Recommendation Statement
Date: February 2009
This report was first published in Annals of Internal Medicine in
February 2009 (Ann Intern Med 2009;150:188-93. http://www.annals.org).
Summary of Recommendation and Evidence
- The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.
Grade: I Statement.
|
Go to the Clinical Considerations section for information on risk assessment and
suggestions for practice regarding the I statement.
Select for a Clinical Summary of this recommendation and suggestions for clinical
practice.
Contents
Rationale
Clinical Considerations
Useful Resources
Discussion
Recommendations of Other Groups
References
Members of the USPSTF
Rationale
Importance
Skin
cancer—basal cell carcinoma, squamous cell carcinoma, and melanoma—is the most
commonly diagnosed cancer. Although melanoma accounts for about 5% to 6% of
skin cancer diagnoses, it accounts for approximately 75% of the mortality from
skin cancer.1
Detection
There
is fair evidence that screening by clinicians is moderately accurate in
detecting melanoma. The evidence is insufficient to determine the extent to
which screening by patient self-examination accurately detects skin cancer.
Benefits
of Detection and Early Treatment
The
evidence is insufficient (lack of studies) to determine whether early detection
of skin cancer reduces mortality or morbidity from skin cancer. This is a
critical gap in the evidence.
Harms
of Detection and Early Treatment
The
evidence is insufficient (lack of studies) to determine the magnitude of harms
from screening for skin cancer. Potential harms of screening for skin cancer
include misdiagnosis, overdiagnosis, and the resultant harms from biopsies and
overtreatment. This is a critical gap in the evidence.
USPSTF
Assessment
The
USPSTF concludes that the current evidence is insufficient to assess the
balance of benefits and harms of screening for skin cancer by primary care
clinicians or by patient skin self-examination. If this service is used,
patients should be made aware of the uncertainty about the balance of benefits
and harms.
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Clinical
Considerations
Patient
Population Under Consideration
This
recommendation applies to the adult general population without a history of
premalignant or malignant lesions. The USPSTF did not examine the outcomes
related to surveillance of patients at extremely high risk, such as those with
familial syndromes (for example, the familial atypical mole and melanoma
syndrome).
Suggestions
for Practice Regarding the I Statement
Clinicians should remain alert for skin lesions with malignant
features noted in the context of physical examinations performed for other
purposes. Asymmetry, border irregularity, color variability, diameter greater
than 6 mm (ABCD criteria), or rapidly changing lesions are features associated
with an increased risk for cancer. Biopsy of suspicious lesions is warranted.
Assessment
of Risk
Clinicians
should be aware that fair-skinned men and women older than 65 years, patients
with atypical moles, and those with more than 50 moles constitute known groups
at substantially increased risk for melanoma. Other risk factors for skin
cancer include family history and a considerable past history of sun exposure
and sunburns. Benefits from screening are uncertain, even in high-risk
patients.
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Useful
Resources
The
USPSTF has previously reviewed the evidence for counseling to prevent skin
cancer. The recommendation statement and supporting documents are available on
the AHRQ Web site (http://www.preventiveservices.ahrq.gov). The U.S. Task Force on
Community Preventive Services has reviewed the evidence on interventions
designed to reduce skin cancer; the recommendations are available at The
Community Guide (http://www.thecommunityguide.org.
).
