2020 Skin Cancer Report

2O2O Melanoma Skin Cancer Report Stemming the global epidemic

About us 50%

Euromelanoma

The Global Coalition for Melanoma Patient Advocacy The Global Coalition for Melanoma Patient Advocacy was formed in 2014 by the Melanoma Research Foundation in response to the global need to bring the patient voice to the melanoma space. The group has grown to include organisations from 27 different countries and is enthusiastically supported by its partners around the world, as well as the global patient, healthcare and pharmaceutical communities. The Coalition meets the vital needs of the worldwide melanoma community through three working groups, which each specialize in a unique area that addresses globally relevant issues for melanoma patients; Melanoma Awareness and Patient Resources, Patient Advocacy and Access to Treatment, and Collaboration and Recruitment. The Global Coalition for Melanoma Patient Advocacy meets annually and is determined to make the deadliest skin cancer curable through its worldwide partnership. For more information or with questions about the Global Coalition, email:

Euromelanoma is Europe’s leading skin cancer awareness group. It is run by a network of European dermatologists who give up their time to promote and share information on skin cancer prevention, early diagnosis and treatment. It focuses on public awareness of skin cancer, including an annual ‘Euromelanoma Screening Day’; sharing knowledge and best practice with the healthcare community; and working with policymakers to ensure the treatment of skin cancer is fully recognised and supported in healthcare systems and policies. Euromelanoma is a registered charity and is active in 33 countries. For more information or with questions about Euromelanoma visit:

www.euromelanoma.org

global@melanoma.org

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Global Coalition | Euromelanoma | 2020 Melanoma Skin Cancer Report

Contents 50%

Section 1

4 Introduction

Section 2

Skin cancer in 2020 & beyond: a growing epidemic

Melanoma Today Melanoma Tomorrow

6 8

Section 3

3 key battlegrounds for fighting skin cancer

Improving public awareness of skin cancer risk factors Reducing intentional tanning Making skin self-examinations a regular habit

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12 14

3

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IntroductionP

For a second year, Euromelanoma and the Global Coalition for Melanoma Patient Advocacy are partnering to run a global melanoma awareness campaign. By combining our resources, we hope to reach hundreds of millions of people in over 50 participating countries.

This report is at the heart of that campaign. Its purpose is to show that the world has a melanoma problem. And that it’s getting worse. Over the last decade, the annual cases of melanoma, the deadliest form of skin cancer, have increased by nearly 50% to over 287,000 1 . This translates to more than 60,000 1 melanoma- related deaths per year.

millions. This makes skin cancer the world’s most common cancer. 1,000,000

non-melanoma cases a year.

Albeit less dangerous because they aremore easily treated, there were still 65,000 1 non-melanoma- related deaths recorded in the last year. When combined with melanoma-related fatalities, this equates to one person dying from skin cancer every four minutes.

Annual cases of melanoma, the deadliest form of skin cancer, have increased by nearly 50% to over 287,000. 1

50%

This equates to one person dying from skin cancer every 4 minutes.

Add to these figures the current incidence and mortality rates for non-melanoma skin cancers, and we can see why dermatologists believe skin cancer should now be seen as a global epidemic. Official figures fromtheWorldHealthOrganization estimate that there are currently over one million 1 cases of non-melanoma skin cancer each year. However, with many countries not officially recording cases of non-melanoma skin cancer, the real incidence is widely thought to run into several

For a cancer that can usually be beaten if caught early, this statistic is shocking. More shocking though are the projections for skin cancer over the next 20 years. The latest data from the WHO predicts that, by 2025, the number of deaths

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Global Coalition | Euromelanoma | 2020 Melanoma Skin Cancer Report

resulting from melanoma will increase by 20% 2 , rising to 74% 3 by 2040.

cancers. So, the second half of this report sets out the three battlegrounds dermatologists believe are key to reversing the current trend. In response to the melanoma epidemic, we need a social epidemic that changes thinking and behaviours.

We need a social epidemic that changes thinking and behaviours.

The number of deaths resulting from melanoma will increase by 20% 2

The first section of this report therefore uses hard facts and figures to quantify the size of the world’s melanoma challenge. Is this scaremongering? Absolutely. The data shows a wake-up call is needed.

