Title: Generational shift in melanoma incidence and mortality in Queensland, Australia, 1995-2014

Short title: Generational shift in melanoma

Authors: Joanne F. Aitken1-3, Danny R. Youlden1,4, Peter D. Baade1,5, H. Peter Soyer6,7, Adèle C. Green8-10, B. Mark Smithers.11,12

1 Cancer Council Queensland, Brisbane, Queensland, Australia2 Institute for Resilient Regions, University of Southern Queensland, Brisbane, Queensland,

Australia 3 School of Public Health and Social Work, Queensland University of Technology, Brisbane,

Queensland, Australia4 Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia5 School of Mathematical Sciences, Queensland University of Technology, Queensland,

Australia6 Dermatology Research Centre, The University of Queensland, The University of

Queensland Diamantina Institute, Brisbane, Queensland, Australia7 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia8 QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.9 CRUK Manchester Institute and Division of Musculoskeletal & Dermatological Sciences,

University of Manchester, Manchester, United Kingdom10 Australian Skin and Skin Cancer Research Centre, Brisbane, Queensland, Australia11 Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland,

Australia12 Discipline of Surgery, Faculty of Medicine, The University of Queensland, Brisbane,

Queensland, Australia

Corresponding Author: Prof Joanne Aitken, Cancer Council Queensland, PO Box 201, Spring Hill, QLD 4004, Australia; E-mail: JoanneAitken@cancerqld.org.au; Telephone: +61-7-36345300; Facsimile: +61-7-32598727.

Key words: melanoma, incidence, mortality, trends, Queensland

Abbreviations: APC - annual percentage change; CI – confidence interval; UV – ultraviolet.

Article category: Research - Epidemiology

Novelty and impact: Within a population having the highest recorded incidence of melanoma in the world, we show that rates of invasive melanoma have peaked over the last two decades for persons aged under 60. Coupled with stable or declining mortality rates, except in men aged 60 and over, our results provide substantive evidence that long-running melanoma prevention (through sun protection) and early detection campaigns have resulted in a reduction in the burden of melanoma across successive generations.

Word counts: Abstract = 244; Body of text = 3,484Table count: 2Figure count: 3Supplementary tables and figures: 1Reference count: 40

1

Abstract

Public campaigns encouraging sun protection for skin cancer prevention began in

Queensland, Australia, in the early 1980s. We examined recent trends to assess whether

earlier evidence of stabilizing melanoma incidence in young people has persisted.

Anonymised incidence and mortality data for in situ and invasive melanoma for the 20 years

1995-2014 were obtained from the Queensland Cancer Registry. Time trends were

analysed using joinpoint regression. Birth cohort patterns were assessed using age-period-

cohort models. Melanoma incidence in Queensland remains the highest recorded in the

world (age-standardised incidence of invasive melanoma (2010-2014) = 72/100,000/annum).

Over the 20-year period, incidence of in situ melanoma increased in all age groups.

Incidence of both thin (≤1mm) and thick (>1mm) invasive melanoma was either stable or

decreased in people under 60, while it increased in those aged 60 and above, particularly in

men. Age-period-cohort analysis revealed decreasing age-specific incidence of invasive

melanoma under 40 years of age, beginning with the birth cohort born around the mid-

1960s, with steepest falls for those born around 1980 and later. Age-specific incidence was

stable between 40-59 years of age from the 1945 birth cohort onwards. Melanoma mortality

over the period was stable or decreased in all groups except in men aged 60 or over. These

findings are evidence of real advances in the prevention and early detection of invasive

melanoma in this very high-risk population. They make a compelling case for continued

public health efforts to reduce the burden of melanoma in susceptible populations.

2

Introduction

Queensland, the second-largest Australian state, has long had the highest recorded

melanoma incidence in the world 1 due to the combination of a largely white-skinned

population, high ambient UV radiation and an outdoor lifestyle.2 Public education to

encourage awareness of the importance of early diagnosis of melanoma began in

Queensland in the early 1960s in what was one of the first such campaigns in the world.3

When solar radiation came to be understood as the main cause of skin cancer,4-6 these

campaigns were expanded to encompass prevention through protection from sun exposure.

