This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on counseling to prevent skin cancer and the supporting scientific evidence, and updates the 1996 recommendation contained in the Guide to Clinical Preventive Services, Second Edition1.
Summary of Recommendation
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Clinical Considerations Scientific Evidence Recommendations of Others References Members of the Task Force Contact the Task Force Available Products| Task Force Ratings Strength of Recommendations and Quality of Evidence |
Melanoma is a leading cause of cancer death in the United States. The lifetime risk for dying of melanoma is 0.36 percent in white men and 0.21 percent in white women.3 Between 1973 and 1995, the age-adjusted incidence of melanoma increased more than 100 percent, from 5.7 per 100,000 people to 13.3 per 100,000 people. The increase in annual incidence rates is likely due to several factors, including increased sun exposure and possibly earlier detection of melanoma. Although primary prevention efforts have focused on young people, the elderly (especially elderly men) bear a disproportionate burden of morbidity and mortality from melanoma and nonmelanoma skin cancer. Men older than age 65 account for 22 percent of the newly diagnosed cases of malignant melanoma each year and women in the same age group account for 14 percent. Basal cell and squamous cell carcinomas are more than 10 times as common as melanoma but account for less morbidity and mortality. Squamous cell cancers, however, may account for 20 percent of all deaths from skin cancer.
Preventive strategies include reducing sun exposure (e.g., by wearing protective clothing and using sunscreen regularly), avoiding sunlamps and tanning equipment, and practicing skin self-examination. There is little direct evidence, however, that any of these interventions reduce skin cancer morbidity or mortality.
Avoiding direct sunlight by staying indoors or in the shade or by wearing protective clothing is the most effective measure for reducing exposure to ultraviolet light, but there are no randomized trials of sun avoidance to prevent skin cancer. In numerous observational studies, increased sun exposure in childhood and adolescence is associated with increased risk for non-melanoma skin cancer, which usually occurs in sun-exposed areas such as the face.
Recent studies provide a more complex picture of the relationship between sun exposure and melanoma, however. While melanoma incidence is higher in regions near the equator where ultraviolet exposure is most intense, melanoma often occurs in areas of the body not exposed to the sun. In observational studies, intermittent or intense sun exposure was associated with increased risk for melanoma; chronic exposure was associated with lower risk, as was the ability to tan.4-7
Six of 19 case-control studies found a positive association between use of sun lamps and melanoma risk, but most did not adjust for recreational sun exposure or for the dosage and timing of sunlamp exposure.8 Among 9 studies that examined the duration, frequency, or timing of sunlamp or tanning bed exposure, 4 found a positive association, particularly if the dose of exposure was high and if it caused burning.
Daily sunscreen use on the hands and face reduced the total incidence of squamous cell cancer in a randomized trial of 1,621 residents in Australia (rate ratio [RR], 0.61; 95 percent confidence interval [CI], 0.46 to 0.81).9 Sunscreen had no effect on basal cell cancer. Based on this trial, 140 people would need to use sunscreen daily for 4 ½ years to prevent 1 case of squamous cell cancer. An earlier randomized trial demonstrated that sunscreen use reduced solar keratoses, precursors of squamous cell cancers.10 There are no direct data about the effect of sunscreen on melanoma incidence. An unblinded randomized trial showed children at high risk for skin cancers who used sunscreen developed fewer nevi than those who did not. Several epidemiologic studies have found higher risk for melanoma among users of sunscreens than among non-users.11-13 A recent meta-analysis of population-based case-control studies found no effect of sunscreen use on risk for melanoma.14 The conflicting results may reflect the fact that sunscreen use is more common among fair-skinned people, who are at higher risk for melanoma, than it is among darker-skinned people; or, this finding may reflect the fact that sunscreen use could be harmful if it encourages longer stays in the sun without protecting completely against cancer-causing radiation.
The only evidence for the effectiveness of skin self-examination comes from a single case-control study.1,15 After adjustment for other risk factors, skin self-examination was associated with lower incidence of melanoma (odds ratio [OR], 0.66; 95 percent CI, 0.44 to 0.99) and lower mortality from melanoma (OR, 0.37; 95 percent CI, 0.16 to 0.84), although the definition of "self-examination" was limited. This study did not provide sufficient evidence that skin self-examination would reduce the incidence of melanoma or improve outcomes of melanoma.
