Virginia A. Moyer, MD, MPH; on behalf of the U.S. Preventive Services Task Force
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Requests for Single Reprints: Reprints are available from the USPSTF Web site (www.uspreventiveservicestaskforce.org).
Moyer VA, OBOTUPSTF. Behavioral Counseling to Prevent Skin Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;157:59-65. doi: 10.7326/0003-4819-157-1-201207030-00442
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Published: Ann Intern Med. 2012;157(1):59-65.
Appendix: U.S. Preventive Services Task Force
Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation statement on counseling to prevent skin cancer.
The USPSTF performed a targeted literature search for new evidence that counseling patients about sun protection reduces intermediate outcomes (such as sunburn) or skin cancer. Other key questions addressed the link between counseling and behavior change, the link between behavior change and incidence of skin cancer, and the adverse effects of counseling or sun-protective behavior changes.
The USPSTF recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer (B recommendation).
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults older than 24 years about minimizing risks to prevent skin cancer (I statement).
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
See the Clinical Considerations section for suggestions for practice regarding the I statement.
See the Figure for a summary of the recommendation and suggestions for clinical practice.
Behavioral counseling to prevent skin cancer: clinical summary of U.S. Preventive Services Task Force recommendation.
Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty about net benefit.
What the USPSTF Grades Mean and Suggestions for Practice
Levels of Certainty Regarding Net Benefit
Skin cancer is the most common type of cancer in the United States and is diagnosed in more than 2 million Americans each year. Most cases are basal cell or squamous cell cancer. Whereas basal cell cancer rarely metastasizes and is not associated with cancer deaths, squamous cell cancer has metastatic potential and does account for a small percentage of all cancer deaths (1). Melanoma, although less common, is more deadly. Approximately 70 000 cases of melanoma occurred in 2011 and nearly 8800 deaths. The incidence of melanoma has been increasing among white Americans, from 8.7 per 100 000 persons in 1975 to 27.6 per 100 000 in 2008 (2).
Behavior change interventions are aimed at techniques shown to be effective in reducing ultraviolet (UV) radiation exposure. Ultraviolet radiation comes from exposure to the sun during midday hours and from artificial sources of UV light (such as indoor tanning). Sun-protective behaviors include the use of broad-spectrum sunscreen with a sun-protection factor of 15 or greater, wearing hats or other shade-protective clothing, avoiding the outdoors during midday hours (10 a.m. to 3 p.m.), and avoiding indoor tanning. Utilizing all behaviors is important to minimizing risk.
Epidemiologic evidence (3) links ultraviolet radiation exposure with incidence of all 3 types of skin cancer. The USPSTF found convincing evidence linking UV radiation exposure during childhood and youth to a moderately increased risk for skin cancer later in life; for adults, adequate evidence links UV radiation exposure to a small increase in risk for skin cancer.
Persons with fair skin, light hair and eye color, or freckles or who sunburn easily are at increased risk for skin cancer (1). Most studies of interventions to increase sun-protective behaviors have been limited to populations with a fair skin type.
For children, adolescents, and young adults (persons aged 10 to 24 years), the USPSTF found adequate evidence that counseling interventions that are available in a primary care setting or are referable from primary care can moderately increase the use of sun-protective behaviors.
For adults older than 24 years, the USPSTF found inadequate evidence to determine the effect of counseling on the use of sun-protective behaviors.
The USPSTF found adequate evidence that no appreciable harms are related to counseling or sun-protective behaviors in young persons or adults. Theoretical concerns about sun-protective behaviors include the risk for vitamin D deficiency in adults living in northern latitudes, but little evidence supports this hypothesis.
The USPSTF concludes that for children, adolescents, and young adults aged 10 to 24 years with fair skin, there is moderate certainty that counseling has a moderate net benefit.
The USPSTF concludes that for adults older than 24 years, evidence of the benefits of counseling is sparse and of unknown clinical significance; therefore, the balance of benefits and harms cannot be determined.
This recommendation applies to all asymptomatic persons with no history of skin cancer. Because most trials of skin cancer counseling include only people with a fair skin type, the recommendation for counseling of children, adolescents, and young adults aged 10 to 24 years is limited to this population. Few trials were available to determine the effectiveness of counseling parents or guardians to prevent UV exposure in children younger than 10 years; therefore, the recommendation does not address this population.
Counseling adults is of uncertain potential benefit because of the unknown effectiveness of counseling interventions in changing behavior and because of the less secure link between behavior change in adulthood and risk for skin cancer. Ultraviolet radiation exposure after age 35 years may contribute less to one's lifetime risk for skin cancer than exposure at a younger age.