The “Slip (on a shirt), Slop (on sunscreen), Slap (on a hat)” skin cancer prevention campaign

in the early 1980s, replaced by the national SunSmart campaign in the early 1990s, received

wide coverage 7 and resulted in broad community awareness of both the risk of skin cancer

and the importance of sun protection in Australia’s sunny climate, including in subtropical

Queensland.8 Prevention campaigns for skin cancer continue in Queensland and other

states, with a strong focus on the childhood years, including the long-running SunSmart

Schools Program that encourages a range of activities including school uniforms that meet

sun protection standards and a “No Hat, No Play” policy for outdoor activities.9

The most recent examination of trends in melanoma incidence and mortality across the

Queensland population examined the 21-year period 1982-2002.10 The authors drew two

conclusions: first, that despite an increase in overall incidence during the period, mortality

had remained stable, presumed to be due in large part to earlier diagnosis and, second, that

incidence rates appeared to have stabilized in those under 35 years. This last point is

particularly relevant given that melanoma is the most common type of cancer (excluding

keratinocyte cancers) diagnosed among Australians aged 15-34, estimated to account for

20% of all cancer diagnoses and 9% of all cancer-related deaths in this age group between

2009 and 2013.11

3

We examined trends in melanoma incidence and mortality over the most recent 20-year

period for which data are available (1995-2014) to assess whether the earlier reported

patterns of stabilizing mortality and, in younger people, stabilizing incidence, have been

sustained.

Methods

Data

De-identified information was extracted from the Queensland Cancer Registry for each

patient diagnosed with a first primary invasive or in situ melanoma (ICD-O-3 code “C44”,

morphology code 8720-8790) between 1995 and 2014 inclusive. Data quality was high, with

98.9% of cases in the study being histologically verified and less than 0.1% registered on the

basis of death certificate only.

In the previous incidence study,10 cases of lentigo maligna (morphology code 87422) were

excluded because of concerns about consistency of identification and lack of histopathologic

diagnosis. The introduction of techniques such as dermoscopy and associated training have

improved diagnostic accuracy and pathologic reporting of skin cancers 12, 13 and so to provide

a more complete picture, lentigo maligna cases were included in the present analysis. To

allow direct comparison with the previous results,10 trend analyses were repeated after

excluding cases of lentigo maligna.

For persons with multiple primary invasive melanomas diagnosed during the study period,

only the first diagnosis was included. If both an invasive and an in situ melanoma were

recorded for the same person, only the invasive melanoma was counted even if it was

diagnosed subsequent to the in situ tumour, consistent with the approach used by Coory et

al.10

4

Data items available included sex, age at diagnosis, year of diagnosis, tumour thickness

(categorised as thin (≤ 1mm) or thick (> 1mm)) and, where applicable, age, year and cause

of death. Mortality was confirmed via record linkage between the Queensland Cancer

Registry, the Queensland Register of Births, Deaths and Marriages and the National Death

Index.

Statistical analysis

Incidence trends were analysed separately for in situ and invasive melanomas, according to

sex, broad age group (0-39, 40-59 and 60+ years old), and thickness (invasive only).

Mortality trends were analysed by sex and broad age group. Annual rates were directly age-

standardised to the 2001 Australian Standard Population,14 and joinpoint regression software

(National Cancer Institute) was used to fit trend lines. The joinpoint method starts with the

assumption of a constant trend (no joinpoint) over the entire study period and then uses

Monte Carlo permutation tests to determine any significant changes to the direction or

magnitude of the trend.15 The selected model is the one with the fewest joinpoints that

provides the best fit to the observed data. For this study, a maximum of two joinpoints was

specified for each model with a minimum of 5 years between joinpoints or between a

joinpoint and either end of the time series. Trends were expressed in terms of the annual

percentage change with 95% confidence interval (95% CI). Statistical significance (p <0.05)

was determined using a two-sided t-test.

