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Standing Committee on Health - 08/08/2014 - Skin cancer in Australia

JOHNSTON, Ms Tamara, Community Programs Coordinator, Cancer Council NSW

WHITE, Ms Emma, Project Officer, Skin Cancer Prevention Unit, Cancer Council NSW


CHAIR: Welcome. Do you as witnesses appearing before the committee have any objection to being recorded by the media during participation in this hearing?

Ms Johnston : No.

CHAIR: Although the committee does not require you to give evidence under oath, I advise you that these hearings are formal proceedings of the parliament and warrant the same respect as proceedings of the respective houses. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. Would you like to make a short opening statement to the committee?

Ms Johnston : Yes I would. Today, I am representing the Cancer Council southern region. I work as a community programs coordinator and I work specifically across the Kiama-Shoalhaven area. In my particular role, I work in the community and local cancer specific programs and I address cancer prevention, information and practical support.

Ms White : I am here on behalf of Cancer Council NSW's skin cancer prevention unit. I am based out of the Sydney office. I believe you have already heard from my manager Vanessa Rock, the chair of the national skin cancer committee and manager of the skin cancer prevention unit. I am here to support Tammy if there is any additional information that she needs in relation to skin cancer specifically. I am also Illawarra resident.

Ms Johnston : Our understanding is that at previous hearings you have heard from other Cancer Council representatives. On that basis, we have kept the information today specific to this particular area and from a community perspective. Skin cancer prevention is a key priority working area for us here in the Shoalhaven. We recently undertook a community consultation. We surveyed 214 people and they were volunteers, community members, carers, survivors and some local stakeholders.

CHAIR: How did you do that? Was it at shopping centres or did you send something out?

Ms Johnston : No, it was mainly done through email and also a paper based survey. We sent it out to our networks, people we knew, and asked them to forward it on. It was an anonymously filled out survey. The idea was to find out our priority working areas for this region. Because we are community based and community funded, we like to make sure that we are targeting specific programs that are going to benefit the community and that they particularly want.

CHAIR: Where does the majority of your funding come from?

Ms Johnston : Mainly through fundraising. We are 96 per cent community funded. Daffodil Day is part of it

Ms White : On 22 August.

Ms Johnston : We are ambassadors.

Ms White : The other four per cent comes from government grants primarily.

Ms Johnston : From that consultation, skin cancer prevention was identified as the third highest priority area for prevention in this particular area.

Mr STEPHEN JONES: Below what?

Ms Johnston : The first one was screening and early detection. So you could probably argue that skin cancer sits in there as well. The second one was healthy weight and healthy eating, which we will target through other programs like Eat To Beat It and Kindy Orientations. That was our third highest priority prevention area. We know melanomas are the third most commonly diagnosed cancer in this area and we know that the Shoalhaven LGA has a red spot for skin cancer, and it is the 17th highest LGA for skin cancer prevalence.

In our regions, we work in skin cancer providing prevention programs, information and support and we also have community speakers who are volunteers, and they are trained to go out and do some talks on skin cancer awareness and prevention. They do those in workplaces and at other community events when requested. We also look at our different events like Relay for Life to educate the community on sun safe behaviours and talk about prevention and awareness again. So we use all the opportunities that we can.

Our key priority populations for skin cancer prevention—they probably will not surprise you—are children, adolescents, men of the 50-plus age group and, of course, outdoor workers, but we continue to maintain an ongoing level of activity and support for the other groups in the community. We know that unprotected exposure to UV radiation in the first 15 years of life significantly increases the risk of developing melanoma later in life. So we currently have a really strong presence in the early childhood setting and also primary schools. In the Shoalhaven, we have 88 per cent of Shoalhaven schools registered as SunSmart schools and we also have 94 per cent of the childcare centres registered as SunSmart. So we have quite high numbers in the early childhood and primary school settings now, and we know that what we are doing there seems to be working and we are quite happy with that particular space.

With regard to adolescents, we know that, despite their high levels of awareness about sun protection and skin cancer, adolescents spend more time outdoors, are more likely to get a tan or get sunburnt and have poorer sun practices than other age groups. I am a mother of two high school aged daughters and I have seen firsthand how things are panning out in that space. To address that, we are using Sun Sound at the moment, which you may have heard about at other hearings. Sun Sound is Cancer Council NSW's flagship social marketing program and we target that at teenagers specifically. Sun Sound is a catchy short jingle played regularly over public address systems at outdoor recreational settings, mainly outdoor pools and some beaches. It is a cue to action. The idea is that they hear the jingle and think about sun protection that they may not have thought about before—put some sunscreen on; put a hat on. It is just a reminder because, from what we have learned, it is not that teenagers do not want to protect themselves from the sun; it is often that they forget. We currently have 60 sites across New South Wales and are hoping to grow this over the summer season, target some Shoalhaven outdoor pools, perhaps look at some beaches and work with surf-lifesaving to implement it at a few of the local beaches.

