12.  Screening for Skin Cancer- Including Counseling to Prevent Skin

Cancer



RECOMMENDATION



There is insufficient evidence to recommend for or against either routine

screening for skin cancer by primary care providers or counseling patients

to perform periodic skin self-examinations. A recommendation to consider

referring patients at substantially increased risk of malignant melanoma

to skin cancer specialists for evaluation and surveillance may be made on

other grounds (see Clinical Intervention). Counseling patients at increased

risk of skin cancer to avoid excess sun exposure is recommended, based on

the proven efficacy of risk reduction, although the effectiveness of

counseling has not been well established. There is insufficient evidence to

recommend for or against sunscreen use for the primary prevention of skin

cancer.



Burden of Suffering



Over 800,000 new cases of skin cancer are diagnosed each year.1 More

than 95% of these are basal cell (BCC) and squamous cell (SCC)

carcinomas, also referred to as nonmelanomatous skin cancers (NMSC).

These are highly treatable and rarely metastasize, but local tissue

destruction may cause disfigurement or functional impairment if these

tumors are not detected early.2 They account for approximately 2,100

deaths each year.1 The risk of NMSC is increased by a personal history of

NMSC; older age; light eyes, skin, or hair; poor ability to tan; and

substantial cumulative lifetime sun exposure.3-5



Malignant melanoma (MM) is less common than NMSC but is far deadlier. An

estimated 34,100 new cases and 7,200 deaths (2.2/100,000 population)

from MM occurred in the U.S. in 1995.1,6 The incidence rate varies by race:

9.2/100,000 in whites, 1.9/100,000 in Hispanics, and 0.7-1.2/100,000 in

blacks and Asians.7 In the past two decades, increases of 4%/year in MM

incidence and nearly 2%/year in mortality have been reported.6,8 With a

median age at diagnosis of 53 years,9 MM ranks second among adult-onset

cancers in years of potential life lost per death.10 Significant risk

factors for MM besides white race include melanocytic precursor or

marker lesions (e.g., atypical moles, certain congenital moles), increased

numbers of common moles, immunosuppression, and a family or personal

history of skin cancer, especially MM.11-23 Fewer than 5% of the

population have melanocytic precursor lesions, which have a high

malignant potential and may account for as many as 40% of melanomas.24

For persons with the rare familial atypical mole and melanoma (FAM-M)

syndrome, the MM risk is increased 100-fold or more,11-13 and the

cumulative lifetime risk may approach 100%.11 Persons with intermittent

intense sun exposure or severe sunburns in childhood also appear to have

an increased risk that varies by MM subtype.17,19,20,25-27 Persons with

poor tanning ability, freckles, or light skin, hair, and eye color may have a

small increased risk of MM.17-20,28



Accuracy of Screening Tests



The principal screening test for skin cancer is physical examination of the

skin by a clinician. Detection of a suspicious lesion constitutes a positive

screening test, which then should be confirmed by skin biopsy. The true

sensitivity and specificity of the skin examination are unknown.29 In

virtually all studies evaluating the accuracy of the skin examination, only

clinically suspicious lesions were biopsied and only screen-positive

persons were followed; therefore, sensitivity and specificity cannot be

determined accurately. One study of persons presenting to free skin cancer

screening clinics for screening by dermatologists estimated sensitivity of

the examination using population incidence rates to estimate false-

negative rates; sensitivities were 97% for MM, 94% for BCC, and 89% for

SCC.30 Two or more risk factors for skin cancer were present in 78% of

those screened, however, so sensitivities may have been overestimated.31

Among persons with positive screening clinic examinations, the likelihood

of histologic confirmation has been reported to be 40% for MM, 43% and

57% for BCC, and 14% and 75% for SCC.30,32 For persons presenting for

skin examination to skin clinics, the likelihood of histologic confirmation

given a clinical diagnosis of MM is 38-64% for dermatologists and 72-84%

for skin cancer specialists.33-35 Among patients biopsied by

dermatologists who had histologically confirmed MM, the diagnosis was

suspected in 62-85% of cases.34,36 In a randomized community study

evaluating screening by expert dermatologists, histologic examination

confirmed the clinical diagnosis of SCC in 38% of cases and of BCC in

59%.37 In vivo epiluminescence microscopy appears to improve

dermatologists' diagnostic accuracy for skin lesions,38,39 but it is not a

practical screening tool for primary care physicians.