Patterns of age-specific incidence rates by birth cohort were assessed separately for in situ

and invasive melanomas by fitting age-period-cohort models. Overlapping 10-year birth

cohorts were defined with mid-years 1915, 1925, and so on up to 1995, based on period of

diagnosis (5-year calendar periods from 1995-1999 to 2010-2014) and 5-year age groups

(from 15-19 up to 85-89 years). Within each birth cohort, age-specific incidence was

calculated for each 5-year age group. This analysis was restricted to those aged 15-89

years at diagnosis. The age-period-cohort model was fitted using Poisson regression

5

models, with incidence counts as the outcome variable, birth cohort, age group and calendar

period as covariates, and the log of the respective population count as an offset variable.”

We used the method described by Jemal et al 16 to evaluate the change in the slope (C) for

the age-specific incidence trends for each birth cohort between 1930 and 1980. This change

in slope for a birth cohort j represents the difference between the later birth cohorts (j to j+3)

compared to the earlier birth cohorts (j-3 to j). A negative value indicates that the age-

specific incidence trend slope for birth cohorts coming after birth cohort j has decreased

compared to earlier birth cohorts, specifically, if an increasing trend begins to decelerate or

fall.

Results

A total of 97,114 eligible cases of melanoma diagnosed between 1995 and 2014 were

included in the study cohort. Of these, 55% were invasive (n=53,029) and 45% were in situ

(including lentigo maligna) (n=44,085). Within each of the invasive and in situ groups, more

cases were male (55% and 58% respectively) and the median age at diagnosis was 60

years. Information on thickness was missing for 7% of invasive melanomas per year on

average. Among the remainder, almost three-quarters (73%) were thin (≤1mm) at diagnosis.

Broad incidence trends

Invasive melanoma: Over the 20 years 1995-2014, the age-standardised incidence of

invasive melanoma increased from 73 to 89/100,000 per annum among males, and from 50

to 59/100,000 per annum among females. For all persons combined, the average age-

adjustedstandardised incidence of invasive melanoma for the most recent 5-years 2010-

2014 was 72/100,000 per annum. The modelled data showed a significant

increasefluctuating trends in the overall incidence of both thin and thick invasive melanomas

for both males and females with significant increases from 2006 onwards whereas there

6

were significant increases over the entire study period (1995-2014) for thick invasive

melanomas by sex (Figure 1, Table 1). however, there were m

Marked differences were observed in the corresponding age-specific trends by broad age

group. In people under 40 years, there was a uniform and significant decline in incidence of

thin melanoma (2.5% decline per year in males, 1.7% in females) over the whole 20-year

study period, while the incidence of thick melanoma was stable. Among those aged 40-59

years, incidence was stable over the period, for both thin and thick melanoma. Increasing

incidence was seen only in the oldest age-group (60+ years), for whom incidence of thin

(2.6% per year in both sexes) and thick (2.0% per year in males; 1.1% per year in females)

melanoma increased uniformly over the whole period (Table 1).

In situ melanoma : Over the 20 years 1995-2014, the observed age-standardised incidence

of in situ melanoma increased from 31 to 113/100,000 per annum among males, and from

28 to 83/100,000 per annum among females. For both sexes combined, the average age-

adjustedstandardised incidence of in situ melanoma for the most recent 5-years 2010-2014

was 82/100,000 per annum. The modelled data showed a steep increase in incidence rates

for both sexes throughout the 20-year period, with an average increase of 6.9% per year in

males and, for females, 4.0% per year between 1995-2006 and 8.5% per year between

2006-2014) (Figure 1, Table 1). Over the last 10 years, rates of in situ melanoma increased

uniformly by around 7% per year within each of the three broad age groups (0-39, 40-59,

60+ years), except for males under 40 whose annual increase was somewhat lower at 4.5%

(Table 1). Very similar trends were observed when cases of lentigo maligna were excluded

from the analysis (results not shown).

Incidence trends by calendar period and birth cohort

The age-period-cohort model provided a significantly better fit to the data than either the

age-period model or the age-cohort model for both males and females, indicating that the

7

observed incidence trends are influenced independently by both birth cohort and calendar

period. For brevity, 10-year birth cohorts are referred to in the following by their mid-point

years.

