UK Skin Cancer incidence statistics

This page presents statistics on the incidence of malignant melanoma by age and sex, deprivation, geographic variations and trends over time. The ICD codes for skin cancer are: malignant melanoma ICD9 172 and ICD10 C43, non-melanoma skin cancer ICD9 173 and IC10 C44.

Types of skin cancer

There are two main types of skin cancer, malignant melanoma of the skin and non-melanoma skin cancer (NMSC). Skin cancers are extremely common. In 2006 over 81,600 non-melanoma skin cancers (NMSC) were registered in the UK but registration is known to be incomplete. One study estimated that at least 100,000 cases of NMSC are diagnosed each year. 1,2

It has been estimated that the lifetime risk of developing malignant melanoma is 1 in 91 for men and 1 in 77 for women in the UK. These were calculated in February 2009 using incidence and mortality data for 2001-2005. 3

Figure 1.1 depicts the percentage distribution of malignant melanoma on parts of the body.

 

Malignant melanomas are the least common but most serious type of skin cancer, with more than 10,400 new cases diagnosed in 2006. 3 Melanomas can occur in other body organs e.g. the eye. In this section only cutaneous melanomas (ICD10 C43) are discussed.

The majority of NMSCs are either  basal cell carcinomas (BCCs), also known as rodent ulcers, or  squamous cell carcinomas (SCCs). Both forms are highly treatable and survival rates for NMSCs are over 95%. However, if left untreated, these tumours can become destructive, invading local tissues and causing disfigurement.

Whilst BCCs rarely metastasise, SCC can, and in 2006 there were 577 deaths in the UK from NMSC. 4-6 Around 80% of NMSCs occur in people aged 60 years and over and they constitute a substantial public health problem due to the very large number of cases each year.

Malignant melanoma incidence by age and sex

The latest statistics show that 5,607 cases of malignant melanoma were diagnosed in women and 4,803 in men in the UK in 2006. 7-10 The numbers and rates for the constituent countries of the UK are shown in Table 1.1. 3

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Unlike most malignancies, malignant melanoma is more common in women than men with a M:F ratio of 4:5. In 2006 it was the sixth most common cancer in females and the eigth in males: for both sexes combined it was the sixth most common cancer. 3

The distribution of cases on the body also varies by sex (see Figure 1.1 above): over a third of male cases arise on the trunk of the body, particularly the back, while the most common site for females is on the legs. 11

Malignant melanoma is rare in children, while in adults the incidence rates rise steadily with age ( Figure 1.2). 3

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Although the rates are highest in the over 75s, there is a substantial number of cases at younger adult age. Almost a third (31%) of all cases occur in people aged less than 50 years and in the age-group 15-34 malignant melanoma is the most common cancer (when NMSCs are excluded). This is an unusually young age distribution for an adult cancer and emphasises the importance of its prevention and early treatment to avert the potential loss of many years of life. On average, about 20 years of life are lost for each melanoma death. 12

Malignant melanoma incidence and deprivation

Another unusual feature of malignant melanoma is its positive association with affluence. 9,13 For Scottish patients diagnosed between 1991-95, age-standardised incidence rates in the most affluent areas were nearly twice as high as those in the most deprived areas (13.6 v 7.4 per 100,000 population). 9

In England and Wales between 1988-93, the age-standardised incidence rates for the most deprived areas were between 60-70% lower than those for the most affluent areas. 13 If this difference in incidence is related to access to holidays abroad, where high intensity sun exposure is likely, then the gap between different deprivation groups is likely to narrow as more and more people can afford to holiday abroad. In 2005 UK residents made a record 66.2 million trips abroad, three times as many as in 1985. Two-thirds of these foreign visits were holidays and just under half were package holidays. 14

Geographic variation of malignant melanoma incidence

The Cancer Atlas of the UK and Ireland, which analysed rates at local authority and health board level, showed that male and female melanoma incidence rates have a very similar geographical distribution. The highest rates for both sexes occur in south west England, illustrated for men in Figure 1.3. 15

Higher than average (UK and Ireland average) melanoma incidence rates were also reported for Northern Ireland, Scotland, Ireland and much of southern England. There is some suggestion that the higher rates in Scotland as well as Northern Ireland and Ireland may reflect better ascertainment of cases: another reason for the elevated rates may be the larger proportion of high risk, fair-skinned people in those populations. 15 The Atlas also showed some correlation between areas of low incidence and deprivation.