Obviously we are concerned about the skin cancer statistics and we know two and three are going to be diagnosed by the time they are 70. Knowing that this is largely preventable, we would love to see more public awareness and it would be fantastic to see a federally funded mass social media marketing campaign.

CHAIR: Emma, do you have anything to add?

Ms White : No, I am happy just to respond to questions. I think Vanessa Rock would have covered my work area.

CHAIR: Going back to your survey, you said the No. 1 priority was—

Ms Johnston : Screening and early detection.

CHAIR: In your submission you make a comment that screening is not a viable option, but the information you have given us is based on a couple of reports, one 40 years old and the other about 35 years old, and you have one that goes back to 2008, I think. One of the things that has been raised—and I have been one of the people to raise it—is the fact that the cohort that is mostly getting diagnosed now is the 50-plus cohort, which would be a perfect target in bowel screening programs. Maybe rather than running a skin cancer screening program it would be useful to send a message with the bowel screening, with letters going out to remind them that getting a check for skin cancer would be a good thing to do as well in their cohort. So, rather than a screening program, it could be part of another screening program. What are your thoughts on that?

Ms Johnston : In relation to that, it was the screening program in general that we were against, not the reminder for people to have a skin cancer check in particular. Would you say that, Emma?

Ms White : Yes. I think the evidence is not there that a screening program for skin cancer is the right way to go, which is what the Cancer Council Australia submission that covers all states and territories is referring to. In reference to what Tammy was saying about screening, it was not necessarily skin cancer screening that was the No. 1 priority; it was screening for all cancers.

Ms Johnston : It was screening for all cancers, so that could be bowel and cervical cancers as well.

CHAIR: We heard Andrew's story this morning. Do you do any work with the surf lifesaving groups at all or do you largely leave it up to them?

Ms Johnston : We are looking at working with surf lifesaving clubs this summer. Emma can probably tell you in more depth because that is her area of expertise.

Ms White : I sit on a working group for the Cancer Institute New South Wales. That is a sport and recreation working group and a representative from Surf Life Saving New South Wales also sits on that working group, so we work together under that banner. We also have a partnership agreement with Surf Life Saving New South Wales where we share information: they have shared information for us in the past with their members and we have shared their information. We have also been working together to look at how we can update their sun protection policy so it is in line with Cancer Council New South Wales. Their sun protection policy is likely to sit under Surf Life Saving Australia's policy, which, as we have been told, has been updated as well. In the past their policy has been updated in line with Cancer Council Victoria, so it did meet best practice at that time.

We have generally implemented the sun sound in partnership with local government but, as we are moving forward, it is going to be implemented much more on a three-way partnership basis with local government, surf lifesaving clubs and us.

CHAIR: What about other local sporting groups, particularly junior sporting groups like the NRL and cricket, and getting them at a younger age into good habits early?

Ms White : We have existing partnership agreements with a few of the peak bodies, so with AFL New South Wales and I think off the top of my head Swimming New South Wales, but I am not 100 per cent certain on that. To date we have been working primarily with the peak bodies to filter it down. At the local level there have been some other activities that Tammy might want to talk about.

Ms Johnston : We had Football South Coast approach us about becoming a SunSmart club for a clinic. We worked with them to make sure that they had the right policies in place—that they had the shade and everything was in line with our recommendations.

Ms White : We also work with the office of sport in the New South Wales government. They also sit on the Cancer Institute working group and we work closely with them as well.

CHAIR: Are there any skin cancer clinics purely dedicated to skin cancer checks in this area? At every other hearing we have had them appear and give evidence but they are not here today.

Ms Johnston : Our message is if you have a spot or something that needs checking that you should go to your GP first and then move on from there. I am not aware of skin cancer clinics in this area.

Ms White : There are potentially two in Wollongong that I can think of, but I am not sure about Nowra.

Mrs SUDMALIS: There was one here but it closed about 12 or 18 months ago. It was in North Street.

Ms White : The Cancer Council recommends that people go to their GP as the first port of call.

CHAIR: Do you have a template or a policy you can give schools to implement? If there are things they do not want to implement, do you try to trade them up or supersize them to your policies?

Ms Johnston : Yes, we do. There are 10 recommendations. What are they?

Ms White : They have two options when they join up to the SunSmart program. They can be already implementing the recommendations, which is obviously fantastic, or they can commit to implementing them over a three-year period. Out of those 10 recommendations they are usually doing well in about seven of them and then we work with them to make sure that they implement the other few recommendations. That might include working towards phasing out over a period of time baseball caps, if they have them in the school, because it is not practical for most schools to overnight go from a baseball cap to a broadbrimmed hat. So it is about working with them in the school environment to be able to achieve those behaviour changes.