Invasive melanoma: Age-specific incidence generally fell in age groups under 40 years,

beginning with the 1965 birth cohort, particularly among males (Figure 2). The rate of

decrease in age-specific incidence rates for invasive melanoma was greatest for males and

females born around 1980 (Supp Figure 1). Rates stabilised in all 5-year age groups

between 40 and 59 years, beginning with the 1945 birth cohort. In contrast, age-specific

incidence rates for invasive melanoma in all 5-year age groups from age 60 increased over

the 20-year study period; however, there was a marked deceleration in the rates, as shown

by the gradual flattening of the birth-cohort slopes, in almost all successive birth cohorts from

1930 onwards (Figure 2; Supp Figure 1).

In situ melanoma : There were steep, ongoing increases in the age-specific incidence rates

of in situ melanoma in almost all successive birth cohorts for all 5-year age groups from age

25, for both males and females, although the rate of increase (as measured by the birth

cohort slopes) began to slow from about the 1945 birth cohort, particularly among females

(Figure 2; Supplementary Figure 1).

Mortality trends

A total of 5,061 deaths due to melanoma were reported for Queensland residents between

1995 and 2014, with about two-thirds of these deaths being males (n=3,462, 68%). The

median age at death was 70 years for males and 68 for females. Average annual age-

standardised mortality due to melanoma was 7/100,000 (11/100,000 for males and

4/100,000 for females) between 2010 and 2014.

8

The overall age-standardised melanoma mortality rate was stable for males and females

over the study period although, as was the case for incidence of invasive melanoma, the

age-specific mortality patterns by broad age group were quite distinct (Figure 3 and Table 2).

Melanoma mortality decreased by 3.4% per annum for males under 40 and by 1.8% per

annum for males 40-59. Mortality also fell in females under 40 (2.9% decrease per annum)

while it was stable for females 40 and over. The only group which recorded a significant

increase in melanoma mortality was males aged 60 and over, among whom mortality rose

by 1.8% per annum in the 20 years from 1995 to 2014.

Discussion

At 72 cases per 100,000 per annum on average, the incidence of invasive melanoma in

Queensland remains the highest recorded in the world, substantially more than that of New

Zealand, with the next highest recorded incidence (50/100,000 for the period 2007-2011

using the 2000 United States Standard Population), and higher than that of Australia as a

whole (48/100,000).17 The melanoma mortality rate in Queensland (7/100,000) is similar to

that reported for Australia as a whole (6/100,000 in 2014) 18 but still somewhat higher than in

most other parts of the world such as the Nordic countries (collectively 6/100,000 for males

and 4/100,000 for females in 2014) 19 or the United States (3/100,000 during 2010-2014) 20 .

Whiteman et. al. 17 summarised contemporary public health efforts to prevent melanoma in

six populations (US whites, the United Kingdom, Sweden, Norway, Australia and New

Zealand). Sun protection promotions in the US and Europe have generally been less

coordinated and/or had less population coverage 21, 22 than in Australia and New Zealand,

where mass media campaigns have been conducted since the early 1980s. 7 Therefore it is

perhaps not surprising that invasive melanoma incidence rates are projected to continue to

rise in these countries in contrast to predicted declines within Australia and New Zealand. 17

9

We have shown that age-standardised incidence of invasive melanoma in Queensland is

continuing to stabilize or decline in those under 40 years, has now stabilized in the 40-59

age group, and continues to increase only in people in aged 60 years or over. The much

higher age-specific incidence rates among older Queenslanders are thus driving the overall

increasing age-standardised incidence of invasive melanoma that we observed. An earlier

analysis of the period 1982-2002 in Queensland suggested that incidence of invasive

melanoma was stabilizing in people under 35 years.10 With a further 12 years of data to

2014, our findings add weight to this earlier result and confirm that, over time, rates appear

to be stabilizing and then falling in progressively older age groups.

This result is echoed in the analysis of incidence trends by birth cohort and calendar period.

In the earlier published age-period-cohort analysis, age-specific incidence rates of invasive

melanoma were generally increasing from one birth cohort to the next, particularly among

males, but the rate of increase had begun to slow and had flattened in people younger than

35 and born around 1958 or later.10 This pattern has continued and intensified, with age-

specific incidence rates of invasive melanoma now actually falling in people younger than 40

and born around 1960 or later, particularly among males. The fall is steepest for those born

since the 1980s and this group now has significantly lower melanoma incidence rates than

did earlier generations of Queenslanders at the same age.

