Melanoma, otherwise known as malignant melanoma is the most dangerous skin cancer that we know of due to its potential to metastasize to other parts of the body including the liver, the lungs, bones and the brain. The most common patient groups are men over the age of 50, and women below the age of 30. The mechanism by which melanoma develops is due to damage to the skin DNA that goes unrepaired, triggering events that lead to rapid proliferation of melanocytes, cells that are located between the dermis and epidermis and produce the pigment melanin. The reason we chose melanoma is because we recently had dermatology, where we learned a lot about melanoma and its risk factors, prevention, etc. and being from Norway, we all are very aware of the high incidence in our country, and despite the eagerness of Norway’s population to look tan, there is not a lot of focus on prevention of melanoma.
Melanoma can originate from precursor lesions, or can appear as a new lesion entirely. The tumor will start with a radial growth phase during which metastasis and angiogenesis are not active processes. After a period of time, the tumor cells will start to grow vertically, invading deeper skin tissue. As with most cancers, early detection is the key prognostic factor. This can prove challenging as the distinction between melanoma and moles is known to be difficult. Patients are therefore asked to keep track of any changes in existing moles, or to be on the lookout for any new lesions that develop. During the growth phase, melanoma patients may notice typical signs such as changes in size, colour, irregularity, itching, bleeding. These changes typically occur on the back of men, or on the legs of women, however melanoma can occur anywhere on the skin as well as eyes or oral mucosa.
According to USPharmacist, “In 2015, 1.2 million Americans had melanoma and based on data for 2013 to 2015, 2.3% of Americans will be diagnosed with melanoma in their lifetime. The National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) Program estimates that, in 2018, melanoma will constitute 5.3% of all new cancer cases (91,270) and cause 9,320 deaths (1.5% of all cancer deaths).” One of the main risk factors for melanoma is overexposure to sunlight (UV rays), and this has generally due to sunbathing trends become an increased issue in various countries compared to earlier generations. People from more economically developed countries now tend to travel on vacations in order to enjoy the sun and “get a tan”. Suntans are currently looked upon as a sign of beauty, health and status. This has progressed into an increase in production and use of sun tanning beds in countries where there is less sun, such as in Scandinavia. Consequently, due to all these increased exposures to UV rays, the incidence and prevalence of malignant melanoma has steadily increased. When compared to earlier generations, upperclassmen would display their wealth through their pale skin, wearing large hats and resting in the shade, under parasols. Being in the sun, having darker skin was associated with outdoor labor and lower class/wealth.
The countries with the highest reported incidences of melanoma are New Zealand and Australia. Countries like Switzerland, Netherlands and Scandinavia also report among the highest incidences. The combination of cultural, socioeconomic and lifestyle factors all influence the development of melanoma in certain countries. In all these countries, fair skin - Fitzpatrick type I is the most common skin type found in the population. This skin type is associated with higher rates of melanoma as well.
According to a meta-analysis of SEER data, the 5-year survival rate exceeds 90% thanks to early detection. The 5-year survival rate drops to 60% if the melanoma has invaded lymph node tissue by the time of diagnosis. If the cancer spreads distantly, beyond the lymph nodes, the 5-year survival drops to less than 20%. In 1975, survival rates were 81.9% and have since, in 2012 improved to 93.2% for all races combined. For people with fair skin color, the rates increased from 82% to 93.2%. For people with darker skin colors, the rates increased from 56.7% to 69.1%. According to the same study: “The number of new melanoma cases was 22.8 per 100,000 men and women per year. The number of deaths was 2.6 per 100,000 men and women per year. Melanoma is the most common cancer in adults aged 20 to 30 years and the leading cause of cancer death in women aged 25 to 30 years. From 2003 to 2012, the melanoma death rate remained unchanged. The yearly incidence rate of melanoma was 21% higher in men than in women (1.7% vs. 1.4%), but the difference in incidence was less (13%) in whites. The incidence remained stable in Hispanic men, but it decreased by 1.7% every year in Hispanic women.” Diagnostic measures are very advanced, and usually not a problem in countries where the incidence is high. The problem rather lies with the attention and awareness of melanoma and its prevention.
The ABCDEs of melanoma:
- Asymmetry - is the lesion asymmetric?
- Border - is the border irregular?
- Colour - is the colour uniform? Are there multiple colours?
- Diameter/Difference - Is the lesion greater than 6mm?
- Evolution/Elevation - Has it changed over time?
- (F) - Firm to touch
- (G) - Growing
- Risk factors
- UV light exposure
A major risk factor of melanoma is exposure to ultraviolet rays. The main source of UV rays is from sunlight, but also tanning beds and sun lamps. The UV rays damage the cells of the skin - and when this damage affects the DNA of genes that control the skin cell growth, the skin cancer begins. The areas of the body that are more frequently exposed to sun are also the areas that are more prone to skin cancer. These areas are the face, neck and arms.
Moles
A mole, also called a nevus, is a benign pigmented tumor. They come in different size and shape and are usually harmless. But some nevi can develop to be malignant. In the dermatology course this year we learned that people with over ten nevi on the arm and fifty nevi on the body or more are at higher risk for developing melanoma. Humans are usually not born with moles, but if they are, the moles are called congenital melanocytic nevi. Risk of developing melanoma from this type is between 0-10%, and increases with size.
Another type is atypical moles or dysplastic nevi, they look a little like normal moles but have a tendency of malignancy. They are usually bigger and have an abnormal shape. Dysplastic nevi often runs in families and a small percentage mye develop into melanomas. An inherited condition with dysplastic nevi is called dysplastic nevus syndrome and this disease are associated with having a close relative with melanoma.