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Discussion
Burden
of Disease
Skin
cancer is the most commonly diagnosed cancer in the United States. The majority
of these skin cancer cases are basal cell carcinoma and squamous cell skin
cancer. Basal cell and squamous cell skin cancer uncommonly metastasize or lead
to death. Melanoma is eighth in frequency of occurrence of all causes of cancer
in the United States. Although less common than other skin cancer types,
melanoma may metastasize and lead to death. The lifetime risk for a diagnosis
of melanoma in the United States is 1.94% for males and 1.30% for females; the
lifetime risk for death from melanoma is 0.35% for males and 0.20% for females.2
Scope
of Review
In
its previous review of screening for skin cancer in 2001, the USPSTF concluded
that there was insufficient evidence to recommend for or against routine screening for skin cancer with a whole-body skin
examination for early detection of cutaneous melanoma, basal cell cancer, or
squamous cell skin cancer (an I statement).3
The USPSTF issued this statement after reviewing the available evidence and concluding that there was little to no evidence regarding the effectiveness of skin examination by clinicians in reducing mortality or morbidity from skin cancer. The USPSTF also concluded that information was limited about the ability of primary care providers to perform adequate examinations in the context of usual care. Therefore, the USPSTF determined that this evidence update should focus on a systematic review of the evidence on screening for skin cancer with morbidity and mortality outcomes. In addition, the USPSTF examined the evidence on the stage of detection by screening and on the accuracy of whole-body examination by primary care clinicians and self-examination by patients.
Accuracy
of Screening Tests
Primary
care physicians are moderately accurate in diagnosing melanoma, with a
sensitivity of 42% to 100% and a specificity of 70% to 98%. A large systematic
review analyzed the evidence on diagnostic accuracy of primary care physicians
and dermatologists; most of the studies used images of lesions that had been
histologically confirmed. The systematic review included 11 studies with primary care physicians and found a sensitivity of 42% to 100% and
a specificity of 98% in the diagnosis of melanoma. The authors concluded that
the evidence was insufficient to determine whether dermatologists and primary
care physicians differed in accuracy.4 However, most studies on the accuracy
of diagnosis of melanoma by primary care physicians evaluated the ability to
identify melanoma from images of lesions of a known diagnosis; the
applicability of this evidence to a whole-body skin examination in the setting
of screening for skin cancer is not clear.
Effectiveness
of Early Detection
No
randomized studies have directly examined whether screening by clinicians is
associated with improved clinical outcomes, such as reduced morbidity or
mortality from skin cancer. The possibility that earlier treatment as a result
of screening improves health outcomes must rely on indirect evidence.
Screening
consistently identifies melanomas that are, on average, thinner than those
found during usual care. It is not known if detection of these lesions leads to
decreased morbidity or mortality. A large evaluation study of the American
Academy of Dermatology's Skin Cancer Screening Program5 found that, during
1992 to 1994, there was a higher percentage of lesions in early stages
(<1.50 mm) in participants who had received screening through the American
Academy of Dermatology program than in cases documented in the Surveillance, Epidemiology, and End Results (SEER) registry: 10% and 2%, respectively (P <0.001). A poor-quality case-control
study in which skin self-examination was associated with a lower incidence of fatal
melanoma provides indirect but insufficient evidence that the shift to earlier
stages found in screening may be associated with better clinical outcomes. Evidence
from studies of the consequences of delay in diagnosis is inconsistent.
Even
without formal screening programs, the mortality rate from basal cell and
squamous cell carcinoma is low compared with the mortality rate from melanoma; in
theory, early detection and treatment could reduce morbidity and disfigurement
from these cancers. No studies were found, however, that evaluate whether
screening improves the outcomes of these types of cancer.
The
USPSTF could not assess the magnitude of the benefits from screening for skin
cancer by physicians or by self-examination because evidence on screening was
limited.
Potential
Harms of Screening
Information
on the harms of screening is limited. The majority of suspected melanoma
lesions detected during screening programs are not actually melanoma, and these
false-positive results lead to biopsies and possibly unnecessary treatment. In
addition to detecting false-positive lesions, screening identifies nonmelanoma
skin cancers and thin melanomas; some of these lesions may have little
potential for malignant spread and mortality. Surgical or other treatment of
these lesions could result in overtreatment. Information on harms is limited, therefore
the USPSTF could not assess the magnitude of harms from screening.