The evidence presented here is consistent with a birth cohort effect that coincides with the

introduction of sun safety campaigns during the last decades of the 20th century, and is seen

most strongly in those generations born since the 1980s who have lived with the sun

protection message from childhood.23 Migrant studies have highlighted the importance of

early life sun exposure to melanoma incidence in later life.24, 25 The reduced risk enjoyed by

recent birth cohorts in Queensland is likely to persist as these birth cohorts age, potentially

resulting in declining age-specific incidence rates in successively older age groups.

Moreover, the observation that age-specific melanoma incidence rates are now stabilizing in

10

birth cohorts born as early as 1945 suggests that the benefits of sun protection campaigns

have also extended to those who first experienced these campaigns as young adults.

Another possible reason for reduced sun exposure in younger generations is an increase in

indoor leisure activities (eg. television watching, playing video games and using computers).

It has been estimated that children in the United States have lost 50% of time spent on

unstructured outdoor activities since the 1970s 26 and instead use screen devices for an

average of 7 hours per day.27 This change in lifestyle, however, seems less likely to explain

the stabilisation in malignant melanoma incidence that we observed among the middle-aged

cohorts during the study period.

It has been proposed that the decreasing incidence of invasive melanoma in young age

groups in Queensland could also be explained by the effect of immigration by people with

darker skin who are at low melanoma risk.28 We have previously used a simulation study 29

to demonstrate that melanoma incidence rates among younger Queenslanders are

decreasing irrespective of changes in the ethnic mix of the population. This finding held true

even under the extreme assumption that the entire population increase within this age group

since 1982 was due to immigration from low melanoma risk countries.,29 providing

compelling The results support for our assertion that public education campaigns and a

changing attitude to sun exposure have played a key role in the observed reduction of

melanoma incidence among more recent birth cohorts in Queensland.

The down-turning trends in age-standardised incidence of invasive melanoma among

younger people in Queensland are unusual in white populations around the world. A recent

examination of trends in 39 countries by Erdmann et al 30 showed increases in incidence in

virtually all Caucasian populations examined, including in people aged under 45. However,

in line with our results, the authors pointed to an apparent decline or stabilization in

melanoma risk among birth cohorts since the 1950s in New Zealand, CanadaNorth America

11

and Australia as a whole, for males and females, and noted that this is consistent with a

change in generational UV exposure particularly in childhood.30-32

Ultimately, a reduction in melanoma mortality is the true measure of success of prevention

and early detection campaigns. In Queensland, there has indeed been a significant decline

in melanoma mortality rates approaching 2% per annum in males 40-59 years, and an even

steeper decline of around 3% per annum in both sexes under 40. This contrasts with males

over 60, with melanoma mortality continuing to increase at roughly the same pace (about 2%

per annum) as the increase in incidence of thick melanomas among males in this age group.

That this increase is occurring beside even steeper increases in in situ lesions in older men

suggests that it is not for lack of efforts to improve early diagnosis. New strategies, such as

regular skin screening targeted to better-defined high risk groups, are needed, although

earlier detection of rapidly invasive, nodular lesions (comprising about one-third of thick

melanomas diagnosed in older men) remains a challenge.33

As it has done since records began in 1982, in situ melanoma incidence continues to climb

in Queensland at a much faster pace than that of invasive melanoma. Rapid annual

increases in the incidence of in situ melanoma have been reported in other white-skinned

populations including the United States,34 the Netherlands 35 and Denmark 36, with rates in

the last two increasing at an even faster pace than those in Queensland. These trends are

likely explained, at least in part, by improved understanding and awareness, both among

clinicians and the public, of the critical importance of early detection and treatment of this

disease. Broad concern about skin cancer in the very high-risk Queensland population is

manifest in an increasing demand for and availability of skin screening examinations, a rapid

growth over recent years in the number of primary care skin cancer clinics,37, 38 and improved

opportunities for clinical training in early diagnosis in primary care. This is perhaps coupled

with a heightened level of clinical suspicion, a degree of diagnostic shift and increased

potential for histopathologic over-diagnosis.39, 40 The long-term increase in in situ lesions is

12

far outstripping the decrease in melanoma mortality, implying that in a significant proportion

of cases, the treatment of in situ melanoma is likely to have had no impact on the patient’s

longevity. While the excision of innocuous lesions carries a significant cost both to patients

and the health system, it is difficult to see the situation changing, given the potentially

serious consequences of a missed melanoma and limited understanding and recognition of

which atypical melanocytic lesions are benign and which are malignant and at risk of

progression.