We examine the need for ongoing public education regarding melanoma risk factors, strategies for reducing intentional tanning, and the need for making frequent skin self-examinations a regular habit.

Data shows a wake-up call is needed.

While its growing prevalence must be recognised, it’s equally important that people know that melanoma skin cancer is one of the most preventable and, if detected early, treatable

Kyleigh LiPira CEO of the Melanoma Research Foundation, founding member of the Global Coalition for Melanoma Patient Advocacy

Veronique del Marmol Chair of Euromelanoma

References 1. Global Cancer Observatory – 2018 data from ‘Cancer Today’

2. Global Cancer Observatory – projected 2025 data from ‘Cancer Tomorrow’ 3. Global Cancer Observatory – projected 2040 data from ‘Cancer Tomorrow’

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Skin cancer in 2O2O & beyond A growing epidemic: melanoma today

Global incidence and mortality rates

Top and bottom five countries by mortality-to-incidence ratio

In 2018, 287,723 cases of melanoma skin cancer and 1,042,056* of non-melanoma skin cancer were diagnosed globally. 60,712 people died of melanoma skin cancer and 65,155 of non-melanoma skin cancer.

Mortality-to-incidence ratio (MIR) indicates there is huge disparity between the treatment outcomes of the top and bottom five countries:

* non-melanoma skin cancer is under reported and widely acknowledged to run into several million

2018

Mortality-to-incidence ratio (MIR)

1.

Australia Germany

11% 11% 12% 12% 12%

Change since 2008

2. 3. 4. 5.

Luxembourg

Incidence rates of melanoma skin cancer rose by 44% between 2008 1 and 2018 with deaths increasing by 32%.

Denmark

Switzerland

38. Bosnia &

37%

Herzegovina

Top and bottom five countries by incidence per capita

39. Montenegro

38% 39% 43% 46%

40. Romania 41. Bulgaria 42. Poland

Globally, one person in every 26,522 developed melanoma skin cancer in 2018, however the incidence rate per capita varied widely between countries:

Incidence and mortality of melanoma v lung cancer

2018

Per capita 2 1 in 1,746 1 in 1,983 1 in 2,243 1 in 2,316 1 in 2,645 1 in 26,049 1 in 28,280 1 in 40,984 1 in 41,768 1 in 69,968

1.

Australia Norway Denmark Sweden Germany

2. 3. 4. 5.

With an average MIR of 21%, melanoma skin cancer remains one of the most treatable cancers compared to others, such as lung cancer, which has an 84% MIR.

Incidence and mortality by sex

38. Argentina 39. Brazil 40. Mexico 41. Albania 42. Japan

Men are 10% more likely to develop melanoma skin cancer than women, and are 4%more likely to die from melanoma than women.

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Global Coalition | Euromelanoma | 2020 Melanoma Skin Cancer Report

Estimated crude incidence rates of melanoma in 2018 for both sexes, all ages

The relationship with the Human Development Index 4

Incidence by body site 3

References 1. Calculated using Globocan 2008 data 2. C alculated using United Nations Department of Economic and Social Affairs Population Dynamics data 3. Melanoma skin cancer incidence statistics, Cancer Research UK 4. W orld Cancer Research Journal, Global Incidence and mortality of skin cancer by histological subtype and its relationship with the human development index (HDI); an ecology study in 2018 All other figures from the Global Cancer Observatory – 2018 data from ‘Cancer Today’ • People in countries with a high Human Development Index (HDI) score are more likely to be diagnosed with melanoma • But people in countries with a lower HDI score are more likely to die from it

14%

23%

25%

19%

20%

41%

38%

13%

7 7

Many dermatologists already believe that skin cancer has reached epidemic proportions. But a new online tool created by the Global Cancer Observatory for the World Health Organization gives us shocking insight into how incidence and mortality rates for melanoma and non-melanoma skin cancer could rise even further over time. Skin cancer in 2O2O & beyond A growing epidemic: melanoma tomorrow

This tool predicts that by 2025, the number of cases of melanoma skin cancer diagnosed worldwide will rise 18% to 340,271 with the number of deaths increasing 20% to 72,886. By 2040, the figures are staggering. Nearly half a million (466,914) people will be diagnosed with melanoma skin cancer, an increase of 62% on 2018 figures, while 105,904 will die from the disease, an increase of 74%.

