Euroviews. Policymakers should better protect outdoor workers from the sun ǀ View

Workers are seen in silhouette, along with the Eiffel Tower, as they construct scaffolding on the Place de la Concorde as the sun sets on an autumn day in Paris, France
Workers are seen in silhouette, along with the Eiffel Tower, as they construct scaffolding on the Place de la Concorde as the sun sets on an autumn day in Paris, France Copyright REUTERS/Philippe Wojazer
Copyright REUTERS/Philippe Wojazer
By Prof. Dr. Swen Malte John, Kathi Apostolidis
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The opinions expressed in this article are those of the author and do not represent in any way the editorial position of Euronews.

In Europe alone, 14.5 million workers spend at least 75 per cent of their working lives outdoors without adequate protection and are at greater risk of developing skin cancer. Yet this invisible risk is being vastly neglected.


Did you know that skin cancer is the most common form of cancer, and that each year between two and three million people worldwide are diagnosed with non-melanoma skin cancer (NMSC)? Every year, more and more people are diagnosed with NMSC, with an average annual increase of three to eight per cent in fair-skinned populations in Europe, the US and Canada over the last 30 years. NMSC is the most common and, if detected early enough, one of the few curable types of cancer. Yet, according to all expert prognoses, incidence rates for skin cancer are set to further increase. Are policymakers doing enough to protect Europeans from this type of cancer?

Ninety percent of NMSC is attributable to excessive exposure to ultraviolet radiation (UVR) from the sun. The effects of recreational solar UV radiation inducing skin cancer are largely recognised, and numerous national campaigns have been launched over the past decades as a response. However, in Europe alone, 14.5 million workers spend at least 75 per cent of their working lives outdoors without adequate protection and are at greater risk of developing skin cancer. Yet this invisible risk is being vastly neglected, and it poses a clear challenge to our health care systems and society at large. If we are to address the problem, it will require concrete thinking about how to improve patient care, legal recognition and compensation for those affected.

Many countries lack the necessary health policies and employment regulations, to the point that NMSC is not widely recognised as the occupational disease it is. The risk is further increased due to lack of awareness of the dangers of outdoor work and the necessary precautions, even within the occupational groups concerned. The current situation is all the more shocking as recent studies show that outdoor workers face at least a twofold risk of developing NMSC compared to the general population. Once again, exposure limits for outdoor workers are lacking. According to recent data from Germany and Canada, the internationally recommended exposure limit of 1.3 SED/d is regularly exceeded for outdoor workers by more than five times. In 1992, the World Health Organisation (WHO) and the UN International Agency for Research on Cancer (IARC) classed solar UV radiation as a Group 1 human carcinogen, alongside asbestos and plutonium.

As a result, affected workers go unnoticed, cases of NMSC go un(der)reported, unscreened, uncared for at early stages, and uncompensated. Much like the invisible threat of climate change, NMSC has been allowed to go unaddressed because the effects are late to surface and the cause is invisible to the naked eye. It is as if the sun’s distance from the earth has made it too remote a danger for policymakers to consider. Out of sight, out of mind. However, just because we do not see UV radiation, doesn’t mean that it does not pose a serious risk to outdoor workers. This blindness to the dangers of solar UV radiation does no justice to the hard-working farmers and fishermen, and those employees who build our roads and houses, care for our gardens and clean our streets, and carry out countless other essential tasks outdoors. Action must be taken and the sooner the better.

So, where do we start? Public awareness raising campaigns seem to bear fruit: people´s knowledge of solar UV radiation risks has increased the use of sunscreen during leisure time. Why then shouldn´t this be possible for occupational skin cancer (OSC)? Must we wait until skin cancer becomes Europe’s leading cancer and health care expenditure (as it already is in Australia)?

The Patient Journey

There is currently little awareness globally of the risk of NMSC even among those affected, many of them outdoor workers in construction and farming, recreation and public services. While usually treatable, NMSC can quickly spread to other parts of the body causing serious complications. Patients with advanced NMSC also face considerable psychological strain as a result of skin lesions, such as scarring and disfigurement on the face and neck. In some cases, patients feel powerless, or even withdraw from loved ones and retreat into denial. This in turn creates a burden on patients, caregivers, and communities. However, with stronger occupational protections and prevention through awareness campaigns and a strong support network it is possible for outdoor workers to overcome and even avoid these challenges completely and improve patients’ chances of survival and quality of life.

As the world’s most frequently occurring cancer, non-melanoma skin cancer is already among the costliest oncological conditions treated. Currently ninety per cent of medical costs related to skin cancer are spent on treatment, while less than ten per cent goes to prevention. Indeed, the annual direct (medical and non-medical) costs of occupational skin cancer in Europe are estimated to range from EUR 341 to EUR 853 million and are likely to increase. The burden is even higher if intangible costs are considered (reduction of quality of life, life losses and cumulative life course impairment), which could range from EUR 1,040 to EUR 2,040 million per year. As a result, health policymakers should consider the significant potential economic savings of powerful prevention measures. The prevention of skin cancer at work is essential to avoiding long-term costs and decreasing the burden of this disease. In professions with increased sun exposure, greater awareness, protection measures and systematic dermatological screenings provide value for money.

Finally, the under-reporting of skin cancer remains problematic, as it prevents policymakers from properly appraising the threat. For this reason, the link between non-melanoma skin cancer and the workplace remains largely underappreciated by workers, employers and dermatologists. Regrettably, in many countries, the lack of national reporting systems exacerbates the situation. Establishing a comprehensive reporting system is essential to raising awareness of the real cost of skin cancer and consequently ensuring that policymakers react to protect those in danger.

With increased attention and research one thing is becoming as clear as day, NMSC is an occupational disease for European outdoor workers and needs to be recognised as such. As a first step, this can be addressed at the EU level, where the scope of the optical radiation EU Directive 2006/25 could simply be extended to natural UV radiation. This will be one important objective of our joint efforts of the European Association of Dermatology and Venereology and the European Cancer Patient Coalition in discussions with the new European Parliament and European Commission.

  • Prof. Dr. Swen Malte John is the Chairman of the Department of Dermatology & Environmental Medicine, University of Osnabrück, EADV, ICOH
  • Kathi Apostolidis is the President of European Cancer Patient Coalition (ECPC)


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