Around 48,000 new cases of melanoma occur each year in the EU. Within the EU, there is considerable variability of rates as shown in Figure 1.4 with the highest rates for the fairer-skinned north Europeans. 16 The UK melanoma incidence rates for both men and women are above the EU average.

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World melanoma incidence rates reflect the high risk for white populations in sunny climates with Australia and New Zealand leading the world with age-standardised rates between 30-40 per 100,000 population ( Figure 1.5) 17 (see risk factors section for incidence rates by ethnicity).

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Trends in malignant melanoma incidence

Over the last thirty years, the incidence of malignant melanoma has increased more than for any other common cancer in the UK. As Figure 1.6 shows, the male rates have increased more than five times from around 2.5 in 1975 to 14.3 in 2006, while the female rates have more than tripled from 3.9 to 15.4 over the same period in Great Britain. 11

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When the rates are analysed by age, it can be seen that there have been increases at all ages with the largest increase in the over 65s ( Figure 1.7 and Figure 1.8). 11

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The malignant melanoma incidence rates in the UK are shown in Figure 1.9

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This pattern of increasing malignant melanoma incidence rates, with a faster rate of increase for men than women, is a feature of many fair-skinned populations. 18 In Europe, the increases began first with Scandinavia and the UK and then spread to western, southern and eastern Europe. 19 In most populations the increase has been mainly for thin melanomas. 20,21

Some of the increase may be due to increased surveillance and early detection as well as changes in diagnostic criteria but most is considered to be real and linked to changes in sun behaviour as discussed in the risk factors section. 22-24

Benefits from primary prevention are not expected to lead to a significant reduction in incidence for at least two decades although the higher proportion of thinner lesions will have immediate survival benefit (see survival). 25

Worldwide the incidence of cutaneous melanoma is increasing faster than any other common cancer with an approximate doubling of rates every 10-20 years in countries with white populations. 18

The main preventable cause is known but translating this knowledge into changes in behaviour is not easy. Surveys in the UK have revealed that the majority of people regard a sun tan as a sign of health and few are knowledgeable about the dangers of UVR. 26 However, there is evidence that there has been modest behavioural change particularly with regard to protecting children from over-exposure to sunlight. More public education is needed especially for high risk groups.

Further research into the many unanswered questions concerning the synthesis of vitamin D from sunlight such as establishing optimal vitamin D levels and how much UVR exposure is required to synthesise different levels of vitamin D, is ongoing. In the UK, the national skin cancer prevention programme, SunSmart, is run by Cancer Research UK and mainly funded by the UK Departments of Health. 27

UK Skin Cancer mortality statistics

This page presents malignant melanoma mortality statistics including by age and sex and trends over time.

Malignant Melanoma mortality by age and sex

In 2007 there were 2,042 deaths from malignant melanoma in the UK ( Table 2.1). 1-4

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The numbers of deaths and the age-specific rates are shown in Figure 2.1. The mortality rates rise steadily with age but as the chart shows, substantial numbers of deaths occur in younger people. In 2007, 117 people aged under 40 died from malignant melanoma and over half of all deaths were in people aged under 70.

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Malignant melanoma mortality trends over time

The  age-standardised mortality rates in the UK ( Figure 2.2) show a continuous rise for men from around 1.2 per 100,000 in the early 1970s to 3.1 in 2007. Female rates were slightly higher than those for men in the early 1970s at 1.4 per 100,000 but seem to level off from the 1990s onwards and since then have remained at around 2.0 per 100,000.

Increases in mortality reflect increases in incidence but are much less pronounced due to the effects of earlier diagnosis and improving treatment. The lower mortality rates since the mid-1980s for women compared with men, despite the higher female incidence, is a reflection of the better female survival rates, partly the result of the larger proportion of thinner lesions in women compared with men.

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Age-specific malignant melanoma mortality trends in the UK are very similar to those for incidence with the greatest increase in the oldest age groups.

Rates for men aged over 65 have seen a 5-fold increase from 3 per 100,000 in 1971 to 15 in 2007 ( Figure 2.3).