There are a number of reasons why we could see melanoma skin cancer rising so dramatically in the future. The link between exposure to the sun and skin cancer wasn’t discovered until 1956 and this information wasn’t widely translated into actionable information for the public for several decades. Even today, anyone aged 50 or above, would have spent a large proportion of their life unaware of the risk of sun exposure.

Incidence

Mortality

500,000

The link between exposure to the sun and skin cancer wasn’t discovered until 1956.

375,000 250,000

125,000

The aim of sun safe campaigns is to reduce risk. But there’s a worrying development identified in research by IPSOS for La Roche-Posay. It found that young people aged 15 to 19 took the biggest risks and used the least protection in the sun.This is concerning, given that this age group grew up with sun safe messaging. Even if they later revert to sun safe behaviour when they grow older, the damage may have been done. The risk of melanoma in later life doubles 1 if a child or adolescent has experienced just one blistering sunburn.

0

2018

2025

2040

Ask any dermatologist and they will tell you the number of patients they see being diagnosed with melanoma and non-melanoma skin cancer is increasing. But the figures predicted for 2040, with half a million people diagnosed with melanoma skin cancer a year resulting in over 100,000 deaths, are truly shocking. 500,000

Young people aged 15 to 19 took the biggest risks and used the least protection in the sun.

15-19

melanoma cases a year.

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Global Coalition | Euromelanoma | 2020 Melanoma Skin Cancer Report

We also know that life expectancy is increasing. While this is good news, dealing with an ageing population throws up some challenges for tackling melanoma and non-melanoma skin cancer. We know that incidence rates increase with age. This is largely due to accumulated sun exposure over a person’s lifetime. And it equates to a ticking time bomb for melanoma and non-melanoma skin cancer incidence rates.

There are a number of possible reasons for this. People in more developed countries are more likely to be diagnosed and treated quickly, whereas those in less developed countries may not seek medical treatment immediately. This may be due to income, lack of awareness of the signs of skin cancer or simply a lack of healthcare provision. This needs to change. We know that delaying treatment of a stage 1 melanoma by just one month (30 days) increases the risk of death by 5%. This rises to 41% if treatment is delayed by around four months (119 days). 1

47% 74%

100%

23%

Delaying treatment of a stage 1 melanoma by just one month increases the risk of death by 5%.

Another factor affecting skin cancer incidence is the environment. When the hole in the ozone layer was at its largest, cases of skin cancer rose dramatically. Worryingly, recent reports show the hole is now growing again. Experts fear this will lead to people being exposed to unprecedented levels of UVB radiation from the sun. This means that if the climate crisis worsens, the effect on melanoma and non-melanoma skin cancer diagnosis could actually be far greater than the figures predicted by the World Health Organization. As we saw in the 2018 data, a high incidence rate in a country does not automatically translate to a high mortality rate. Instead, while people in countries with high HDI scores are more likely to be diagnosed with the disease, it is people in countries with low HDI scores that will die from it. 1-18 19-40 41-59 60-78 Sun exposure based on 78 year life span. 1

Finally, figures are under-reported. Many countries with low socioeconomic status have inadequate cancer registries. This means the number of cases may not be recorded accurately, giving an incomplete picture. Predictions give an indication of the likely burden of melanoma and non-melanoma skin cancer both on individual countries, and on the world, as well as the catastrophic human cost. They are our best guess. But we have the power to change the future. Melanoma and non-melanoma skin cancer is preventable and, if caught early, treatable. It is imperative these figures act as a wake-up call for healthcare professionals, policymakers and the public the world over. We can all take action to ensure these figures do not become a reality.

