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Counseling to Prevent Skin Cancer
Recommendations and Rationale of the U.S. Preventive Services Task Force
Alfred O. Berg, MD, MPH; and the U.S. Preventive Services Task Force, with editorial and technical support from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
Arch Dermatol. 2004;140:251-252.
SUMMARY
. . . The U.S. Preventive Services Task Force (USPSTF) finds insufficient evidence to recommend for or against routine counseling by primary care clinicians to prevent skin cancer. Although counseling parents may increase children's use of sunscreen, the USPSTF found little evidence to determine the effects of counseling on the sun protection behaviors of adults. These behaviors include wearing protective clothing, reducing excessive sun exposure, avoiding sun lamps and tanning beds, or practicing skin self-examination.
CLINICAL CONSIDERATIONS
• Using sunscreen has been shown to prevent squamous cell skin cancer. The evidence for the effect of sunscreen use in preventing melanoma, however, is mixed. Sunscreens that block both ultraviolet A (UV-A) and ultraviolet B (UV-B) light may be more effective in preventing squamous cell cancer and its precursors than those that block only UV-B light. However, people who use sunscreen alone could increase their risk for melanoma if they increase the time they spend in the sun.
• UV exposure increases the risk for skin cancer among people with all skin types, but especially fair-skinned people. Those who sunburn readily and tan poorly, namely those with red or blond hair and fair skin that freckles or burns easily, are at highest risk for developing skin cancer and would benefit most from sun protection behaviors. The incidence of melanoma among whites is 20 times higher than it is among blacks; the incidence of melanoma among whites is approximately four times higher than it is among Hispanics.
• Observational studies indicate that intermittent or intense sun exposure is a greater risk factor for melanoma than chronic exposure. These studies support the hypothesis that preventing sunburn, especially in childhood, may reduce the lifetime risk for melanoma.
• Other measures for preventing skin cancer include avoiding direct exposure to midday sun (between the hours of 10:00 a.m. and 4:00 p.m.) to reduce exposure to ultraviolet (UV) rays and covering skin exposed to the sun (by wearing protective clothing such as broad-brimmed hats, long-sleeved shirts, long pants, and sunglasses).
• The effects of sunlamps and tanning beds on the risk for melanoma are unclear because of limited study design and conflicting results from retrospective studies.
• Only a single case-control study of skin self-examination has reported a lower risk for melanoma among patients who reported ever examining their skin over 5 years. Although results from this study suggest that skin self-examination may be effective in preventing skin cancer, these results are not definitive.
RECOMMENDATIONS OF OTHERS
The American Cancer Society,1 the American Academy of Dermatology,2 the American Academy of Pediatrics,3 the American College of Obstetricians and Gynecologists,4 and a National Institutes of Health consensus panel5 all recommend patient education concerning sun avoidance and sunscreen use. The American Academy of Family Physicians recommends sun protection for all with increased sun exposure.6 The American College of Preventive Medicine (ACPM) concluded that sun-protective measures (e.g., clothing, hats, opaque sunscreens) are probably effective in reducing skin cancer but that the evidence does not support discussion of sunscreen and sun protection with every patient. ACPM concluded that evidence is insufficient to advise patients that chemical sunscreens protect against malignant melanoma and that their use may actually lead to increased risk.7 Recently, the International Agency for Research on Cancer (IARC), part of the World Health Organization, qualified their recommendation for sunscreen use in ways that address the importance of learning more about potential harms of counseling for sunscreen use as follows:
Sunscreens probably prevent squamous-cell carcinoma of the skin when used mainly during unintentional sun exposure. No conclusion can be drawn about the cancer-preventive activity of topical use of sunscreens against basal-cell carcinoma and cutaneous melanoma. Use of sunscreens can extend the duration of intentional sun exposure, such as sunbathing. Such an extension may increase the risk for cutaneous melanoma. . . .8
e-mail (Dr Berg): uspstf{at}ahrq.gov
The standard MMWR format has been modified to accommodate other publications of the report.
Redacted from MMWR;52(RR15):13-17.
2 text boxes, 19 references (1-18, 28) omitted; original references 19-27 renumbered 1-8 below for presentation in this redaction.
From U.S. Preventive Services Task Force, c/o Center for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality.
REFERENCES
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1. American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2003. Atlanta, GA: American Cancer Society. Available at http://www.cancer.org/docroot/STT/content/STT_1x_Cancer_Prevention__Early_Detection_Facts__Figures_2003.asp or at http://www.cancer.org/downloads/STT/CPED2003PWSecured.pdf.
2. Lim HW, Cooper K. The health impact of solar radiation and prevention strategies: report of the Environmental Council, American Academy of Dermatology. J Am Acad Dermatol. 1999;41:81-99.
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3. American Academy of Pediatrics, Committee on Environmental Health. Ultraviolet light: a hazard to children. Pediatrics. 1999;104:328-33.
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4. American College of Obstetricians and Gynecologists. Primary and preventive care: periodic assessments. ACOG Committee Opinion 246. Washington, DC: ACOG, 2000.
5. NIH Consensus Development Program. Diagnosis and treatment of early melanoma. NIH Consensus Development Conference, January 27--29, 1992. Vol. 10, No. 1. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health. Available at http://consensus.nih.gov/cons/088/088_intro.htm.
6. American Academy of Family Physicians. "Safe-Sun" Guidelines. Leawood, KS: American Academy of Family Physicians, 2000. Available at http://www.aafp.org/afp/20000715/375ph.html.
7. Ferrini RL, Perlman M, Hill L. Skin protection from ultraviolet light exposure: American College of Preventive Medicine Practice Policy Statement. Washington, DC: American College of Preventive Medicine. Available at http://www.acpm.org/skinprot.htm.
8. International Agency for Research on Cancer (IARC). Handbooks of Cancer Prevention: Sunscreens. Vol. 5. Lyon, France: IARC Press, 2001.
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