% (p>0.001). DISCUSSION: General practitioners manage most lesions themselves and refer appropriately. Areas of educational need were identified with respect to management of inadequately treated or recurrent lesions.

Minor skin excisions in general practice in North Queensland.

OBJECTIVE: To describe the demographics of patients presenting with skin cancer to general practitioners in rural North Queensland, the sites from which skin cancers are removed, and their histology. METHODS: Data was recorded from 1247 consecutive patients who attended for minor skin lesion excisions. RESULTS: Close to half (46.7%) of lesions excised were skin cancers. We excised more squamous cell carcinomas than basal cell carcinomas (0.74:1). Our number needed to treat (benign or dysplastic naevi excised per melanoma) was 8.4. Mean age for excision of melanoma, basal cell carcinoma and squamous cell carcinoma was 55, 60.9 and 63.8 years respectively. Relative tumour density was greatest in the face, scalp and neck region for all skin cancers. DISCUSSION: In this sample of Mackay GPs, there was a very high yield of skin cancers from all excisions. We could consider lowering our threshold for excision of pigmented lesions.

Predictors of sunburn in North Queensland recreational boat users.

ISSUE ADDRESSED: Identify personal and situationalfactors predicting sunburn in north Queensland recreational boat users over summer. METHODS: Cross-sectional survey with prospective 24-hour follow-up for sunburn, conducted in Townsville, north Queensland, during the summer of 2003. Ninety-three out of 100 boat users returning after a day trip agreed to participate. All were followed up, with three later excluded from analysis due to prior sunburn (n=90, response rate 93%). RESULTS: Overall, 48% of participants experienced sunburn as a result of their boat trip; 57% of these developed sunburn on the face and 43% on both the V of the neck and the legs. Factors found to increase the occurrence of sunburn were longer time on the water between 10 am-2 pm, not wearing a wide-brimmed hat, not working outdoors, and going boating less than once per month. CONCLUSIONS: The survey shows unacceptably high levels of sunburn in north Queensland boat users. Sunburn appears related to not using optimal sun protection between 10 am and 2 pm. Boat users in the tropics need to wear a brimmed hat to better protect the face, a collared long-sleeved shirt buttoned up at the throat to protect the V of the neck and arms, long pants, and rely less on sunscreen and on darker skin types that are perceived to sunburn less readily.

Management of superficial basal cell carcinoma: focus on imiquimod.

Superficial basal cell carcinoma comprise up to 25% of all histological sub-types. They are more likely to occur on younger persons and females and although generally more common on the trunk, also occur frequently on the exposed areas of the head and neck especially in areas of high sun exposure. In the last decade, new treatment options such as topical applications that modify the immune response have been trialed for effectiveness in treating these lesions. Imiquimod 5% cream has been shown to stimulate the innate and cell mediated immune system. The short-term success of imiquimod 5% cream in randomized controlled trials comparing different treatment regimes and dosing as a treatment for small superficial basal cell carcinoma (BCC) not on the face or neck is in the range of 82% for 5 times per week application. A high proportion of participants with good response rates to topical treatment (58%-92%) experience local side effects such as itching and burning, less commonly erosion and ulceration, but the proportion of participants ceasing treatment has not been high. To date one long-term study indicates a treatment success rate of 78%-81% and that initial response is a predictor of long-term outcome. Recurrences tend to occur within the first year after treatment. Future research will compare this preparation to the gold standard treatment for superficial BCC - surgical excision.

Agreement between histological diagnosis of skin lesions by histopathologists and a dermato-histopathologist.

BACKGROUND: Skin cancer is an increasing problem in fair-skinned populations worldwide. It is important that doctors are able to diagnose skin lesions accurately, and this is supported by accurate histological diagnosis. OBJECTIVE: To compare agreement for histological diagnosis between local histopathologists with a dermato-histopathologist from a stratified random sample of excised skin lesions derived from a set of epidemiological data. METHODS: All excised and histologically confirmed skin cancers in Townsville/Thuringowa, Australia from December 1996 to October 1999 were recorded. A stratified sample of 407 of 8694 skin excisions slides was analyzed. Results Positive predictive values (PPVs) for the primary histological diagnosis were above 90% for basal cell carcinoma, cutaneous melanoma, and common naevus. For squamous cell carcinoma (SCC), the PPV was 72.6% [95% CI = (65.5, 79.0)]. DISCUSSION: Lack of agreement between histopathologists regarding the diagnosis of SCC and actinic keratosis has been previously recognized in the literature and this is again reflected in our study. The result also illustrates the difficulty involved for doctors in accurately clinically diagnosing lesions for which a consensus is hard to reach histologically.