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Malignant melanoma mortality rates for women over 65 have more than tripled from 3 per 100,000 to 11 per 100,000 over the same period ( Figure 2.4). At younger ages, there is some indication that female rates are levelling off - an encouraging trend also recorded in other white populations of North America, Australia and the Nordic countries. 5,6

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Skin cancer - survival statistics

This page presents malignant melanoma survival statistics including five year survival by tumour thickness and age and sex. Over the last thirty years, survival from malignant melanoma has continually improved as Figure 3.1-3 shows for England and Wales. 1-5

Malignant melanoma - One, five and ten-year survival rates

Over the last thirty years, survival from malignant melanoma has continually improved as Figures 3.1-3.31-5 show for England and Wales.

The latest estimates of five-year relative survival for patients diagnosed in 2001-06 is 81% for men and 90% for women. Survival rates are even higher in Scotland, with a 5 year relative rate of 87% for men diagnosed in 2000-2004 and 93% for women.6 Rates are consistently higher for women than men.

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Malignant melanoma - Five-year survival rates by tumour thickness

The most powerful prognostic factor for melanoma patients is the thickness of the tumour with highest survival for the thinnest tumours ( Figure 3.4).7

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Malignant melanoma - Five-year survival rates by age and sex

Younger patients tend to have higher survival rates than older patients as shown in Figure 3.32 for England and Wales.

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Substantial differences in survival between deprivation groups have also been recorded: for male patients diagnosed in 1996-1999 in England and Wales, five-year survival was 7% higher in the most affluent compared to the least affluent groups.8

Skin Cancer risk factors

The main preventable risk factor for skin cancer is excess exposure to ultraviolet radiation(UVR) 1, the principal source of which is the sun (Figure 4.1).

This section contains information on the risk factors of skin cancer and includes ultraviolet radiation, types of exposure, sunbeds, skin type and hair and eye colour, sunscreen, vitamin D and other risk factors.

Skin cancer risk - Ultraviolet radiation

It is estimated that at least two-thirds of melanomas and 90% of non-melanoma skin cancers are caused by sun exposure. 53, 54Table 4.1 gives incidence rates by ethnic group in the USA. 3

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Skin cancer risk - Types of sun exposure

Risk of melanoma is most strongly linked to intermittent exposure to high-intensity sunlight, often resulting in sunburn rather than to chronic exposure, typical of that received by people with outdoor occupations. 4 A history of sunburn doubles the risk of melanoma. 55, 56

Sunburn, especially in childhood, also increases risk of basal cell carcinoma. 57-62 Risk of squamous cell carcinoma is strongly related to long-term occupational exposure to sunlight. 57-59, 63

Skin cancer risk - sunbeds

Sunbeds and sunlamps are a source of artificial UVR. Before the 1980s these appliances primarily emitted UVB and sometimes UVC. 8Since then, commercial salons using mainly UVA lamps (these lamps may also emit some UVB) have become popular. 8,9 This variable spectral output over time and also between appliances, complicates the measurement of risk. 10

In 1999 a quarter of men and a third of women in Britain reported using a sunbed or tanning machine in the previous six months and there was even higher use amongst young people ( Figure 4.2). 11 Any impact of sunbed use is therefore likely to be greater in the future.

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The most recent meta-analysis concluded that the use of sunbeds increases risk of melanoma, especially when used before the age of 35. 64 Use of a sunbed at any age doubles the risk of squamous cell carcinoma. 64 In June 2009, the International Agency for Research on Cancer raised the classification of sunbed use to Group 1 "carcinogenic to humans". 74

One UK study using modelling techniques estimated that sunbed use caused one hundred deaths a year from melanoma in the UK. 14

The possibility that younger people and those with high risk skin types are at greatest risk is widely recognised and in 2003 the International Commission on Non-Ionizing Radiation Protection (ICNIRP) 10 and the World Health Organisation (WHO) 15 recommended that certain categories of people should not use sunbeds as shown in Table 4.2.