References 1. Skin Cancer Facts & Statistics: Skin Cancer Foundation

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3 key battlegrounds for fighting skin cancer Improving public awareness of skin cancer risk factors

The problem Skin protection

• 6 8% of people only protect their skin in certain situations, yet 87% of people ‘always’ or ‘often’ protect their children’s skin 1

92% of people recognise that sun exposure can cause health problems. 1

92%

Recognising the risks

74% recognise that the risk of developing skin cancer is linked to a family history of the disease. 1

But only 18% of people always protect their skin from the sun. 1

18%

The solution

Dr David Fisher – Chairman of the Department of Dermatology and Director of the Melanoma Program at Massachusetts General Hospital, Harvard Medical School There is clearly a difference between people’s awareness of skin cancer risk and their corresponding behaviour in terms of protecting their skin. The explanation for this is multi-factorial but it mostly relates to a monotony of human behaviour. While there may be a cerebral recognition of the risk, our daily practice and routines mean we become used to what we see in the mirror in front of us. This is normal psychology. Unless we have had experience with skin cancer, either directly ourselves or through a loved one, the potential danger can feel quite removed. As with other types of health risk, our natural complacency means we see it as something that happens to other people. I am often asked if there is a safe dose of UV. The simple fact is that any UV exposure can be harmful. Determining the level of risk is complex because it varies significantly for different individuals. What’s important is that each person understands their own particular risk profile – and this is determined by both environmental and family-related factors.

The simple fact is that any UV exposure can be harmful.

From an environmental perspective, one should consider not just the amount of time spent in the sun, but the intensity of UV exposure. For example, a longer time spent outside in Boston in the winter may have a lower UV intensity than a shorter time exposed to the summer sun in Florida. Similarly, the degree of protection is also a factor. Has a suitable sunblock been applied, and have you been wearing long-sleeved clothing and a hat?

Managing the risk of exposure is dependent on your location, the season, and the protective measures taken.

When considering your risk profile, you should also think about family-related factors. Are you naturally light-skinned, and therefore more susceptible to

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Global Coalition | Euromelanoma | 2020 Melanoma Skin Cancer Report

• 8 8% of people link the risk of skin cancer with a lack of protection during exposure to the sun 1 • 8 1% associate skin cancer with regular use of tanning beds 1

• 7 2% associate the risk of developing skin cancer with the number and size of their moles 1 • 6 8% believe risk of skin cancer is linked to the fairness of their skin 1

75% recognise developing skin cancer is linked to the level of sun exposure, and number of sunburns, during childhood or adolescence. 1

References 1. Skin cancer prevention study by La Roche-Posay and Ipsos

sunburn? Is melanoma or non-melanoma skin cancer prevalent in your family? Do you have a history of childhood sunburn from family holidays? What can be done to bridge the gap between awareness of sun exposure risk, and people’s corresponding sun protection behaviour? Firstly, we should recognise that we have a huge opportunity for positive change. If you look across the spectrum of human cancers, there are actually very few where we can be sure of the cause. Smoking and lung cancer is obviously one. The relationship between UV exposure and both melanoma and non-melanoma skin cancers also has a clear correlation. We must therefore continue to have public education programmes, like this one, that challenge people’s understanding of their own risk factors and break the cycle of harmful behaviours. My experience is that messages about skin cancer risk tend to resonate more with people when you describe the need to protect their children – because they usually take more care of their children than themselves. This kind of intervention becomes even more powerful when parents teach children to protect themselves, so that these learned habits

continue after they’re no longer in the care of their parents.

Messages about skin cancer risk tend to resonate more

with people when you describe the need to protect their children.

Secondly, we should accept that people like being in the sun. There is now evidence that the UV exposure response in our skin produces endorphins and is an opiate addictive pathway. Put simply, it feels good. One theory is that being attracted to the sun 100,000 years ago might have been the only way to protect yourself from vitamin D deficiency – which would otherwise be fatal. Interestingly, this is probably the origin of Caucasian skin, which made it easier for light to produce vitamin D. But today, vitamin D supplements are readily and cheaply available. They satisfy your need for vitamin D, without adding potential risk of skin cancer from sun exposure. So, instead of demonising the enjoyment people feel from being in the sun, we should recognise it, offer constructive alternatives, and help people to take appropriate measures to protect their skin.