Mr STEPHEN JONES: I do not know if you were in the room earlier today. We heard a bit of evidence regarding GP training. One of my areas of interest in this space is what we are doing in prevention and primary care. When I go to my GP I regularly get asked whether I smoke, drink—all of that. I cannot ever remember being asked how I stay safe in the sun. Do you have any views about the sorts of opportunistic messaging or the care that could be given through the GP network?

Ms Johnston : I think that comes back down to the primary care setting and the training that they go through. That would be something that would be part of their regular questions about your sun behaviours, about any spots that might be worrying you and whether or not you have regular checks. Would you agree with that?

Ms White : Yes, it is about ensuring that GPs have the most up-to-date clinical guidelines and things like that so they can make those decisions.

Mr STEPHEN JONES: Mr Irons was asking about sporting organisations. Do you risk rate particular sports or sporting organisations when you are focused on prevention and education?

Ms White : Did you say, 'Do we risk rate them,' as in do we prioritise what sporting groups we work with?

Mr STEPHEN JONES: I am assuming, but I do not know, cross country skiing is probably not high in the area that you focus on but there might be others that are?

Ms White : Our area in the sporting groups is relatively new. Being a community funded organisation, obviously our resources have had to be dedicated to certain areas which is why we have focused so much on the childcare and primary school setting to date. We know that the evidence is that the first 15 years of life is the most critical.

It is a very early piece of our work where we have prioritised the sporting groups. As I said, we have got some high-level relationships with those few peak sporting bodies. We are really starting to work closely with surf lifesaving as one of the priority areas at the moment because we know that the nippers are outside and exposed to the sun. They are in that priority target audience where we have potential to prevent skin cancer in the long term. But in putting a risk rating specifically, we have not done anything or categorised all of the sports and said this risk rating is 'x'.

Mr STEPHEN JONES: Young kids play sport summer and winter.

Ms White : Yes, so we obviously would be considering the sports that are most appropriate, the time of day they are outside and how long they are going to be exposed for. If they are only outside for a short period of time during the middle of winter then it weighs up differently to if they are outside at a surf carnival all day in the middle of summer.

Mr STEPHEN JONES: Or little athletics.

Ms White : Some sports are run at night and things like that so it is all taken into consideration.

Mrs SUDMALIS: I just have one somewhat trivial question. You have got the Sun Sound, is it? Which age group is that specifically targeted to?

Ms White : It is specifically targeted to teenagers, 12 to 18 years, with a primary target audience of 15 to 17 years. We actually did a research project with the University of Wollongong back in 2007 through an ARC grant into that audience and found a large percentage of those teenagers, about 36 per cent, in that age group are not averse to using sun protection but they just forget. So like we heard Andrew say before, his kids go outside having fun with their friends. It is not that they are necessarily not doing it on purpose but they do not have that reminder so that is where the Sun Sound is supposed to come in.

Mrs SUDMALIS: I am just so curious because that is such a disparate group of young people that some of them will listen to a particular style of music, others will completely switch off and others will get abusive. I am wondering how on earth did you develop something that is universally acceptable? Have you trialled it with them yet?

Ms White : It was piloted in 2009. It only goes for five seconds so it is not like it is a song.

CHAIR: Could you sing it for us?

Ms White : I have got it on my phone; I could play it for you if you like. It goes for five seconds and then it has three words at the end that say, 'Be Sun Sound,' so it has a call to action. It was developed by Ben Lee, who in 2009 was quite popular teenage musician.

Mr STEPHEN JONES: Do you mean he is not anymore?

Ms White : I am sorry; I do not know if he is—I am not a teenager. But it has been well received in the evaluation.

Mrs SUDMALIS: You did well then.

CHAIR: One of the things we have heard is that there might be a child who has got sunburnt on the weekend but they still allow them to go out and do sport already being in a sunburnt condition. Also does the time of day they run their PT and sporting events enter your template or recommendations at all?

Ms Johnston : It is in our recommendation that they schedule outdoor play in the sun safe times. I think we have even recommended perhaps in the summer changing the lunch break to an earlier time of day if necessary and having play at a time when the UV rays are not quite at their peak. But it is up to the individual school so it is a hard thing. I guess they have always got their own timetables and own agendas to compete with as well but obviously we would prefer that if the children are outside playing or playing sport that it was in a time of day when the UV ratings are at their lowest. The schools could perhaps schedule them earlier in the morning when they first arrive at school rather than in the middle or later part of the day that most schools seem to do.

CHAIR: When is the best time to start getting skin checks? I know my son had one when he was 19 but only because I forced him to. He spends a lot of time outside doing sport and being at the beach. He actually had some skin removed. Does the Cancer Council have any recommended times or just whenever?

