Skin cancer risk factors among primary school children: Investigations in Western Hungary
Introduction
The incidence of different skin cancer types, such as melanoma, in young and middle-aged people is increasing worldwide (Garbe and Leiter, 2009, Gaudi and Kásler, 2003, Ries et al., 2000). As for the mortality rates, after increasing during the 1970s and 1980s in the United States of America and in Europe, in the 1990s a levelling off was observed in many countries (Garbe and Leiter, 2009). Moreover mortality for melanoma started to decline in recent cohorts in Australia, North America, UK and Sweden, where specific skin cancer prevention campaigns were more stressed (Severi et al., 2002).
Epidemiological studies emphasize the role of the geographical location; the pole to equator gradient of melanoma incidence and consequences of migration are also well-documented (Armstrong and Kricker, 2001, Conti et al., 1994, Khlat et al., 1992, MacKie et al., 2002, Parkin et al., 1997, Remontet et al., 2003).
Since there is no significant difference in solar radiation among the different regions, geographical location and migration have no discernible effect on melanoma incidence in Hungary. The disease is the 7th and 6th most frequent cancer among women and men, the incidence is continuously increasing. The National Cancer Register of Hungary recorded 1117 new malignant melanoma cases in 2001 (600 females and 517 males), which mainly affected the 50–75-year-old population (Gaudi and Kásler, 2002). The malignant melanoma death rate was 3.19 per 100 000 in the same year, the mortality rate is higher in men than in women (Gaudi and Kásler, 2002, Gaudi and Kásler, 2003). Using the European standard population as reference, the age-standardised death rate was 1.95 in women and 3.74 in men per 100 000 population (European mortality database, 2009). Due to the increase in incidence and mortality rate, melanoma must be considered a severe public health issue also in Hungary.
Among the Caucasians, fair skin-type characteristics, presence of freckles and number of moles are well known melanoma constitutional risk factors (Bliss et al., 1995, Gandini et al., 2005a, Gandini et al., 2005b). Intermittent sun exposure and history of sunburns in childhood and adulthood significantly increase the risk; furthermore the risk increases with the number of sunburns (Autier, 2004, Gandini et al., 2005a, Gandini et al., 2005b, Veierod et al., 2003). Excessive sunbathing and sunburns sustained in childhood significantly increase the risk of developing melanoma later in life (Autier, 2004, Veierod et al., 2003).
Melanoma is an aggressive tumour with unfavourable prognosis if diagnosed at an advanced stage; therefore, effective prevention and early diagnosis are key factors in decreasing morbidity and mortality (Somlai, 2003). According to studies, skin cancer is largely preventable by public education and behaviour change (Hill et al., 1992). Moreover, healthy habits established in childhood may be sustained throughout life, thus sun protection habits should begin early in life, be taught as part of routine preventive health care and in school settings (Geller et al., 2003, Marks, 1987, O'Riordan et al., 2003).
This cross-sectional study is part of an international project, coordinated by the “Regina Elena” Cancer Institute, Rome, Italy with the participation of other European and non-European countries, investigating sun sensitivity factors and sun protection practice in primary school children. The programme aims children and their parents to bring notice to the harmful effects of excessive sunbathing. The results in samples from Spanish and Italian children are already available (Cercato et al., 2008, Ramazzotti et al., 2009).
The aim of this study is to evaluate the factors associated with sunburns, and with sun protection practice in Hungarian school-age children.
Section snippets
Methods
During the school-year 2003/2004, 2530 children attending the 1st–4th grades in the primary schools of two cities of the Western-Transdanubian Region in Hungary (Győr, Zalaegerszeg) were surveyed. 19 schools were selected and cluster sampling was used. The median age was 8 (range 5–12) years. At the beginning of the school-year parents were informed about the aim and the phases of the project. They were asked to sign informed consent forms and to fill in the questionnaire with their children
Results
Table 1, Table 2 show the characteristics of the study population. Fairness of complexion is a common feature: light eyes, fair hair (red, fair/light brown) and fair skin represent 47%, 66% and 42% of cases, respectively.
Sun exposure is frequently reported: the majority of children usually spent their summer holiday outside the city at the waterfront (64%) or in the mountains (17%) and 93% of the participants reported to get sun-tanned at the end of the summer. Although 67% of the whole samples
Discussion
Over the last few decades a significant increase in the number of patients suffering from skin cancer was reported worldwide (Gaudi and Kásler, 2003, Garbe and Leiter, 2009, Ries et al., 2000). Early diagnosis and effective prevention may play an important role in decreasing the morbidity and the mortality rate for melanoma (Somlai, 2003). The U.S. Task Force on Community Preventive Services found that education and policy approaches to increasing sun protection behaviour were effective when
Conclusion
Even though Hungary is not surrounded by water, spending holidays at the waterfront, where health damaging effects of solar radiation are enhanced is very popular among primary school children. Due to public health education and advertisements, the majority of children already use some kind of sun protection, mainly sunscreen and T-shirt. However, the high rate of subjects referring sunburn experience evidences that sun protection habit is not effective. In several other epidemiological studies
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Acknowledgments
Dr. E. Conti who prematurely died, made decisive contributions to the study.
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Contributed equally to this work.