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3 key battlegrounds for fighting skin cancer Reducing intentional tanning

• A nd 49% of people cannot imagine coming back from holidays without being tanned 1 • Y et… 92% of people know sun exposure can cause health problems 1

The problem The desirability of tanned skin

61%

93% of people recognise that tanning accelerates skin ageing. 1

61% of people believe having tanned skin is attractive. 1

The solution

Dr Mariano Suppa – Dermatologist and author of several papers on the relationship between skin cancer and sunbed use It should now be beyond doubt that intentional tanning, and the use of sunbeds in particular, presents increased risk of skin cancer. In countries where sunbed use is prevalent, we have seen increased melanoma incidence rates amongst younger people. This disease should no longer be considered something of concern to just older generations. So what should be done about it? Although winning this battle will be slow, I think success lies in using different kinds of interventions – in terms of public education, social change and regulation.

Melanoma Patient Advocacy, are important vehicles for engagement and education through these media channels. Similarly, more action is needed in terms of occupational sun exposure. The construction and postal industries, for example, require their staff to be outside for much of the day. Employers have a duty of care to educate and protect these kinds of outdoor workers. Is appropriate clothing and sunblock being provided? Is training given about skin protection and self-examination? Are shift patterns organised to minimise sun exposure? While some organisations demonstrate good practice, there’s huge potential for progress in this area. Social change But knowledge of risk does not always translate into less risky behaviour. To really strike at the heart of this issue, we need to see the kind of social and cultural change that makes having tanned skin less desirable. We live in an age where being tanned is ‘cool’. The standard of beauty is to have a fit, tanned body. But it hasn’t always been like that. 100 years ago, being pale was in fashion and we saw ‘the noble classes’ walking in the sun carrying umbrellas. This was opposed to having a tan, which implied you were an outdoor labourer. The positive message for our modern times should be to embrace the natural, untanned appearance of your skin – whatever its original colour.

Success lies in using different kinds of interventions.

Education The starting point for positive behavioural change is to ensure people at least have the right facts and understanding. The media – broadcast, print and particularly social media – is key in raising awareness of skin cancer, its effect, and what causes it. Public awareness programmes, like this global campaign from Euromelanoma and the Global Coalition for

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Global Coalition | Euromelanoma | 2020 Melanoma Skin Cancer Report

Sunbed use • U se of sunbeds before the age of 30 results in a six-fold increase in risk of melanoma 2 • 14 lifetime sunbed sessions increase the risk of melanoma by 19% 3 • In the US, the cost of treating skin cancers caused by sunbeds is an estimated $127.3 billion 4

References

1. Skin cancer prevention study by La Roche-Posay and Ipsos, 2015 2.  Association between indoor tanning and melanoma in younger men and women, by D Lazovich, R Vogel Isaksson Vogel, MAWeinstock et al, 2016 3. Indoor tanning and melanoma risk, by R Ghiasvand, CS Rueegg, E Weiderpass et al, 2017 4. The health and economic implications of the use of tanning devices, by HR Waters, AAdamson, 2018 5. Skin Cancer Facts & Statistics: Skin Cancer Foundation

More people develop skin cancer because of indoor tanning than develop lung cancer because of smoking. 5

Two things in particular can help here. Firstly, the influence of celebrities shouldn’t be underestimated. These social icons, with their millions of Instagram followers, would do a lot of good if they promoted a ‘natural’ look more than their time spent sunbathing in exotic locations. Celebrities sharing their stories about skin cancer and melanoma is part of this. The actor Hugh Jackman, for example, was very open about the treatment he received for skin cancer. This role model strategy is a good way of changing the public’s perception of having tanned skin.

outright ban has been criticised, and not just by the industry that makes and sells them. There is a valid argument that a complete ban could backfire, driving the practice of sunbed use underground – where it cannot be properly monitored and regulated (as was the case with the prohibition of alcohol in the United States in the 1920s). European countries have taken the right approach by banning the use of sunbeds by people under the age of 18. 18 From a legislative point of view, I think the majority of European countries have taken the right approach by banning the use of sunbeds by people under the age of 18. This is something that is more feasible and controllable. Other regulations could include restrictions on advertising, restrictions on sunbed use for those at high risk of skin cancer (i.e. fair skin or a family history of the disease), the systematic registration of tanning equipment, the ban of coin-operated self-tanning machines, and the mandatory presence of supervising staff trainedby independent authorities. For these to be effective, salons must of course comply with the regulations. Non-compliance must therefore result in severe sanctions.

Social icons, with their millions of Instagram followers, would do a lot of good if they promoted a ‘natural’ look.