Skin type can be visually assessed by primary care clinicians. Fair skin type can be defined by eye and hair color; freckling; and historical factors, such as usual reaction to sun exposure (always or usually burning or infrequently tanning).
Effective interventions were generally of low intensity and almost entirely done during the primary care interaction or visit. Successful counseling interventions used cancer prevention or appearance-focused messages to reach specific audiences. The latter types of messages were successful at reducing intent to pursue indoor tanning among late-adolescent women (the population most likely to do so). Appearance-focused interventions used various methods, including self-guided booklets, a video on photoaging, and 30-minute peer counseling sessions. One study (4) used UV facial photography as an adjunct to the appearance-focused video. The UV camera can be used to demonstrate to patients the extent of skin damage from UV exposure.
The Community Preventive Services Task Force recommends education and policy interventions for the prevention of skin cancer (5). These interventions combine community-based communications and policy and regulation to increase preventive behaviors (such as covering up, using shade, or avoiding the sun during peak UV hours) among populations in specific settings, including primary school and outdoor recreational settings.
The U.S. Food and Drug Administration has information to help guide patients and clinicians on the use and effectiveness of broad-spectrum sunscreens (www.fda.gov/sunscreen). It has determined that, if used as directed, broad-spectrum sunscreens with a sun-protection factor of 15 or greater protect against both UV-A and UV-B radiation and reduce the risk for skin cancer and early skin aging. It also has consumer education materials on the dangers of indoor tanning.
Although outside the scope of this recommendation, community-based interventions to promote and support sun safety, such as direct peer-to-peer support, social marketing initiatives, workplace initiatives, and public policy actions, may offer additional sizeable benefits.
The USPSTF recommendation on screening for skin cancer is available at www.uspreventiveservicestaskforce.org.
Various education materials using different media were found to be effective in counseling children, adolescents, and young adults. Several organizations that focus on sun safety or skin cancer prevention have created age-appropriate educational materials, many of which include appearance-based messages. (Examples from the National Cancer Institute can be found at http://rtips.cancer.gov/rtips.) Primary care practitioners may consider which materials can be easily implemented in their setting and for their population. The time required by the clinician to provide brief counseling is the main cost of these services.
Some practices may incur additional costs for materials or technologies, such as professionally produced booklets, computer-based interventions, or UV imaging devices. Commercial products are available that allow patients and clinicians to see the damaging effects of UV radiation on the skin. Some of these products use a black light (such as a Wood lamp) to produce UV light; a camera can also be outfitted to filter visible light and reveal only the UV image. These techniques highlight the pigmented or freckled areas of the skin resulting from skin damage.
One interesting aspect of implementation, given the positive recommendations from the Community Preventive Services Task Force, is the potential to link community-based and local policy efforts with consistent messages delivered by clinicians through brief counseling.
Further randomized, controlled trials are needed to develop effective interventions for children. A better understanding of the effectiveness of counseling on the use of sun-protective behaviors in adults and the effect of UV exposure during adulthood, in terms of risk for skin cancer, would be valuable to address the key evidence gap about counseling for that age group. Research is also needed to further develop technologies and vehicles for administering relevant interventions for behavior change.
Skin cancer is the most common type of cancer, affecting more than 2 million Americans each year. The exact number of cases is difficult to estimate because most cases of nonmelanoma skin cancer are not reported to registries (6). The most common types are basal cell and squamous cell cancer. Melanoma is much less common—the incidence among white Americans in 2008 was about 27.6 cases per 100 000 persons. It is more than 20 times more common in white than in African American persons, but it can occur in all racial and ethnic groups (2). Although less common, melanoma is responsible for 75% of skin cancer deaths, and age-adjusted incidence rates have increased over the past 35 years (1). Of note, basal cell and squamous cell cancer can also be associated with substantial morbidity and costs; in the case of older adults or immunosuppressed persons, squamous cell cancer can result in death (3).
The USPSTF requested a review of the evidence to update its 2003 recommendation (1). The scope of the literature review included a search for direct evidence that counseling patients about sun protection reduces intermediate outcomes (such as sunburn) or skin cancer. Other key questions addressed the link between counseling and behavior change, the link between behavior change and incidence of skin cancer, and the adverse effects of counseling or sun-protective behavior changes.
Both traditional cancer prevention and appearance-focused messages (that stress the aging effect of UV radiation on the skin) were effective in certain populations. In young adults, 1 randomized, controlled trial (4) used a video intervention with or without UV facial photography. This intervention resulted in a decrease in objectively measured skin pigment 12 months after the intervention. Three additional studies in young adults (7–9) used appearance-based interventions. The interventions ranged from a self-guided booklet to a 30-minute counseling session with a peer counselor. In these studies, the intervention reduced indoor tanning behavior by up to 35%. Smaller albeit significant improvements were seen in composite scores of sun-protective behaviors in a trial of young adolescents (10) who were given brief clinician counseling with computer-assisted feedback.