Primary care physicians and others lacking specialized training in

dermatology would be expected to have greater difficulty in evaluating

skin lesions. Several studies have reported that, compared to

dermatologists, nondermatologists make significantly fewer correct

diagnoses of skin lesions (including MM and BCC) from color

photographs.40-42 In one such study, at least five of six photographs of

MM were correctly identified by 69% of the dermatologists but by only

12% of the nondermatologists; at least one of two atypical moles was

recognized by 96% of the dermatologists but by only 42% of the

nondermatologists.40



One factor affecting the yield of screening for skin cancer is the

proportion of the body surface examined. Only 20% of MM occur on normally

exposed body surfaces, in contrast to 85-90% of NMSC.9,27

Dermatologists estimate that detection of MM is 2-6 times more likely

with a total-body skin examination (TSE).43,44 A second factor that

affects yield is the frequency of examination. If the interval between

examinations is too long, new cancers may not be detected before they

have progressed to an advanced stage. There are no published data

available, however, with which to determine the optimal frequency of

examination in the general population; annual or biennial intervals have

been recommended on the basis of clinical judgment. Poor patient

compliance with recommendations for yearly total skin examinations may

reduce the effectiveness of this intervention; in one study, only 22/524

(4.2%) patients returned for the yearly TSE that was recommended on the

first visit.45



In terms of risk to the patient, no serious adverse effects associated with

TSE and follow-up biopsy have been reported, and experts view it as

acceptable and safe.33 Embarrassment may be an adverse effect,46

because modesty is one of the main reasons given for refusing a TSE.44

Medical expenses may also be increased because office visits must be

lengthened to accommodate complete undressing, "chaperoning,"

examination, and redressing,46 and because more frequent referrals and

biopsies are likely to result. There are no controlled studies evaluating

any adverse effects of TSE.



Patient self-examination would be expected to be less accurate than

physician examination in evaluating skin lesions. One study evaluated

patients' ability to apply a seven-point checklist to the skin lesion that

prompted their referral to a dermatologist.35 The patient checklist had a

sensitivity of 71%, specificity of 99%, and positive predictive value of 7%

for MM diagnosis, using the dermatologist's clinical diagnosis as the "gold

standard." The sensitivity and specificity using histologic diagnosis as the

reference standard would likely be lower. No data were found evaluating

the ability of patients to detect suspicious lesions, the accuracy of

periodic skin self-examination, or the efficacy of self-examination

instructions in reducing errors.



Effectiveness of Early Detection



Early treatment might reduce morbidity and disfigurement for patients

with BCC and SCC,2 but no studies were found that have evaluated whether

such cancers discovered by screening have a better outcome than those

which present clinically.



For MM, there have also been no controlled trials evaluating the impact of

screening on morbidity or mortality. A time-series study of an educational

campaign to encourage MM screening by primary providers in Scotland

found a trend toward a reduction in both thick tumors (p < 0.05) and

mortality (not statistically tested) in women (but not men) after the

campaign.47 Women were overrepresented in the screened population,

which may explain the difference in mortality by sex. No control group

was included, so differences due to historical trends or other factors

cannot be excluded. The authors noted that in Denmark, which has

comparable incidence rates, the MM mortality in women rose during this

period.