Secondly, getting the message right is key. Research shows that sunbed users are more concerned about the possible ageing effects of artificial tanning than the risk of skin cancer. So, strong messages and images about the long-term negative cosmetic consequences are needed. Regulation Lastly, I think governments and policymakers have an important role to play. When you consider that sunbeds are carcinogenic, and that has been proven, the first thought might be to ban them. But an

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3 key battlegrounds for fighting skin cancer Making skin self-examinations a regular habit

The problem

Only 11% of people have their moles checked by a dermatologist at least once a year. 1

Dermatologists say skin self-examinations should be carried out every month.

11%

The solution Prof Veronique del Marmol – European Chair of Euromelanoma and Head of Dermatology, Erasmus Hospital, Brussels Creating a habit It seems a simple fact of life that slipping into bad habits is far easier than finding time for something healthy in your routine. But melanoma and non-melanoma skin cancer incidence rates are increasing, so we must find ways to make skin self-examinations a consistent feature in our monthly calendar. What are some of the ways to do this? As the figures above show, people tend to take more care of others than themselves. Whether at the family dinner table, or checking- in with friends and loved ones on Snapchat, a quick question about the last time they did a skin check could be life-changing. Let’s make sun protection and skin checks part of our regular conversations. Almost all of us now have a mobile phone. Either through the calendar app or a reminder app, it’s very simple to set up an automatic monthly alert to conduct a skin self-examination. And for those of uswho aren’t keenon technology- based assistance, there’s a naturally occurring reminder that’s free for everyone on the planet

to use: a full moon. Regardless of where you are on earth, your gender, age or religion, a full moon happens once every four weeks. This is why our public awareness campaign in 2020 asks people to ‘Look Up’ – and see a full moon as their monthly reminder to conduct a skin check. How and where to look The monthly skin self-examination should cover the whole body, front and back, with particular attention given to areas exposed to the sun. We always recommend standing in front of a full- length mirror with a hand mirror, so that hard-to- reach places can also be checked.

Step 1 Look at your face, including your nose, lips, mouth and on and behind your ears

Step 2 Check your scalp, using a comb to part your hair. If you do not have much hair, check your entire scalp very thoroughly

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Global Coalition | Euromelanoma | 2020 Melanoma Skin Cancer Report

• J ust 33% of people self-check their moles at least once a year 1 •  44% of people have told someone else to get their moles checked 1

73% of people think they do more for the health of the people they love than their own health. 1

References 1. Skin cancer prevention study by La Roche-Posay and Ipsos

What to look for When conducting amonthly skin self-examination, it makes sense to check for both melanoma and non-melanoma skin cancer. People should look for moles that: • H ave changed size, colour and/or shape • A ppear different to the rest (what we call ‘the ugly duckling’ sign) • A re asymmetric or have uneven borders • F eel rough or scaly • A re multi-coloured • A re itchy • A re bleeding or oozing • L ook pearly • L ook like a wound but do not heal For melanoma in particular, the ‘ABCDE’ rule is a good way to remember the signs to look for: A - Is the mole Asymmetric? B - Does it have uneven Borders?

Step 3 Check the front and back of your hands, and in between your fingers

Step 4 Then focus on your neck, chest and upper body. Women should be sure to check between and underneath their breasts

Step 5 Bend your elbows to check the upper arms and armpits

Step 6 Use a hand mirror to check the back of your neck and back, from top to bottom

C - Does it contain different Colours? D - Is it larger than 6mm diameter? E - Is there an Evolution in growth?

Step 7 Check your buttocks and the back of your legs. Finish by checking the soles of your feet and in between your toes

If you see two or more warning signs, consult a doctor without delay. It may be nothing, but it’s always better to be safe than sorry. Skin cancer, both melanoma and non-melanoma, can usually be treated successfully if caught early.

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To protect yourself from melanoma...

If you see the sun, take action to protect your skin

If you see the full moon, it is your monthly, skin check reminder

Melanoma and non-melanoma skin cancer can be easily treated when diagnosed early, so we want people to make skin self-examinations a regular part of their routine. We asked ourselves what would remind people to check their skin once every four weeks, that everyone could see, wherever they are in the world. The answer, of course, is the full moon, the concept for our 2O2O campaign.

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