The ICNIRP also concluded that anyone using suntanning appliances is likely to raise their risk of skin cancer, eye damage, photodermatosis, photosensitivity and premature skin ageing. 10

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Skin cancer risk - skin type, hair and eye colour

( see alsoMolecular Biologysection)

People with light eyes, skin or hair, or who sunburn easily or do not tan, have an increased risk of skin cancer. 57, 59, 62, 63, 65 In addition, people with a large number of moles, or just one or more unusually shaped or large moles, have an increased risk of melanoma. 66 Risk increases with the number of moles. People with very high numbers (100+) of common moles on their bodies have nearly seven times the risk compared to people with very few (0-15 moles). 16

People with dysplastic moles and a family history of melanoma (dysplastic mole syndrome) have a 500-fold increased risk of developing melanoma. 17Development of moles is caused by exposure to sunlight as well as being genetically determined and most are acquired during childhood. 18,19

Chronic sun exposure is the most important environmental factor determining development of moles rather than number of sunburn episodes. 19 A UK study of moles in twins concluded that the emergence of moles in adolescents is under strong genetic control. 20 Freckling is associated with an increased risk of melanoma, independent of number of moles. 19

In terms of hair colour, people with red and light hair have the highest risk for melanoma. 7 The risk for people with red hair is as much as four times higher than for people with dark brown or black hair while people with blond hair had twice the risk of dark-haired individuals. 7,21

There is an approximately three-fold risk increase for melanoma associated with very pale skin compared to people with the darkest white skin. There are similar differences in risk for those with skin that does not tan compared with those whose skin develops a strong tan. 2

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Malignant melanoma risk - sunscreen

There is divergent evidence for a protective role of sunscreen in melanoma aetiology. Data from in vitro studies have shown significantly higher DNA damage in skin not treated with sunscreen versus treated skin 22, and a randomised trial carried out in the 1990s found children randomised to SPF30 sunscreen application developed fewer moles over a three-year period. 23

The most recent review considered 18 case-control studies and reported no association overall between sunscreen use and risk of melanoma but it is possible that people use sunscreen in order to spend longer in the sun or to avoid using protective clothing, which would cancel out any protective effect. 24, 67, 68

Skin cancer risk - Vitamin D

It has been known for many decades that the only thoroughly established beneficial effect of solar ultraviolet radiation on the skin is the synthesis of vitamin D and its role in maintaining bone health. But evidence is emerging that suggests that sunlight exposure, and the resulting cutaneous synthesis of vitamin D, might have a beneficial influence for certain major cancers, most notably colorectal cancer. 25-29.

However, the picture is by no means clear and more research is needed before exposure to solar UVR could be recommended as a means of reducing the incidence or mortality of cancer.

Skin cancer - other risk factors

People with a family history of melanoma have roughly double the risk of developing the disease compared to people without a family history. 65 Rare families exist in which 3 or more cases occur. In these families a significant proportion have a hereditary susceptibility gene such as CDKN2A and as gene carriers are at considerable lifetime risk of melanoma ( see alsoMolecular Biology section). People with a family history of squamous cell carcinoma or basal cell carcinoma have an increased risk of non-melanoma skin cancer. 60, 62, 69

US registry studies report an increased risk of melanoma in women previously diagnosed with breast cancer and in people previously diagnosed with non-Hodgkin lymphoma. In both cases, the association was bi-directional, supporting a shared genetic or environmental factor but further studies are needed to confirm these findings. 32,33.

People with a previous non-melanoma skin cancer have a much higher risk of developing a second one. 70-72

People who have had renal transplants have been shown to have a 33-fold increased risk of non-melanoma skin cancer and a higher risk of melanoma also. 73

Skin Cancer molecular biology and genetics

This page contains information on the molecular biology and genetics of skin cancer. 

The molecular stages of melanoma pathogenesis are not fully understood, but a number of key genes and pathways have been implicated in the disease.

The melanocortin receptor gene, MC1R, influences skin pigmentation and polymorphisms in this gene are common. Particular variants have been identified that are linked to an increased risk of melanoma. 1,2 There is some evidence that polymorphisms in the oculocutaneous albinism gene, OCA2, may also increase risk. 3

Other pathways that may play a role in carcinogenesis include the MAPK and HGF/SF-MET signalling pathways. 4 Also, 30-50% of melanoma samples demonstrate loss of heterozygosity at chromosome 10q. Some, but not all, of these samples have mutations in the tumour suppressor gene PTEN, suggesting that additional genes in this region are important. Mutations in the BRAF gene have been observed in up to 60% of patient samples but the role of this gene in melanoma has yet to be elucidated.