More data are available on the effect of screening by dermatologists on MM

thickness. In two large case series of persons with atypical moles who

were screened regularly by dermatologists, all MM detected were either

thin (< 0.89 mm) or in situ.13,15 Time series in the general population,

and cohort studies in FAM-M syndrome kindreds and in persons with a prior

MM, have reported that screening by dermatologists detected significantly

thinner tumors when compared to historical population, kindred, or

personal index cases.47-51 Several countries have reported a consistent

decline over the past 3-4 decades in median thickness of MM, although this

decline has not been directly linked to screening programs.52,53 None of

these studies used concurrent unscreened controls to differentiate the

effects of screening programs from historical trends or lead-time and

length biases.



If clinician screening does in fact result in detection of significantly

thinner MM, mortality might be reduced. Case series and a prediction

model (validated on subsequent incident cases) have reported that survival

is directly related to lesion thickness at the time of resection.9,39,54-56

For example, 5-year survival is 95-99% for persons with lesions  0.75

mm, 66-77% for 1.51-4.0 mm, 41-51% for 4.76-9.75 mm, and 5% for those

with disseminated MM. The likelihood of recurrence after resection also

correlates with lesion thickness. A MM < 1 mm thick is associated with an

8-year disease-free survival rate of 90%, compared with 74% for lesions

1-2 mm thick.57 Although it is possible that lead-time and length biases

account for some of these differences, these data suggest that persons in

whom thinner MM are detected experience a better outcome than those

detected with more advanced disease.



Data on the effectiveness of early detection by skin self-examination are

limited. Preliminary analyses from a population-based case-control study

retrospectively evaluating the efficacy of skin self-examination in

patients with MM suggest a protective effect of skin awareness and self-

examination,58,59 but final results from this study have not yet been

published.



