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Lin JS, Eder M, Weinmann S, et al. Behavioral Counseling to Prevent Skin Cancer: Systematic Evidence Review to Update the 2003 U.S. Preventive Services Task Force Recommendation [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Feb. (Evidence Syntheses, No. 82.)

Cover of Behavioral Counseling to Prevent Skin Cancer

Behavioral Counseling to Prevent Skin Cancer: Systematic Evidence Review to Update the 2003 U.S. Preventive Services Task Force Recommendation [Internet].

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1Introduction

Scope and Purpose

This report was written to support the U.S. Preventive Services Task Force (USPSTF) in updating its 2003 recommendation on counseling for skin cancer prevention. The 2003 report found a single counseling trial, in the context of a community-based educational intervention, that examined the effectiveness of increasing sun-protective behaviors. 1 Given the multi modal nature of this intervention, however, the contribution of the office-based counseling component could not be isolated. In addition to the counseling literature, the previous report also examined the association between sun-protective behaviors and melanoma. This rep ort found that determining the efficacy of sun avoidance and use of protective clothing for the prevention of melanoma is complex. The evidence did support the hypothesis that intermittent sunburn in childhood is a preventable risk factor. However, no trials linking sun avoidance or use of protective clothing to a decrease in skin cancer incidence were identified. Finally, the report found one trial showing a modest benefit of sunscreen in preventing squamous cell carcinoma. A meta-analysis of case-control studies, however, showed that sunscreen use was not associated with an increased or decreased risk for melanoma.

The primary evidence gaps identified by the 2003 USPSTF recommendation were uncertainty about whether clinician counseling is effective in changing patient behaviors to reduce skin cancer and uncertainty about potential harms of sun-protective behaviors. Additionally, the USPSTF noted that only fair-quality evidence linked sunscreen use or use of indoor tanning to skin cancer outcomes. Therefore, this review focuses on new trial evidence for counseling interventions to prevent skin cancer conducted in primary care, and also reexamines previous trials that were not conducted in primary care but may be considered feasible for primary care adoption or represent community interventions to which primary care can refer patients.2 The early detection of skin cancer with skin self-examination is addressed in the recently updated evidence review on skin cancer screening.3 This review also examines the harms directly associated with counseling interventions, epidemiologic associations between key behaviors in counseling interventions (i.e., decreased sun exposure, sunlamp or tanning bed avoidance, and sunscreen use) and relevant skin cancer outcomes, and the potential harms associated with these sun-protective behaviors.

Background

Condition Definition

The three major types of skin cancer are melanoma, squamous cell carcinoma, and basal cell carcinoma.4 There are four major subtypes of cutaneous melanoma: superficial spreading, nodular, lentigo maligna, and acral lentiginous.1 Some melanomas are not easily classified into a single category and may have overlapping features.

Burden of Preventable Illness

Skin cancer is the most common cancer in the United States. Over 1 million persons are diagnosed annually in the United States with cutaneous malignant melanoma, squamous cell carcinoma, or basal cell carcinoma.4 While melanoma is less common than basal cell and squamous cell carcinoma, it is also more deadly.4 Incidence rates of melanoma have also been increasing worldwide. Age-adjusted incidence rates of melanoma among white Americans have risen from approximately 8.7 per 100,000 in 1975 to 26.4 per 100,000 in 2005.5 An estimated 62,480 persons were expected to develop melanoma in 2008, which means 1 in 52 men and 1 in 77 women will develop this potentially lethal cancer during their lifetimes.6 Several factors may contribute to increasing incidence rates, including increased exposure to carcinogenic factors (i.e., ultraviolet [UV] exposure), increased public awareness of the warning signs of melanoma, and increased screening by clinicians.7–9 Mortality rates are more than 5-fold lower than incidence rates, but depend upon stage at diagnosis.10 Five-year survival of melanoma is 99 percent if diagnosed at a localized stage, but only 65 percent or 15 percent if diagnosed at a regional or distant stage, respectively.10

Of the approximately 1.3 million cases of skin cancer diagnosed each year, about 800,000 to 900,000 are basal cell carcinoma, and 200,000 to 300,000 are squamous cell carcinoma.4 While squamous cell cancer accounts for less than 0.1 percent of all cancer deaths, it does have the potential to metastasize and may account for a significant proportion of mortality from skin cancer in older persons and immunosuppressed persons.11 In contrast, survival rates for those with basal cell carcinoma are indistinguishable from those of the general population.11 On the basis of mortality, squamous cell and basal cell carcinoma are often not considered important problems. Because of their high and rising incidence, however, squamous cell and basal cell carcinoma pose a significant economic burden. Based on 1995 Medicare claims data, it was estimated that squamous cell and basal cell carcinoma are the fifth most costly type of malignant cancer to treat (behind lung, prostate, colon, and breast cancer), and represented approximately 4.5 percent of costs associated with management of all types of cancer.12