Community and worksite educational interventions have demonstrated effectiveness for increasing the use of skin protection measures, such as wearing hats and long-sleeve shirts and staying in the shade; however, evidence addressing the effectiveness of clinician counseling to prevent skin cancer is extremely limited. Most studies of counseling have examined intermediate outcomes such as knowledge and attitudes rather than changes in behavior. In a recent survey, 60 percent of pediatricians said that they usually or always counsel patients about skin protection, but advice to use sunscreen is more common than advice about wearing protective clothing or avoiding the midday sun.16
Simple reminders and instructional materials for clinicians can overcome some of the barriers to regular counseling. A randomized trial of a community-based intervention involving 10 towns in New Hampshire suggests that office-based counseling by physicians may be an effective component of a multi-modal program to promote skin protection.17 The proportion of children utilizing some sun protection increased significantly in the intervention towns (from 78 to 87 percent) compared to a decrease in the control communities (from 85 to 80 percent). More parents reported receiving some sun protection information from a clinician in the intervention towns. However, most of the change was due to increased sunscreen use rather than to reduced sun exposure.
There are limited data regarding potential harms of counseling or of specific skin protection behaviors. A possible result of skin cancer counseling that focuses on the use of sunscreen can lead to a false sense of security, which might lead to more time in the sun. For example, a randomized trial with young adults found that those who used sunscreen with a high sun protection factor (SPF) stayed longer in the sun than those who used sunscreen with a lower SPF.18 There has been some concern that use of sun protection factor (SPF) of 15 results in vitamin D deficiency. However, a randomized trial in people over 40 years of age found that sunscreen use over the summer had no effect on 25-hydroxyvitamin D3 levels. Concerns related to sun avoidance include reduced physical activity levels among children and negative effects on mental health. However, no studies have evaluated the effects of sun protection behaviors on these outcomes.
The American Cancer Society,19 the American Academy of Dermatology,20 the American Academy of Pediatrics,21 the American College of Obstetricians and Gynecologists,22 and a National Institutes of Health consensus panel23 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.24 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.25 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."26
The Task Force on Community Preventive Services found insufficient evidence to determine the effectiveness of a range of population-based interventions to reduce unprotected ultraviolet light exposure and recommended additional research on educational and policy approaches, media campaigns, and both health care setting and community-based interventions. 27
1. U.S. Preventive Services Task Force. Screening for Skin Cancer. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996:141-52.
2. Helfand M, Krages K. Counseling to Prevent Skin Cancer. Summary of the Evidence for the U.S. Preventive Services Task Force. Rockville, MD: Department of Health and Human Services, Agency for Healthcare Research and Quality. Available at www.ahrq.gov/clinic/3rduspstf/skcacoun/skcounsum.htm.
3. Ries LA, Kosary CL, Hankey BF, Miller BA, Edwards BK, eds. SEER Cancer Statistics Review, 1973-95. Bethesda: National Cancer Institute; 1998.
4. Nelemans PJ, Rampen FH, Ruiter DJ, Verbeek AL. An addition to the controversy on sunlight exposure and melanoma risk: a meta-analytical approach. J Clin Epidemiol 1995;48(11):1331-42.
5. Elwood M, Jopson J. Melanoma and sun exposure: an overview of published studies. Int J Cancer 1997;73(2):198-203.
6. Walter S, King W, Marrett L. Association of cutaneous malignant melanoma with intermittent exposure to ultraviolet radiation: results of a case-control study in Ontario, Canada. Int J Epidemiol 1999;28(3):418-27.
7. Holly EA, Aston DA, Cress RD, Ahn DK, Kristiansen JJ. Cutaneous melanoma in women. I. Exposure to sunlight, ability to tan, and other risk factors related to ultraviolet light. Am J Epidemiol 1995;141(10):923-33.
8. Swerdlow AJ, Weinstock MA. Do tanning lamps cause melanoma? An epidemiologic assessment. J Am Acad Dermatol 1998;38(1):89-98.
9. Green A, Williams G, Neale R, et al. Daily sunscreen application and beta-carotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet 1999;354(9180):723-9.
10. Thompson SC, Jolley D, Marks R. Reduction of solar keratoses by regular sunscreen use. N Engl J Med 1993;329(16):1147-51.
11. Autier P, Dore JF, Schifflers E, et al. Melanoma and use of sunscreens: an EORTC case-control study in Germany, Belgium and France. The EORTC Melanoma Cooperative Group. Int J Cancer 1995;61(6):749-55.