Ms Johnston : We do not have a recommended time but I think the recommendations would be to know your own skin and if there is something suspicious there. Ask your GP at the first sign of any mole or freckle changing or any changes at all.

CHAIR: We heard that through Andrew's efforts, his awareness program and fundraising that there were an extra 900 people who got skin checks. Is that the type of thing that prompts people to do it? Do you think they need to be shocked into going to get a check? Or do you think they are still fairly complacent and maybe that is the only way they will get it done?

Ms Johnston : Everyone is different so for some people shocking them in to having a skin check will work and for others it will not. But we are always trying different things in a well rounded approach.

CHAIR: Have you tried a shocking campaign?

Ms Johnston : I do not think we have had a shocking campaign.

Ms White : No, we do not really do mass media. In New South Wales the Cancer Institute generally do that. They did the dark side of tanning campaign that show the internal process of melanoma moving through a teenager's body. For the last three years they have aired the Wes Bonny Testimonial Campaign which is about Wes Bonny, who was a 26-year-old who died of melanoma. It is the personal story of his family and friends and what it was like for them to go through that. So that is where that fits in. We do more of the environmental strategies and changing behaviour at the grassroots level.

CHAIR: There seems to be quite a few different campaigns. Do you think it would be better to have one concerted effort into one type of campaign?

Ms Johnston : Yes.

Ms White : Yes, I agree.

CHAIR: And send a united message out instead of diversifying?

Ms Johnston : Definitely, a nationally funded mass media campaign is what the Cancer Council is advocating for.

CHAIR: What do you think about the UV message against a campaign like Slip, Slop, Slap? Do you think the UV campaign will be as effective as that? That has probably been the most effective campaign so far, hasn't it?

Ms White : The Slip, Slop, Slap campaign is definitely the most widely recognised campaign in Australia. Tammy and I went out last summer to some of the pools playing Sun Sound and they still had signage up for Slip, Slop, Slap form the 80s so we know that it has sticking power. I do not really have a firm recommendation on whether the UV campaign is going to be more effective. In New South Wales specifically the UV is above three most of the time nearly all year round. It is only really in that June and July period and towards the more southern part of the state that it drops below three. So we know anytime that the UV is above three, you need to be using sun protection. In Queensland, it is pretty much above three all year round. So if you are telling them to use the UV ratings, you should be using sun protection all year.

CHAIR: I cannot imagine people going to check their apps, saying, 'What's the UV rating? Shall I go and put something on?'

Ms White : It is becoming much more embedded into the child-care sector, as part of the SunSmart program. Child-care settings seem to be using the UV a lot more. It is a very helpful message, and the SunSmart app helps out with that as well. Whether it is going to be more effective, I cannot make a comment.

Ms Johnston : In talking to Andrew Rust earlier, he said he actually uses the app to check the UV rating regularly.

CHAIR: But he is educated!

Ms Johnston : Yes, he is. And an educator.

Mr STEPHEN JONES: Through the work of yourselves and many others, you have pretty much nailed it in the school sector, particularly the primary-school sector. I know a dad with kids in primary school. His kids sit inside if they do not take their hats to school. I am wondering how well that goes once they do hit the 15 and 16 age group and they become fashion conscious. What is the relationship you guys have with the fashion industry and what sort of influence do you guys have over the way they promote or design looks, fashion, clothing—if any?

Ms Johnston : I would not say we have any relationship with the fashion industry at the moment. We do just stick to our recommendations for the kids to display sun-safe behaviours—with longer shirts when the sun is out, rash vests, sunscreen and hats. I agree, it is really challenging. For teenagers, that is something that is important to them and they want to look like their peers and dress like their peers, and if that is a risky behaviour, in the sun, then that is always a challenge. Do you agree?

Ms White : Cancer Council NSW has retail stores that sell sun-safety products as well. In New South Wales we have about six.

Mr STEPHEN JONES: I can get my daughter to wear one now, but I reckon I will have Buckley's chance when she is 16!

Ms Johnston : Yes, I can relate to that.

Ms White : We have seen that teenagers are definitely a hard-to-reach audience for sun protection and for many other health behaviours.

CHAIR: In regard to support groups in the area, if you hear of someone who has been diagnosed are you able to provide them with a list of support groups?

Ms Johnston : Yes, we are. If we hear of someone who is diagnosed and we do have a full directory we usually ask them to ring our helpline and we direct them to a full spectrum of resources. That would include whatever the local support group is in their particular area.

CHAIR: Ladies, thank you for coming in today to assist us with your evidence to the committee. If you have been asked to provide additional information or you think there is anything further that could help the committee's inquiry, please have it to the secretary by 21 August. If we have any further questions for you, we will send them in writing through the secretariat. Once again, thank you for coming to see us. We appreciate it.

Ms Johnston : Thank you having me.

Ms White : Thank you for the opportunity.