Evidence of the effectiveness of counseling interventions in adults older than 24 years or in parents of young children is limited. A cluster randomized, controlled trial (11) that provided counseling to parents of newborns in a series of 4 well-child visits showed statistically significant improvement in composite sun-protection scores in the intervention group. However, most individual measures were statistically insignificant, and overall it was difficult to determine the clinical relevance of the small improvements. In adults, 4 of 5 intervention studies (12–15) that used telephone counseling sessions packaged with tailored risk feedback or a self-directed, computer-based intervention found significant improvements in a composite sun-protection score, but the differences were small and of uncertain clinical significance.
The USPSTF looked for evidence of a paradoxical decrease in sun-protective behaviors in 10 randomized, controlled trials of interventions designed to increase protective behaviors and found none. It also looked for evidence that children receiving counseling to avoid the outdoors would be less physically active as a result; 2 studies (16, 17), one of which was conducted in a primary care setting, found neither a decrease in outdoor activity time nor an increase in body mass in young persons who received an intervention for skin cancer prevention.
The hypothetical effect of a decrease in vitamin D level as a result of sun-protective behavior, which is mostly a concern in adulthood, continues to be investigated. The limited body of available epidemiologic evidence suggests that some types of cancer may be inversely linked to sun exposure in persons with lighter pigmentation, but the available studies did not assess or control for vitamin D levels.
The USPSTF assessed 12 observational studies that found increased risk for both squamous cell and basal cell cancer from intermittent sun exposure in childhood. Intermittent sun exposure during childhood, especially sunbathing, was also associated with an increased risk for melanoma in 14 observational studies. Studies that measured long-term or total sun exposure found no association between increased exposure and risk for skin cancer (1).
There was limited evidence to evaluate the association between use of indoor tanning beds and the risk for squamous cell or basal cell cancer. Four of 5 observational studies showed no statistically significant association. One larger study did show an increased risk but did not adjust for sun exposure. Twelve observational studies evaluated the association between indoor tanning and melanoma incidence. One cohort study found an association between regular solarium use over 2 to 3 decades and an increased risk for melanoma (risk ratio [RR], 2.37). Of the 11 case–control studies, most of those with negative results did not adjust for skin phenotype, whereas 3 of 4 studies with positive results did adjust for skin phenotype. These studies found an association between increased use of tanning beds and increased risk for melanoma (1).
One randomized, controlled trial found that persons who regularly used sunscreen had a decreased risk for squamous cell but not basal cell cancer. The Nambour Skin Cancer Prevention Trial (18) reported RRs of 0.65 (95% CI, 0.45 to 0.94) for squamous cell cancer and 1.02 (CI, 0.78 to 1.35) for basal cell cancer. Ten-year follow-up of secondary study outcomes revealed a decreased risk for invasive melanoma (RR, 0.27 [CI, 0.08 to 0.97]) but not preinvasive melanoma (RR, 0.73 [CI, 0.29 to 1.81]) in the intervention group (19). Two cohort studies showed no protective effect of sunscreen on risk for basal cell or squamous cell cancer. In addition, 2 case–control studies showed a harmful effect from sunscreen use. However, these 4 studies used only crude measures of sunscreen use and did not adjust for sun exposure. Five observational studies showed mixed protective and harmful associations between sunscreen use and melanoma risk. Two found no association, 1 found a protective effect, and 2 found harmful effects (1).
The USPSTF determined that the interventions studied were of moderate benefit in changing risky behaviors in young persons. The link of behavior change to outcomes is supported by a body of evidence comprising a few trials and a substantial body of observational evidence showing that the strongest connection between UV radiation exposure and skin cancer stems from UV exposure in youth. The interventions themselves are not associated with any known risks or harms. The USPSTF assessed the range of probable harms to be no greater than small. For children, adolescents, and young adults aged 10 to 24 years, the USPSTF concluded with moderate certainty that the net benefits are moderate for counseling to decrease UV exposure and reduce the risk for skin cancer.
For adults, there was inadequate evidence on the efficacy of counseling to change behavior. Although counseling was found to have negligible harms, evidence on the harms of sun-protective behaviors in adults was inadequate. Finally, the USPSTF assessed the data supporting a link between decreased UV radiation in adulthood and risk for skin cancer and determined that there was evidence of a small benefit. As a result, and particularly because of the inadequacy of evidence about the efficacy of counseling in adults, the USPSTF concluded that the balance of benefits and harms could not be assessed for this population.