Effectiveness of lifestyle measures in the treatment of gastroesophageal reflux disease - a case series.

AIM: To assess the effectiveness of lifestyle measures in the treatment of gastroesophageal reflux disease (GERD) among adults attending a dietetic practice. METHODS: A retrospective case series of adult patients presenting with GERD to a dietetic practice over a three year period. The routine lifestyle counselling for treatment of symptoms of GERD included: not reclining within two to three hours of eating; a diet low in fat; small frequent meals; avoiding dietary components considered to relax the lower esophageal sphincter; and avoiding local irritants. RESULTS: Twenty three cases were included (12 male). Eighteen, (9 female) were referred by their doctor, 7 (6 female) presented for GERD alone, 7 (4 female) presented for GERD together with comorbidities, and 9 (1 female) incidentally mentioned GERD during a dietary consultation for another disorder. Thirteen participants (9 female) had previously undergone endoscopies, 18 (11 female) were taking medication for GERD, and 19 (7 female) had comorbidities. Twenty two (10 female) reported an improvement in symptoms with 11/18 taking GERD medication at presentation reducing their medication following treatment. CONCLUSIONS: These results suggest that a more thorough investigation of lifestyle modification in the treatment of GERD is warranted.

Can sutures get wet? Prospective randomised controlled trial of wound management in general practice.

OBJECTIVE: To compare standard management of keeping wounds dry and covered with allowing wounds to be uncovered and wet in the first 48 hours after minor skin excision. DESIGN: Prospective, randomised controlled, multicentre trial testing for equivalence of infection rates. SETTING: Primary care in regional centre, Queensland, Australia. PARTICIPANTS: 857 patients randomised to either keep their wound dry and covered (n = 442) or remove the dressing and wet the wound (n = 415). RESULTS: The incidence of infection in the intervention group (8.4%) was not inferior to the incidence in the control group (8.9%) (P < 0.05). The one sided 95% confidence interval for the difference of infection rates was infinity to 0.028. CONCLUSION: These results indicate that wounds can be uncovered and allowed to get wet in the first 48 hours after minor skin excision without increasing the incidence of infection.

Lifestyle changes as a treatment of gastroesophageal reflux disease: a survey of general practitioners in North Queensland, Australia.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder in developed countries, with the usual treatment being medication. Previously, lifestyle modification was the only treatment for GERD; however, its effectiveness has not been assessed. METHODS: All practicing general practitioner (GP) members of two Divisions of General Practice (n = 193) in North Queensland, Australia, were surveyed in 2001 using a postal questionnaire to determine their views and practices relating to such treatment among adults with GERD. RESULTS: The response rate was 70.5%. Of those who responded, 17.6% recommended diet and postural advice as a first line of treatment, with postural advice (89.7%), avoid known precipitants (86.0%), reduce weight if overweight (79.4%), eat a low fat diet (45.6%), and stop smoking (17.6%) being the most common recommendations. Of the nine possible changes, the median number recommended was 3, interquartile range (IQR; 3, 4). Eighty-nine percent of GPs thought >/= 10% of patients with GERD would benefit from lifestyle changes, but almost half thought

Multiple nonmelanoma skin cancer in an exposed Australian population.

BACKGROUND: Patients with nonmelanoma skin cancer (NMSC) frequently develop multiple skin cancers. The study presents incidence rates and rates of excision of NMSC for a population living in a high-risk environment for skin cancer. METHODS: Between 1997 and 1999 a prospective population-based study collected information on all histologically confirmed NMSCs in Townsville, Australia. RESULTS: Of the 6708 patients recorded with NMSC, 38.5% had multiple lesions. Yearly age-standardized incidence rates (per 100,000 inhabitants) of basal cell carcinoma (BCC) were 1444.8 for men, 942.7 for women, and of squamous cell carcinoma (SCC) were 805.0 for men, and 423.6 for women. Compared to incidence rates, age-standardized rates of lesions of BCC were 2.1 times higher in men, 1.6 times higher in women, and of SCC were 1.8 times higher in men and 1.4 times higher in women. CONCLUSIONS: The occurrence of multiple NMSCs compromises results of short-term studies on incidence. Further discussions on the most appropriate strategies to describe the real burden of NMSC are warranted.