Skin & hair types
The risk of melanoma is much higher in people with pale skin, blond or red hair, green or blue eyes, or fair skin with freckles. That is to say that Caucasians are more prone to developing skin cancer.
Family history
If you have a first-degree relative with melanoma you are at higher risk of developing the disease, and around 10% of all people with melanoma have a family history of the type of cancer.
The increased risk might be because of a family tendency to have fair skin or some gene changes that runs in the family. Families also share the same lifestyle of being out in the sun.
Personal history
You are at a higher risk of developing melanoma if you already have had a melanoma. People who have had basal or squamous cell skin cancers are also at increased risk of getting melanoma.
Immunocompromised
If your immune system is weakened (from certain diseases or medical treatment), then your body can not work properly to fight against diseases, including cancer and melanoma.
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Age & gender
Melanoma is more likely to occur in elderly, but can occur at any age. In fact, melanoma is one of the most common cancers in people younger than 30 years old, especially women. The risk is higher for women under the age of 50, but after the age of 50 the risk is higher in men.
Other diseases
Xeroderma Pigmentosum is a rare condition that affects the cells of the skin. It is an inherited disease that impairs the cells ability to repair damage to DNA. When having this disease you are at higher risk of developing melanoma.
Implementation of a health policy model
What is health policy?
According to World Health Organization, a health policy refers to a set of plans, decisions, and actions undertaken to achieve a health care goal within a society. It can achieve several things:
- It defines a vision for the future which in turn helps to establish targets and points of reference for short and medium term.
- Outlines priorities and the expected roles of different groups.
- It builds consensus and informs people.
- Choice of health policy
In Norway, the incidence of malignant melanoma is among the highest in the world, with about 1500 cases reported each year. Early diagnosis and appropriate surgical treatment cure many patients, as many as 80-90%. Therefore, the goal for the health policy should be prevention, early detection, diagnosis, and treatment of malignant melanoma, all achieved by increased attention to the risk factors and increased awareness in the general population.
In order to achieve this goal, we’ve chosen the ‘streams model’, also known as The Kingdon’s Three Stream Policy Window model. This model couples three streams, problem, policy, and political, to make a policy change. The problem, here the increased incidence of malignant melanoma in Norway and the lack of awareness to the risk factors. The policy stream is related to the alternatives that can be implemented and political stream is the willingness and ability of politicians to make a policy change.
We’ve decided not to use ‘the Stages model’ and ‘the Network model’ because we’ve found them to be inefficient. The former consist of negative feedback loops and re-alterations of the problem, and since our problem is already well-defined, the continuous re-alterations are unnecessary. The latter, ‘the Network model’,
Knowledge Exchange plan
With the incidences of melanoma increasing world-wide, it is necessary to take action. When it comes to Melanoma, a cancer which is fairly easily avoidable. The most important action that will be done is to inform the public. The most important aspects being the rise in occurrence, risk-factors, prognosis and of course prevention. But to get this knowledge to the public, we need a “Knowledge exchange plan”.
The message to share is straight forward, we want to raise awareness about Melanoma. Not just the disease in general, but maybe most importantly the risk-factors and prevention. The impact, or the action we want the “campaign” to have is to lower the occurrence of preventable incidences of Melanoma in the general public. This plan will need to be tailored to each of the identified audience respectfully. Especially when regarding what medium we use the distribute the information. We are proposing a campaign which will be subdivided into two parts. One part that targets the 12-25-year demographic and one more generalized part of the campaign.
With the increasing reach and influence the online blogger, YouTubers and “influencers” has been shown to have on the younger demographic, a campaign with a group of these people at the helm will have a great impact. We have many incidences in Norway where bloggers have raised their concerns about political issues which have led to greater awareness and change.
An example of this is from 2015 when the Norwegian blogger Sofie Elise Isachsen single handedly started a campaign to stop the use of palm oil in Norwegian food products. The campaign resulted in a nationwide boycott of all products including the oil and a few weeks later, these products were taken off the market. With the use of this kind of influence and reach, we could spread the awareness within the younger demographic. If we can reach the younger demographic and make it a part of their everyday conversations we think the campaign can make a difference.
The other part of the campaign would be a more generalized one, focused on the rest of the population. With more traditional modes of informing. Posters and billboards in the public room, infomercials, news articles and televised debates. We think that with this knowledge exchange plan, done right. We could make an impact on the preventable incidences of melanoma. Of course, this plan is not suitable for all nations. But for a country like Norway, where the online “influencers” have the reach that they do, we think this plan can make a difference. Say that the campaign we have proposed did make an impact and showed results, an important next step would be to remind the public regularly. A one time campaign is all well and good, but we think the campaign in some way or form should be repeated. We propose a 4 year interval between each campaign.
Current public health regulations
When it comes to regulations that the public health system in Norway are doing, or have done in the past, there is not a lot. There have been a few smaller campaigns consisting of televised infomercials. But they have not been followed by substantial results. This is why we think we need a new take on the campaigning that can really make a difference. As discussed earlier in the essay.
Public health challenges
As we see it, there is no issue with the diagnostic tools used, or the work done by the dermatologists that get the patients. The problem lies with the general awareness. If we can spread the awareness and make the public use sunscreen and do checkups with a dermatologist more frequently on their own accord, there will be a marked decrease in melanoma related deaths in Norway. The challenge will be to spread the awareness in a way that is understood and remembered.
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