The main strengths of our study were the very large size of the sample and the use of

population-based data comprising all eligible in situ and invasive melanomas registered in

Queensland. It should be noted that improvements in the recording of melanoma thickness

have resulted in a reduction over time in the proportion of invasive melanoma with unknown

thickness, which may have influenced observed trends in thin and thick melanoma in both

the previous and present studies. However, this is becoming less of a problem as thickness

was only missing for a minority of malignant cases in our data (7%), so while the proportion

of melanoma cases with a recorded thickness has improved over time, the influence of this

on the observed results is likely to be minimal.

In summary, the results presented here for the period 1995-2014 in Queensland reveal:

(1) stable or falling incidence of invasive melanoma in those under 60 years; (2) a birth

cohort effect manifested in declining age-specific incidence rates of invasive melanoma

starting with those born in the 1960s, with steepest declines among those born in the 1980s

or later; and (3) stable or declining melanoma mortality rates in all groups except males aged

60 and over. This is strong evidence for real advances in the prevention and early detection

of invasive melanoma in this very high-risk population. Nevertheless, Queensland continues

to have the highest recorded incidence of melanoma of any population world-wide and there

is no room for complacency. These findings, together with recent international evidence,

13

make a compelling case for a continuation and strengthening of public health efforts to

reduce the incidence and mortality of melanoma in all susceptible populations around the

world.

14

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Figure Legends

Figure 1: Trends in the incidence rates of in situ and invasive melanomas by thickness and sex in Queensland, 1995-2014. Includes in situ lentigo maligna. Rates were directly age-standardised to the 2001 Australian Standard Population. Trends calculated using JoinPoint regression. Corresponding annual percentage changes are shown in Table 1.

Figure 2: Age-specific incidence rates of in situ and invasive melanoma by mid-year of birth cohort, Queensland, 1995-2014. The years of birth on the horizontal axes in Figure 2 indicate the mid-points of overlapping 10-year birth cohorts. The points vertically above each mid-point year show that cohort’s age-specific incidence rates (noting the log scale).

Figure 3: Trends in the mortality rates of invasive melanomas by age at death and sex in Queensland, 1995-2014. Rates were directly age-standardised to the 2001 Australian Standard Population. Trends calculated using JoinPoint regression. Y-axis is shown on a log scale.

Supplementary Figure 1: Parameter estimates of birth cohort effects in in situ and invasive melanoma incidence rates for males and females in Queensland, Australia, 1995-2014. Includes in situ lentigo maligna melanoma. The change in slope (C) for a “centre year” compares the previous three parameter estimates with the subsequent three parameter estimates (see methods). * - indicates that the C value is statistically significant at the 95% level. Note that while the values of the estimates would change depending on the parameterisation of the age-period-cohort model, the shape of the curve, and the corresponding C values, remains consistent.

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Table 1: Annual percentage change (APC)a in the age-standardised incidence ratesb of in situc and invasive melanomas by sex, thickness and broad age group in Queensland, 1995-2014

Trend 1d Trend 2d Trend 3d

Sex, tumour behaviour/thickness and age group n Years APC (95% CI) Years APC (95% CI) Years APC (95% CI)Males – in situ 24,445 1995-2014 +6.9 (+6.1,+7.6) 0-39 years 2,006 1995-2014 +4.5 (+3.2,+5.8) 40-59 years 6,036 1995-2014 +7.2 (+6.6,+7.9) 60+ years 7,776 1995-2014 +7.0 (+6.2,+7.9)Males – invasive 30,831 1995-2014 +0.7 (+0.4,+1.1) 0-39 years 3,670 1995-2014 -2.4 (-3.0,-1.7) 40-59 years 9,975 1995-2014 -0.6 (-1.2,+0.0) 60+ years 17,186 1995-2014 +2.1 (+1.7,+2.5)Males – inv. <= 1 mm 20,428 1995-2000 +3.6 (-0.7,+8.1) 2000-2006 -1.7 (-5.2,+2.0) 2006-2014 +2.5 (+0.9,+4.1) 0-39 years 2,801 1995-2014 -2.5 (-3.3,-1.8) 40-59 years 6,988 1995-2014 -0.3 (-1.0,+0.5) 60+ years 9,702 1995-2014 +2.6 (+2.6,+3.1)Males – inv. > 1 mm 8,235 1995-2014 +1.1 (+0.6,+1.6) 0-39 years 644 1995-2014 -1.2 (-2.5,+0.0) 40-59 years 2,112 1995-2014 -0.9 (-1.8,-0.0) 60+ years 5,155 1995-2014 +2.0 (+1.5,+2.6)