Around 10% of melanoma cases have a strong family history of the disease. Family studies suggest that the disease is often inherited as an autosomal dominant condition with reduced penetrance. A family history doubles the risk of developing the disease. Melanoma is rarely inherited as part of cancer syndromes such as the  Li Fraumeni syndrome.

Between 25-40% of inherited cases carry mutations in the CDKN2A locus on chromosome 9p22. 2,4 This locus harbours two genes, INK4A (p16) and ARF (p14), which influence the RB and p53 pathways. Mutations in CDK4 (p16) have also been reported but are rare. The Melanoma Genetics Consortium (  ) is coordinating the search for additional susceptibility genes in melanoma families. 2 Recently a locus at 1p22 has been reported, although the gene has not yet been identified. 5

In the future a better understanding of the molecular stages of melanoma may help to improve detection and ultimately treatment of this disease. As UV radiation is the dominant carcinogen in melanoma, genotype information could also be used for targeting behavioural intervention strategies to those at greatest risk.

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Skin Cancer symptoms and treatment

This page presents information on the symptoms, and treatment of malignant melanoma.

Malignant melanoma symptoms

A change in the colour, size or shape of an existing mole is the most common symptom of melanoma. To determine which pigmented lesions require further investigation, a 7-point checklist may be used ( Table 6.1).

The presence of any major feature is an indication for referral to a specialist centre and the presence of minor features increases suspicion. 1

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Malignant melanoma treatment

Guidelines on the treatment of malignant melanoma have been published in Scotland and by the British Association of Dermatologists and the Melanoma Study Group. 1,2 Guidance on the organisation of services for skin cancer patients by the NHS in England and Wales is expected in 2006. 3

Suspected lesions should be removed with at least a 2mm margin of normal skin (see Table 6.2) and a cuff of subdermal fat to enable an accurate histopathological report including a measure of Breslow thickness. 4

Staging is based on the TNM classification with revisions from the American Joint Committee on Cancer. 5 Stage I and II patients have no nodal involvement and varying thicknesses of tumour with or without ulceration. Stage III patients have evidence of lymph node involvement while stage IV patients have metastatic disease classified accordingly to the site of spread.

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Patients with early stage disease (stage 0, I and IIA) when the tumours are thin and have no nodal spread can be treated with surgery alone: they have an excellent prognosis with five-year survival rates in excess of 95%.

As tumour depth increases, so excision margins widen and survival is worse as risk of developing nodal metastases directly relates to tumour thickness - see Table 6.2 above. 6Sentinel node biopsy is increasingly used to determine nodal spread with the advantage of limiting radical node dissection to those patients who have evidence of cancer in the sentinel node but its role remains as yet unproven.

Patients with stage IIB and above disease are at risk of recurrent disease and as there is currently no standard adjuvant systemic therapy for these patients, they should be offered entry into clinical trials wherever possible. A number of adjuvant therapies are under investigation to prevent local or systemic recurrence including immunotherapies such as interferon and vaccines and chemotherapy.

Treatment for patients with metastatic disease may include further surgery to remove metastatic disease, single agent chemotherapy with dacarbazine and palliative radiotherapy. Clinical trials are also investigating new combinations of chemotherapy and immunotherapy for stage IV patients.

Early diagnosis is critical if survival rates are to improve further. Patients at risk of melanoma should be referred to specialist centres as rapidly as possible. Studies generally show that delays are predominantly patient- rather than physician-related with longer delays reported for older patients and men. 1 This may be one reason why older patients have lower survival than younger patients and men have worse survival than women (see Survival section).

Improving the low public awareness of the risk factors and symptoms of melanoma is therefore crucial. Good patient information is also important as many patients are at risk of disease recurrence and will need to attend for follow-up for several years.

As well as prevention, a key message is for the earlier diagnosis of skin cancer when treatment is much more effective.

This is particularly important for men who are less knowledgeable than women about skin cancer prevention messages and are less likely to do something to protect themselves. 7 Consequently men are usually diagnosed at a later stage than women, have significantly lower survival rates and their incidence is increasing at a faster rate than for women while their mortality rates have yet to level off.

Trials are ongoing to determine more effective treatments for both early and late stage melanoma as well as looking at the best type of psychological support and follow-up for patients. 8 Advances in understanding the molecular biology of melanoma will help develop new treatments, monitor the effects of treatments and tailor therapies to individual patients.