Primary Prevention



Primary prevention of skin cancer may involve limiting exposure to solar

radiation (by limiting sun exposure, avoiding tanning facilities, and

wearing protective clothing) or applying sunscreen preparations. Although

the effectiveness of these maneuvers has not been evaluated in clinical

trials, avoiding sun exposure or using protective clothing is likely to

decrease the risk of MM and NMSC, since both types of cancer have been

associated with sun exposure in numerous cohort and case-control

studies.3,4,17,19,20,25-27 Use of tanning facilities has not been directly

linked to cancer risk, but skin damage after use is common.60,61 Many

adolescents report using such facilities,61 and severe sunburns occurring

at a young age may increase the risk of subsequent

melanoma.17,19,20,26,27 The principal adverse effect associated with

avoiding exposure to ultraviolet and other solar radiation is failure to

acquire a suntan, which may be perceived as undesirable by some.48,62,63



The evidence that sunscreens prevent skin cancer is less clear. Sunscreen

agents are formulated and tested for their ability to prevent the acute

effects of solar ultraviolet radiation (i.e., sunburn).64 Most currently

available sunscreens block ultraviolet B (UVB) wavelengths, and a few

block ultraviolet A (UVA) rays.65 Only the physical sunblocks (e.g., zinc

oxide, talc, etc.) block all solar rays. A randomized controlled trial

evaluated the regular use of UVA- and UVB-blocking sunscreens by persons

40 years of age with previous solar keratoses (which are precursors of

SCC, although their risk of malignant transformation is low).66 The

development of solar keratoses over a 6-month period was significantly

reduced, implying that the risk of SCC may also be reduced. The

generalizability of the results achieved by these highly motivated

volunteers is unknown, and the study did not adequately describe

investigator blinding, lesion classification, or the adequacy of

randomization. Studies in albino laboratory rodents have also reported

that sunscreens can reduce the incidence of tumors resembling human SCC

after UV radiation.64,67-69 Animal data are more limited for MM, but a

recent study in mice reported that sunscreen failed to protect against UV

radiation-induced increases in melanoma incidence, although it did

prevent sunburn.70 In a fish model, both UVA and visible light, which are

not blocked by many currently available sunscreens, were highly effective

in inducing melanomas.71 Several case-control and cohort studies found

either no effect or a significantly increased risk of BCC72 and MM73,74 in

sunscreen users, after adjusting their risk estimates for phenotype (e.g.,

hair color, tendency to sunburn). The increased risk found in several of

these studies may be due to residual confounding, since in all studies

adjustment for phenotype reduced the crude risk estimates. It is also

possible that sunscreens may increase skin cancer risk by encouraging

susceptible persons to prolong exposure of greater skin surfae areas to

solar rays that are not blocked by most currently used sunscreens. There

is as yet no direct evidence that sunscreens prevent skin cancer in

humans, but clinical trials of sunscreen in humans are unlikely to be

conducted due to cost and time constraints. Sunscreens are associated

with mild to moderate side effects in 1-2% of users, including contact and

photocontact dermatitis, contact urticaria, and comedogenicity, although

these are readily reversible when use is discontinued.65,75,76



There are few data examining the effectiveness of counseling patients to

protect themselves from sunlight. A case series evaluating counseling

given at the time of removal of a skin cancer, and on a yearly basis

thereafter, reported increased use of protective clothing and sunscreen

and reduced deliberate tanning at 2-6-year follow-up.77 This study

included only the two-thirds of patients who complied with follow-up and

was not able to determine how much of the effect seen was due to the

surgery alone. There is also evidence from case series that public

education can increase knowledge and beliefs about the health risks of sun

exposure,48,78 but cross-sectional surveys give conflicting results about

whether knowledgeable persons act on this information.62,63,79

Community and worksite educational interventions to reduce the risk of

skin cancer, including one with a concurrent control group, have

demonstrated significantly increased use of sun protection measures,

such as hats, shirts, and staying in the shade, after the intervention.80,81

Whether the results of such educational interventions can be generalized

to clinician counseling is not known. No studies on the effectiveness of

counseling in reducing skin cancer incidence or mortality were found.



Recommendations of Other Groups



The American Cancer Society recommends monthly skin self-examination

for all adults8 and physician skin examination every 3 years in persons

20-39 years old and annually in persons  40 years old.82 The American

Academy of Dermatology,2,83 and a National Institutes of Health (NIH)

Consensus Panel84 recommend regular screening visits for skin cancer

and patient education concerning periodic skin self-examinations. The NIH

Consensus Panel also recommended that some family members of patients

with MM be enrolled in surveillance programs.84 The Canadian Task Force

on the Periodic Health Examination does not recommend for or against

routine screening for skin cancer or periodic skin self-examination, but

suggests that TSE for a very select subgroup of individuals at high risk

(e.g., those with familial atypical mole and melanoma syndrome) may be

prudent.85 The American Academy of Family Physicians recommends

complete skin examination for adolescents and adults with increased

recreational or occupational exposure to sunlight, a family or personal

history of skin cancer, or evidence of precursor lesions; these

recommendations are under review.86 The American Cancer Society,8 the

American Academy of Dermatology,2,83 the American Medical

Association,87 and the NIH Consensus Panel84 all recommend patient

education concerning sun avoidance and sunscreen use. The American

Academy of Family Physicians recommends skin protection from

ultraviolet light for all persons with increased exposure to sunlight.86

The Canadian Task Force recommends avoidance of sun exposure and use of

protective clothing, but it does not recommend either for or against

sunscreen use for the prevention of skin cancer.85 The American Academy

of Dermatology,88 the American Medical Association,87 the American

Cancer Society,89 and the NIH Consensus Panel84 have recommended

avoiding artificial tanning devices.



Discussion



Basal cell and squamous cell skin carcinomas are very common but are

slow-growing and rarely metastasize. It is unlikely that population

screening would substantially improve the already excellent outcome of

persons with these tumors. The principal potential benefit of periodic skin

examination lies in discovering early MM. The sensitivity and specificity

of skin examination by primary physicians, and the optimal frequency of

such examinations, is unknown, however. MM is, in addition, uncommon in

the general population (lifetime risk of about 1.0%).90 Since 99% of

patients who would be examined annually under a policy of routine

screening would never have MM, it is also important to consider the

potential adverse effects as well as the cost/benefit ratio of skin cancer

screening. Neither of these has been adequately evaluated.33,39 No

controlled studies have demonstrated that screening for MM by primary

providers improves outcome, although a time series study suggests a

possible mortality benefit. There is thus weak evidence that screening by

primary clinicians is effective in improving clinical outcome. In persons

at very high risk for MM (i.e., those with melanocytic precursor or marker

lesions), referral to skin cancer specialists for evaluation may be

justified based on high burden of suffering, minimal adverse effects of

TSE, and greater accuracy of the TSE by such specialists; however, there

is no direct evidence that screening this population reduces mortality.

