Behavioral Counseling for Skin Cancer Prevention
Authors: Nora B. Henrikson, Caitlin C. Morrison, Paula R. Blasi, Matt Nguyen, Kendall C. Shibuya, Carrie D. Patnode
Journal: JAMA (2018)

<h3>Importance</h3> Exposure to UV radiation, especially in childhood, increases skin cancer risk. <h3>Objective</h3> To systematically review the evidence on the benefits and harms of behavioral counseling for skin cancer prevention to inform the US Preventive Services Task Force (USPSTF). <h3>Data Sources</h3> Cochrane Central Register of Controlled Trials, MEDLINE, and PubMed were searched for studies published from January 2009 to March 31, 2016, for skin cancer prevention and from August 2005 to March 31, 2016, for skin self-examination. Surveillance in targeted publications was conducted through February 14, 2018. Studies included in previous USPSTF reports were reevaluated for inclusion. <h3>Study Selection</h3> Fair- and good-quality studies of primary care–relevant behavioral interventions focused on improving skin cancer outcomes, intermediate outcomes, or skin cancer prevention and self-examination behaviors. <h3>Data Extraction and Synthesis</h3> Two investigators independently reviewed abstracts and full-text articles and extracted data into evidence tables. Results were qualitatively summarized but not pooled because of heterogeneity of measures. <h3>Main Outcomes and Measures</h3> Skin cancer, sunburn, precursor skin lesions, sun protection behaviors, and any harms from interventions. <h3>Results</h3> Twenty-one trials in 27 publications were included (N = 20 561). No studies assessed skin cancer outcomes in pediatric populations; 1 adult trial (n = 1356) promoting skin self-examination found no significant difference in participants diagnosed with melanoma in the intervention group vs the control group at 12-month follow-up (0 vs 1 diagnosis). There was no consistent improvement in prevention of sunburn for children (3 trials [n = 2508]) or adults (6 trials [n = 3959]). There were small to moderate increases in sun protection behavior in pediatric populations (6 trials [n = 4252]) and adults (12 trials [n = 13 099]) and small increases in skin self-examination in adults (11 trials [n = 7771]; odds ratios, 1.16-2.6). One of 3 trials of indoor tanning found an intervention effect; an appearance-focused intervention (n = 430) resulted in a smaller increase in mean indoor tanning sessions at 6 months in the intervention group vs the control group. Harms were rarely reported: 1 trial of skin self-examination (n = 1356) found an increase in skin procedures in the intervention group vs the control group at 6 months (8.0% vs 3.6%,<i>P</i> &lt; .001) but not between 6 and 12 months (3.9% vs 3.3%,<i>P</i> = .50), and 1 trial (n = 217) found no between-group difference in skin cancer worry (28.9% vs 18.4%,<i>P</i> = .16). <h3>Conclusions and Relevance</h3> Behavioral interventions can increase sun protection behavior, but there is no consistent evidence that interventions are associated with a reduction in the frequency of sunburn in children or adults and minimal evidence on skin cancer outcomes. Intervention can increase skin self-examination in adults but may lead to increased skin procedures without detecting additional atypical nevi or skin cancers.