American Cancer Society perspective on the American College of Preventive Medicine's policy statements on skin cancer prevention and screening
Authors: C. J. McDonald
Journal: CA A Cancer Journal for Clinicians (1998)

In the January 1998 issue of the American Journal of Preventive Medicine, Dr. Rebecca L. Ferrini and colleagues1, 2 presented two official practice policy statements by the American College of Preventive Medicine on skin cancer, one related to screening and the other to protection from exposure to ultraviolet light. These policies are summarized by Drs. Hill and Ferrini in this issue.3 We find both statements quite timely, both having a degree of concordance with current American Cancer Society opinion. The policy on screening for skin cancer includes little that is controversial or debatable and much that is good for cancer control. With the policy on skin protection, however, the American College of Preventive Medicine joins the growing number of those questioning the use of sunscreens for protection against skin cancer. In spite of citing evidence that sunlight exposure plays a major role in causing both nonmelanoma skin cancer and primary cutaneous malignant melanoma, Ferrini and colleagues conclude that there is "insufficient evidence to recommend for or against sunscreen use in a program to reduce skin cancer."2 To reduce the risk of skin cancer, the American Cancer Society recommends that people (1) limit or avoid exposure to the sun between 10 AM and 4 PM during peak ultraviolet light exposure, (2) when outdoors cover as much skin as possible with hats and protective clothing, and (3) use a sunscreen with a sun protection factor (SPF) of 15 or higher. In addition, children should be protected at all times from the sun.4 This position is in concert with that of the American Academy of Dermatology, whose recommendations are that "sunscreen is beneficial when used regularly as a part of an overall sun protection program including wearing sun-protective clothing, sunglasses, seeking shade whenever possible, and avoiding exposure during peak sun hours."5 What is the evidence for the positions taken by the American Cancer Society and the American Academy of Dermatology, two groups with a longstanding interest in cancer prevention? During the last two to three decades, the incidence of skin cancer has increased alarmingly. The increase parallels the changing lifestyles of most Americans, which permit increased, mostly recreational, exposure to the harmful effects of sunlight. The American Cancer Society has predicted that in 1998, about 1 million cases of skin cancer will be recorded in Americans.6 Of this number, more than 40,000 will develop cutaneous melanoma. It is also estimated that in addition to the considerable morbidity experienced by skin cancer patients, more than 9,000 will die, 7,300 or more from melanoma alone. Melanoma now ranks sixth in incidence among cancers in males and seventh in incidence among cancers in females.6 In 1960, 1 in every 1,500 Americans was expected to develop one or more cutaneous melanomas during his or her lifetime. In the year 2000 that figure is estimated to increase to 1 in every 70.7 Melanoma is the most common cancer in women between the ages of 25 and 35.8 Considerable scientific evidence exists to support the role of sunlight in the development of skin cancer, including malignant melanoma. Cutaneous cancers (including melanoma) tend to occur in a well-defined subset of the population, presently characterized as having fair skin that burns rather than tans, light-colored eyes, and red or blond hair. Other associated factors include heredity and the environment. Australia, a nation populated by individuals having the skin characteristics described earlier and blessed with unending sunshine, has the highest incidence of skin cancer (including cutaneous melanoma) in the world. Experience has shown that a substantial percentage of the melanoma population has at some time during childhood experienced one or more severe sunburns. Cutaneous melanomas occur most often in areas of the body exposed to sun. Most skin cancer experts believe that nonmelanoma skin cancers are preventable if the susceptible individual follows a regular program of sun protection, including the appropriate use of sunscreens. The evidence for malignant melanoma is not so clear cut. It is developing rapidly enough, however, for most experts to suggest that sunscreens, especially those that block the tanning spectrum of the sun, be an integral part of a program for prevention of melanoma. These suggestions are made in spite of several reports, most containing flawed data, questioning the appropriateness of sunscreens for skin cancer prevention. The American Cancer Society recommends that until further evidence exists to the contrary and is supported by unbiased scientific data, sunscreens continue to be included in a regular program of skin cancer prevention, including a program for prevention of cutaneous melanoma in a susceptible population. A well-accepted axiom is that the early detection of cancer increases considerably the potential for cure of that cancer. Skin cancer, including melanoma, is highly visible and thus lends itself to detection in its earliest and most curable stages. Although studies show that skin examination by a trained dermatologist gives the greatest return in a susceptible population, it is exceedingly important in cancer control that physicians who see large numbers of patients each day during routine health examinations become more involved in examining the skin of these patients. Along with dermatologists, all physicians who have assumed the role of principal caregiver must begin to address the current epidemic of skin cancer. The American Cancer Society believes that screening for the presence of skin cancer is well within the domain of the well-trained generalist. As noted by Ferrini and colleagues, a total skin examination is a "noninvasive, quick, and sensitive (89%-97%) screening procedure if done by a physician qualified in the identification of skin cancer."1 Total skin examination has few or no drawbacks, and when coupled with a good organized program of patient education on sun avoidance and cancer prevention, this procedure can go a long way toward reducing the rising incidence of and mortality from cutaneous cancer. The American Cancer Society is pleased to announce the 1999 Cancer Control Career Development Award for Primary Care Physicians. This award is intended to develop academic leaders in primary care specialties emphasizing cancer control: family practice, general internal medicine, obstetrics and gynecology, and pediatrics. Through the Cancer Control Career Development Award, the ACS seeks to support individuals in supervised programs that will develop the candidate's clinical and teaching expertise and his or her capacity to perform independent clinical research or develop innovative curricula in cancer control. It is anticipated that medical school faculty trained under these awards will promote cancer control activities and methodology to students and physicians and enhance cancer control knowledge through increased scholarly activity. Candidates for first-year Cancer Control Career Development Awards for Primary Care Physicians may not have an academic rank above that of Assistant Professor and must not be tenured or be the section head (or equivalent) in their discipline. These awards are intended to support the early development of academic careers that place emphasis on cancer control; physicians with well-established careers and substantial research funding should not apply. In addition, candidates for these awards must be citizens or noncitizen nationals of the United States, or its possessions or territories, or must have been lawfully admitted to the United States for permanent residence at the time of the application. This is a three-year award. The stipend for the award is $50,000 for the first year, $55,000 for the second year, and $60,000 for the third year. The application deadline is October 1, 1998, for awards to begin July 1, 1999. To obtain further information or application materials, please contact your local grants administration office. If you are unsure whether your institution received these materials, information is available from: 404–329–7558 or 404–329–5734 (voice), 404–321–4669 (fax), [email protected] (e-mail), or http://www.cancer.org/grants.