12. Autier P, Dore JF, Cattaruzza MS, et al. Sunscreen use, wearing clothes, and number of nevi in 6- to 7-year-old European children. European Organization for Research and Treatment of Cancer Melanoma Cooperative Group. J Natl Cancer Inst 1998;90(24):1873-80.
13. Westerdahl J, Olsson H, Masback A, Ingvar C, Jonsson N. Is the use of sunscreens a risk factor for malignant melanoma? Melanoma Res 1995;5(1):59-65.
14. Huncharek M, Kupelnick B. Use of topical sunscreens and the risk of malignant melanoma: a meta-analysis of 9067 patients from 11 case-control studies. Am J Public Health 2002;92(7):1173-77.
15. Berwick M, Begg CB, Fine JA, Roush GC, Barnhill RL. Screening for cutaneous melanoma by skin self-examination [see comments]. J Natl Cancer Inst 1996;88(1):17-23.
16. Easton A, Price J, Boehm K, Telljohann S. Sun protection counseling by pediatricians. Arch Pediatr Adolesc Med 1997;151(11):1133-38.
17. Dietrich AJ, Olson AL, Sox CH, Tosteson TD, Grant-Petersson J. Persistent increase in children's sun protection in a randomized controlled community trial. Prev Med 2000;31(5):569-74.
18. Autier P, Dore JF, Negrier S, et al. Sunscreen use and duration of sun exposure: a double-blind, randomized trial. J Natl Cancer Inst 1999;91(15):1304-9.
19. American Cancer Society (ACS). Cancer Prevention & Early Detection Facts & Figures 2003. Atlanta, Georgia. 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. Accessed March 13, 2003.
20. 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 Dermotol 1999;41(1):81-99.
21. Ultraviolet light: a hazard to children (RE9913). American Academy of Pediatrics, Committee on Environmental Health. Pediatrics 1999;104:328-33.
22. American College of Obstetricians and Gynecologists. Primary and preventive care: periodic assessments. ACOG Committee Opinion 246. Washington, DC: ACOG, 2000.
23. Diagnosis and treatment of early melanoma. NIH Consensus Development Conference, January 27-29, 1992. Vol 10, Number 1.
24. "Sun-Safe Guidelines." American Academy of Family Physicians. Available at http://www.aafp.org/afp/20000715/375ph.html. Accessed March 12, 2003.
25. Ferrini RL, Perlman M, Hill L. Skin protection from ultraviolet light exposure: American College of Preventive Medicine Practice Policy Statement. Available at http://www.acpm.org/skinprot.htm. Accessed March 12, 2003.
26. International Agency for Research on Cancer (IARC). Handbooks of Cancer Prevention: Sunscreens. 2001; Vol 5. IARC Press: Lyon, France.
27. Centers for Disease Control and Prevention. Preventing Skin Cancer: Findings of the Task Force on Community Preventive Services on reducing exposure to ultraviolet light. MMWR 2003;52 (No. RR-15): 13-17.
Members of the U.S. Preventive Services Task Force are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland Baltimore, Baltimore, MD); Paul Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H.* (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Mark S. Johnson, M.D., M.P.H. (Chair, Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, M.D., M.P.H.* (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, M.D., M.Sc.* (Clinical Professor and Director, Department of Medicine, University of Texas Health Science Center, San Antonio, TX); C. Tracy Orleans, Ph.D. (Senior Scientist and Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H.* (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N.* (Professor Emeritus, University of Michigan, Ann Arbor, MI); Albert L. Siu, M.D., M.S.P.H. (Professor of Medicine, Chief of Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Professor of Obstetrics and Gynecology and Professor of Public Health, Columbia University, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor, Department of Family Practice and Department of Preventive and Community Medicine, Fairfax, VA).
* Member of the USPSTF at the time this recommendation was finalized.
Address correspondence to: Chair, U.S. Preventive Services Task Force; c/o Project Director, USPSTF; 540 Gaither Road; Rockville, MD 20850; E-mail: uspstf@ahrq.gov.
This recommendation and rationale statement, plus complete information on which this statement is based, including evidence tables and references, are available on the USPSTF Web site at http://www.preventiveservices.ahrq.gov.
Current as of October 2003
Internet Citation:
U.S. Preventive Services Task Force. Counseling to Prevent Skin Cancer: Recommendations and Rationale. October 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/skcacoun/skcarr.htm
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