Risk Factors and High-Risk Groups

Cutaneous melanoma, basal cell carcinoma, and squamous cell carcinoma have well-known host and environmental risk factors. Skin cancer is approximately 10 times more common among Caucasians than among deeply pigmented ethnic groups. Other host factors include history of previous melanoma, family history of skin cancer, and immunosuppression.4,13,14 Several phenotypic characteristics are associated with skin cancer risk, including hair and eye color (through correlation with skin phenotype), freckles, and tendency to sunburn.13,15 As with other types of cancer, skin cancer incidence increases with age, but is also one of the most common types of cancer in young people.4,13 Men are 1.5 to 3 times more likely than women to develop skin cancer, depending on age and type of skin cancer.4,13 The role of genetic factors in the etiology of melanoma is complicated. Several genes that cause increased chromosomal sensitivity to sun damage may explain the role of family history as a risk factor for melanoma. 7 A history of melanoma in first-degree relatives is a strong predictor of melanoma, and about 10 percent of all people with melanoma have a family history of melanoma. Gene mutations have been found in anywhere from about 10 to 40 percent of families with a high rate of melanoma. In addition, two inherited conditions, xeroderma pigmentosum and basal cell nevus syndrome, confer high risk for skin cancer.4

Exposure to solar UV radiation is the most important environmental risk factor for all types of skin cancer.16 UV radiation from the sun is approximately 95% UVA and 5% UVB. In addition to sunlight, indoor tanning is a source of UV exposure. The composition of UV exposure in indoor tanning has changed over time, however, in that earlier sunlamps primarily emitted UVB radiation, and more recent tanning beds emit higher rates of UVA radiation. Sunscreens, used to protect against UV exposure, have likewise changed over time as well, in that UVA protection was not added to sunscreens until 1989. Other environmental factors include exposure to coal tar, pitch, creosote, arsenic, or radium.4

Intermediate outcomes of sun exposure and skin cancer, such as sunburn, acquired nevi, and actinic keratoses, have been established. Sunburn, an inflammatory response to UV radiation, is strongly related to the risk for melanoma. Studies have shown that people with a history of sunburns have double the risk for melanoma.13,17,18 The correlation of sunburns with melanoma may be direct or may be because sunburn is a marker of both sun sensitivity and intermittent sun exposure.13,17 Actinic keratoses, another form of skin damage caused by sun exposure, are also a confirmed risk factor for skin cancer.11,15 At least 60 percent of squamous cell carcinoma cases arise from existing actinic keratoses.19–21 Nevi (i.e., moles) are most likely caused by a combination of genetic and environmental factors, particularly sun exposure. The number of common and atypical nevi significantly increases the risk for melanoma. 7,13,22,23

Current Practice

It is hypothesized that sun exposure should be more easily modifiable through behavioral intervention than many other cancer risk factors and that changes in behavior should have an impact on decreasing cancer incidence.1 Strategies for the primary prevention of skin cancer by limiting UV exposure include avoiding midday sun, wearing protective clothing and broad-brimmed hats, applying sunscreen, and avoiding indoor tanning.13 The American Cancer Society recommends protection from exposure to UV radiation, monthly skin self-examinations, and screening during periodic checkups.4 The Task Force on Community Preventive Services recommends educational and policy approaches in primary schools to improve children’s sun-protective “covering up” behavior.24

The frequency of routine primary care counseling for skin cancer prevention varies across studies. Three recent studies report rates from as low as 22 percent to as high as 76 percent. Specifically, the American Academy of Pediatrics Periodic Survey found that more than 90 percent of pediatricians believed that skin cancer is a significant public health problem, but only 22 percent reported counseling most patients in all age groups. The most common intervention named by pediatricians was advising sunscreen with a sun protection factor (SPF) of ≥15.25 Another study of pediatricians in Texas found that 76 percent routinely recommend sunscreen, 53 percent routinely recommend protective clothing, and 46 percent routinely recommend limiting midday sun exposure.26 A third study showed that primary care physicians, when confronted with a standardized patient at high risk for skin cancer, did not ask questions about skin type or sun exposure habits and only 67 percent recommended sunscreen, 7 percent discussed sunscreen types or procedures for effective use, and 13 percent counseled other skin-protective behaviors.27

Recent studies suggest that Americans’ sun-protective behaviors must be improved. A cross-sectional study from all 50 states of 10,079 boys and girls ages 12 to 18 years found that the prevalence of sunscreen use was 34 percent. Nearly 10 percent used a tanning bed during the prior year. Girls were more likely than boys to use sunscreen and much more likely than boys to report tanning bed use. Furthermore, the majority had at least one sunburn during the prior summer (83 percent), and 36 percent had three or more sunburns.28 Among 28,235 adults participating in the 2005 National Health Interview Survey (NHIS), over 50 percent reported infrequent use of sunscreen, approximately 20 percent of adults aged 18 to 20 years reported use of an indoor tanning device in the past year, and over 40 percent of adults aged 18 to 49 years reported a sunburn during the past year.29

Previous USPSTF Recommendation

In October 2003, the USPSTF concluded that the evidence is insufficient to recommend for or against routine counseling by primary care clinicians to prevent skin cancer (I recommendation). At the time, the USPSTF found insufficient evidence to determine whether clinician counseling is effective in changing patient behaviors to reduce skin cancer risk. Counseling parents may increase the use of sunscreen for children, but there was little evidence to determine the effects of counseling on other preventive behaviors (such as wearing protective clothing, reducing excessive sun exposure, avoiding indoor tanning, or practicing skin self-examination) and little evidence on potential harms.

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