Skin Cancer Prevention for the Primary Care Physician: A Proposal
Creators: name: Parker, Cristy
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2002

description: Skin cancer accounts for one third of newly diagnosed cancers in the United States, making it the most common human malignancy. Although nonmelanoma skin cancers are the most common, melanoma is generally the malignancy that receives the most interest among public health professionals due to its relatively high mortality rate. Malignant melanoma accounts for over 75% of deaths due to skin cancer. The incidence of this cancer seems to be increasing worldwide, doubling approximately every decade. Persons with increased risk include those with clinical evidence of melanocytic precursor or marker lesions (i.e., atypical moles, certain congenital moles), a large number 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. More than 90% of skin cancers are attributed to ultraviolet radiation (UVR) from the sun, and exposure to UVR is the most significant risk factor for skin cancer. Due to this strong association, nearly all skin cancers could be prevented through the use of sun protection strategies for reducing risk. Primary prevention of skin cancer involves reducing avoidable sun exposure and protecting the skin when sun exposure is unavoidable. People know very little about skin cancer and in relationship to a perception that a suntan is attractive, persons in the general population remain committed to seek sun and have low rates of sun protection. Public education campaigns are an important part of the attempt to prevent skin cancers. These interventions include education through the media, outreach to professionals, school-based education, and education and policy changes at outdoor sun exposure sites. Physician counseling is another component of primary prevention. At the American Academy of Dermatology and Centers for Disease Control and Prevention Consensus Conference in 1996, the following recommendations were developed: a) limit exposure to UC radiation, especially between 1 Oa.m. and 4p.m., b) wear protective clothing and sunglasses, c) use sunscreens (SPF-15 or higher) including SPF lip balms, d) avoid artificial tanning devices, e) for children younger than 6 months of age, use hats, clothing, and shading rather an sunscreen, f) encourage children to practice the shadow rule: seek shade when your shadow is shorter than you are tall. Provision of shady areas and preservation of the ozone layer should contribute to primary prevention of skin cancer Because no studies have evaluated whether physician counseling reduces morbidity and mortality from skin cancer, recommendations regarding physician counseling vary. Secondary prevention efforts are aimed at preventing death from cutaneous malignant melanoma by detecting cancers early. Strategies for skin cancer screening can be categorized in four ways: 1) routine screening of the general population in an out-patient setting; 2) surveillance screening, or the examination or individuals who are at high risk or have had a previous skin cancer; 3) mass screening, or population-based screening of asymptomatic individuals; and 4) skin self-examinations. The goal of screening for skin cancer 1s to decrease skin cancer related mortality; however, there have been no controlled trials evaluating this potential impact. Because evidence is based on intermediate measures rather than morbidity and mortality outcomes, recommendations for screening practices widely vary. Screening and surveillance of high-risk persons may be an effective way of detecting melanoma before the malignancy has metastasized. Two studies have also demonstrated that screening high-risk patients for melanoma may be cost effective. Primary Care Physicians are in an ideal position to implement skin cancer prevention counseling and early detection in their practices. Approximately 79% of persons in the US visit their primary care doctor at least once a year, and routine examinations are among the 10 most common reasons for patient visits. Further, in a study of patients diagnosed with malignant melanoma, 87% stated that they had regular physicians, 63% had seen those physicians in the year prior to diagnosis, but only 24% had regular dermatologists. Despite the potential for effectiveness, multiple studies show that skin cancer control practices are performed less frequently than other preventive practices. One key barrier to skin cancer prevention practices involves the conflicting recommendations and lack of morbidity and mortality outcomes from randomized controlled trials. Until the evidence clarifies effective recommendations, efforts in prevention of skin cancer morbidity and mortality will remain anchored in the implicit potential of primary prevention and early detection. During this period of uncertainty, we must use the available evidence to target prevention practices to those who may benefit the most-persons at high risk for skin cancer. The MacKie method of identifying a high-risk population appears to be a feasible way to target high-risk patients for skin cancer prevention efforts. A second barrier to skin cancer prevention practices in the primary care setting is the lack of physician confidence and skill in this area. Education is the answer to overcoming this obstacle, Several studies have demonstrated that educational interventions can improve primary care providers' attitudes, skills, and self-reported behavior toward preventing skin cancer. North Carolina physicians have expressed interest in learning about skin cancer control practices through continuing medical education (CME) presentations, and a CME curriculum focused on improving physician skills and ability to target high-risk patients is warranted. A one-hour CME curriculum is included in this proposal. It will be tested in a randomized controlled trial fashion to determine whether it is effective in improving physician attitudes, knowledge, skill, and self-reported behavior before it is implemented as a CME for North Carolina primary care physicians.