Ultraviolet radiation from both solar and artificial sources has been classified as a human carcinogen by national and international organizations (20). Epidemiologic evidence suggests that the effect of UV radiation exposure from typical doses of sunlight varies over the life span, with some evidence of a window of biological vulnerability in early life that translates into risk for skin cancer decades later. Most of the available evidence concerns the most common lesions: nonmalignant neoplasia and basal cell and squamous cell cancer. It is not clear whether the same mechanisms or schedules apply to risk for melanoma, the most lethal type of skin cancer. For all 3 types, increasing intermittent, or recreational, sun exposure is linked by fair-quality evidence to increased cancer risk, whereas long-term or total sun exposure is not (1).
A draft version of this recommendation statement was posted for public comment on the USPSTF Web site from 8 November to 6 December 2011. The Task Force received 19 comments on the draft recommendation statement. In response to these comments, language describing the evidence gaps for adults and newborns was clarified. More detailed information was added in the Implementation section, and another Web site for relevant resources was added in the Other Approaches to Prevention section. Additional information was added on the basis of recently updated studies and policies or recommendations of other organizations.
This recommendation replaces the USPSTF's 2003 recommendation on counseling about skin cancer prevention at any age (I statement) (21). In the current review, the USPSTF notes the significant studies done in young persons that, although using different approaches, describe a consistent picture of moderate behavior change in persons at the age of greatest vulnerability to UV radiation exposure.
The American Cancer Society advises the importance of protecting children from the sun because of the increased risk for cancer resulting from severe sunburns in childhood (6). The American Academy of Pediatrics has an extensive set of recommendations to protect children from the hazards of UV radiation exposure (22). It recommends that pediatricians incorporate sun safety advice into health maintenance visits at least once per year. The American Congress of Obstetricians and Gynecologists recommends providing guidance to parents to encourage adolescents to regularly use sunscreen and to avoid artificial tanning (23). The American Academy of Family Physicians has endorsed the USPSTF's recommendations on behavioral counseling to prevent skin cancer (24).
* For a list of the members of the USPSTF, see the Appendix.
This article was published at www.annals.org on 8 May 2012.
Members of the U.S. Preventive Services Task Force† at the time this recommendation was finalized are Virginia A. Moyer, MD, MPH, Chair (Baylor College of Medicine, Houston, Texas); Michael L. LeFevre, MD, MSPH, Co-Vice Chair (University of Missouri School of Medicine, Columbia, Missouri); Albert L. Siu, MD, MSPH, Co-Vice Chair (Mount Sinai School of Medicine, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York); Kirsten Bibbins-Domingo, PhD, MD (University of California, San Francisco, San Francisco, California); Linda Ciofu Baumann, PhD, RN (University of Wisconsin, Madison, Wisconsin); Susan J. Curry, PhD (University of Iowa College of Public Health, Iowa City, Iowa); Mark Ebell, MD, MS (University of Georgia, Athens, Georgia); Glenn Flores, MD (University of Texas Southwestern, Dallas, Texas); Adelita Gonzales Cantu, RN, PhD (University of Texas Health Science Center, San Antonio, Texas); David C. Grossman, MD, MPH (Group Health Cooperative, Seattle, Washington); Jessica Herzstein, MD, MPH (Air Products, Allentown, Pennsylvania); Joy Melnikow, MD, MPH (University of California, Davis, Sacramento, California); Wanda K. Nicholson, MD, MPH, MBA (University of North Carolina School of Medicine, Chapel Hill, North Carolina); Douglas K. Owens, MD, MS (Stanford University, Stanford, California); Carolina Reyes, MD, MPH (Virginia Hospital Center, Arlington, Virginia); and Timothy J. Wilt, MD, MPH (University of Minnesota Department of Medicine and Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota). Former USPSTF members who contributed to the development of this recommendation include Allen Dietrich, MD; Lucy Marion, PhD, RN; and Bernadette Melnyk, PhD, RN.
† For a list of current Task Force members, go to www.uspreventiveservicestaskforce.org/members.htm.
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Counseling burden vs benefit?
As recommendations for counseling patients increase, the number of things that can be done during a typical outpatient visit decreases.
Most USPSTF recommendations are based on how well the intervention does to save lives and prevent disease.
How many patients need to be counseled to prevent skin cancer? No idea. It could be that a million patients need to be counseled to prevent one case of skin cancer. And to prevent a death? There is no telling how many would need to be counseled.
Hematology/Oncology, Guidelines, Cancer Screening/Prevention, Prevention/Screening.
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