There is currently only limited evidence of the efficacy of skin self-

examination in reducing melanoma mortality, but preliminary results from

a population-based case-control study appear promising.



There is fair evidence of the efficacy and safety of sun avoidance and use

of protective clothing for the prevention of skin cancer, and weaker

evidence to support avoiding artificial tanning devices. There is also fair

evidence from one randomized controlled trial, supported by animal data,

that sunscreens that block UVA and UVB rays are efficacious in preventing

squamous cell cancer precursors, but data are limited on the efficacy of

sunscreens in preventing skin cancer. There is also good evidence of mild,

reversible adverse effects of sunscreens. Community or worksite

educational interventions may increase the use of these sun protection

measures, but the effectiveness of clinician counseling in modifying such

behaviors is not established.



CLINICAL INTERVENTION



There is insufficient evidence to recommend for or against routine

screening for skin cancer by primary care providers using total-body skin

examination ("C" recommendation). Clinicians should remain alert for skin

lesions with malignant features (i.e., asymmetry, border irregularity,

color variability, diameter > 6 mm, or rapidly changing lesions)84 when

examining patients for other reasons, particularly patients with

established risk factors. Such risk factors include clinical evidence of

melanocytic precursor or marker lesions (e.g., atypical moles, certain

congenital moles), large numbers of common moles, immunosuppression, a

family or personal history of skin cancer, substantial cumulative lifetime

sun exposure, intermittent intense sun exposure or severe sunburns in

childhood, freckles, poor tanning ability, and light skin, hair, and eye

color. Appropriate biopsy specimens should be taken of suspicious lesions.



	Persons with melanocytic precursor or marker lesions (e.g., atypical

moles [also called dysplastic nevi], certain congenital nevi, familial

atypical mole and melanoma syndrome) are at substantially increased risk

for MM. A recommendation to consider referring these patients to skin

cancer specialists for evaluation and surveillance may be made on the

grounds of patient preference or anxiety due to high burden of suffering,

the greater accuracy of TSE when performed by such specialists, and the

relatively limited adverse effects from TSE and follow-up skin biopsy,

although evidence of benefit from such referral is lacking.



	There is also insufficient evidence to recommend for or against

counseling patients to perform periodic self-examination of the skin ("C"

recommendation). Clinicians may wish to educate patients with

established risk factors for skin cancer (see above) concerning signs and

symptoms suggesting cutaneous malignancy and the possible benefits of

periodic self-examination.



	Avoidance of sun exposure, especially between the hours of 10:00 am

and 3:00 pm,65 and the use of protective clothing such as shirts and hats

when outdoors are recommended for adults and children at increased risk

of skin cancer (see above) ("B" recommendation). Counseling such patients

to avoid excess sun exposure and use protective clothing is recommended,

based on the established efficacy of risk reduction from sun avoidance,

the potential for large health benefits, low cost, and low risk of adverse

effects from such counseling, even though the effectiveness of such

counseling is less well established ("C" recommendation).



	There is insufficient evidence to recommend for or against

counseling patients to use sunscreens to prevent skin cancer ("C"

recommendation). The routine use of sunscreens that block both UVA and

UVB radiation may be appropriate for persons who have previously had

solar keratosis and who cannot avoid sun exposure, in order to prevent

additional solar keratoses, which have a small malignant potential.



The draft update of this chapter was prepared for the U.S. Preventive

Services Task Force by Carolyn DiGuiseppi, MD, MPH.



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