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Table 1 (cont.): Annual percentage change (APC)a in the age-standardised incidence ratesb of in situc and invasive melanomas by sex, thickness and broad age group in Queensland, 1995-2014

Trend 1d Trend 2d Trend 3d

Sex, tumour behaviour/thickness and age group n Years APC (95% CI) Years APC (95% CI) Years APC (95% CI)Females – in situ 19,640 1995-2006 +4.0 (+2.0,+6.1) 2006-2014 +8.5 (+6.3,+10.8) 0-39 years 2,791 1995-2004 -1.1 (-4.7,+2.7) 2004-2014 +7.0 (+4.3,+9.8) 40-59 years 5,859 1995-2014 +6.4 (+5.6,+7.2) 60+ years 4,805 1995-2014 +7.1 (+6.1,+8.1)Females – invasive 22,198 1995-2002 +1.2 (+0.0,+2.5) 2002-2006 -2.5 (-6.4,+1.6) 2006-2014 +2.1 (+1.2,+2.9) 0-39 years 4,488 1995-2014 -1.6 (-2.3,-1.0) 40-59 years 8,206 1995-2014 +0.2 (-0.4,+0.8) 60+ years 9,504 1995-2014 +1.8 (+1.3,+2.3)Females – inv. <= 1 mm 15,785 1995-2001 +2.9 (+0.8,+5.0) 2001-2006 -2.4 (-5.7,+0.9) 2006-2014 +2.2 (+1.1,+3.3) 0-39 years 3,590 1995-2014 -1.7 (-2.4,-0.9) 40-59 years 6,111 1995-2014 +0.3 (-0.3,+1.0) 60+ years 5,472 1995-2014 +2.6 (+2.1,+3.2)Females – inv. > 1 mm 5,056 1995-2014 +0.7 (+0.1,+1.2) 0-39 years 623 1995-2014 -0.3 (-1.2,+0.7) 40-59 years 1,381 1995-2014 +0.1 (-0.7,+0.9) 60+ years 2,867 1995-2014 +1.1 (+0.4,+1.8)

Abbreviations: APC = annual percentage change; inv = invasive; 95% CI = 95% confidence interval.Notes: a. Calculated using JoinPoint regression.

b. Rates were directly age-standardised to the 2001 Australian Standard Population.c. Includes in situ lentigo maligna melanoma.d. Statistically significant trends are shown in bold.

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Table 2: Annual percentage change (APC)a in the mortality ratesb of invasive melanomas by age at death and sex in Queensland, 1995-2014

Sex and age group n APC (95% CI)c

Males – all ages 3,462 +0.8 (-0.0,+1.7)Males – 0-39 yrs 166 -3.4 (-5.7,-1.1)Males – 40-59 yrs 769 -1.8 (-3.4,-0.2)Males – 60+ yrs 2,527 +1.8 (+0.9,+2.8)Females – all ages 1,599 -0.5 (-1.3,+0.3)Females – 0-39 yrs 141 -2.9 (-5.0,-0.7)Females – 40-59 yrs 425 -0.3 (-2.1,+1.5)Females – 60+ yrs 1,033 -0.2 (-1.4,+1.0)

Abbreviations: APC = annual percentage change; 95% CI = 95% confidence interval.

Notes: a. Calculated using JoinPoint regression.b. Rates were directly age-standardised to the 2001 Australian Standard Population.c. Statistically significant trends are shown in bold.