Estimate
of Magnitude of Net Benefit
No
studies of the benefits of screening have compared a screened population with
an unscreened population with respect to appropriate health outcomes. Although
some evidence indicates that false-positive results of screening can often lead
to interventions that may cause harm, evidence on the overall harms of
screening is limited. The USPSTF could not assess the magnitude of benefits or
harms, and was therefore unable to estimate the magnitude of net benefit.
How
This Evidence Fits With Biological Understanding
Although
the evidence is insufficient to make a recommendation because of the lack of
evidence on benefits and harms of screening, many advocate whole-body screening
as the best modality for early detection. For early detection to be effective
in reducing adverse health outcomes, early treatment must affect the ultimate
trajectory of the illness. Ecological data have shown that although the
incidence of melanoma is increasing, primarily because of an increase in early
stage lesions (probably from screening), the mortality from melanoma has not
changed substantially.6
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Recommendations
of Others
The
Canadian Task Force on Preventive Health Care last reviewed this topic in 1994
and reported that there was poor evidence to warrant including or excluding
skin cancer screening from the periodic health examination of the general
population.7 It also concluded that there is fair evidence to support the inclusion of whole-body skin examination for a very selected subgroup. The American Academy of Family Physicians concluded that evidence is insufficient to make a
recommendation for or against routine screening for skin cancer in
asymptomatic persons.8 The Physician Data Query (PDQ) program of
evidence-based, peer-reviewed cancer information summaries provided by the
National Cancer Institute reviewed the evidence for screening in 2005 and found
that there is poor evidence that visual examination of the skin in asymptomatic
individuals leads to a reduction in mortality from melanomatous skin cancer.9
The PDQ summary also reports that visual examination of the skin in
asymptomatic individuals may lead to unavoidable increases in harmful
consequences on the basis of fair, although unquantified, evidence.
The
American Cancer Society recommends a cancer-related checkup by a physician,
including a skin examination, during a periodic health examination for people
age 20 years or older. The American Cancer Society also recommends monthly skin
self-examination by all individuals.10 The American College of Preventive Medicine recommends that total cutaneous examinations be performed, targeting
populations at high risk for malignant melanoma.11 The American Academy of Dermatology promotes free skin examinations by volunteer dermatologists for the
general population through the Academy's Melanoma/Skin Cancer Screening
Program. It also encourages regular self-examinations by individuals.5 The American College of Obstetrics and Gynecology recommends skin examinations for women age 13
years or older with increased recreational or occupational exposure to
sunlight, family or personal history of skin cancer, or clinical evidence of
precursor lesions.12
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References
1.
Wolff TA, Tai E, Miller T. Screening for skin cancer: update of the evidence.
Ann Intern Med 2008;150:194-8.
2.
Ries LA, Eisner MP, Kosary CL,
Hankey BF, Miller BA, Clegg L, Mariotto A, et al., eds. SEER Cancer Statistics
Review, 1975–2002. Bethesda, MD: National Cancer Institute; 2005.
3.
US Preventive Services Task Force. Screening for skin cancer: recommendations
and rationale. Am J Prev Med 2001;20:44-6. [PMID: 11306231]
4.
Chen SC, Bravata DM, Weil E, Olkin I. A comparison of dermatologists' and
primary care physicians' accuracy in diagnosing melanoma: a systematic review.
Arch Dermatol 2001;137:1627-34. [PMID: 11735713]
5. Geller AC, Zhang Z, Sober AJ, Halpern AC, Weinstock MA, Daniels S, et
al. The first 15 years of the American Academy of Dermatology skin cancer
screening programs: 1985-1999. J Am Acad Dermatol 2003;48:34-41. [PMID: 12522368]
6. Ries LAG, Eisner
MP, Kosary CL, Hankey BF, Miller BA, Clegg L,
et al. Surveillance, Epidemiology, and End Results (SEER) Program
(www.seer.cancer.gov) SEER*Stat Database: Incidence—SEER 9 Regs Public-Use,
Nov 2004 Sub (1973-2002): National Cancer Institute, DCCPS, Surveillance
Research Program, Cancer Statistics Branch released April 2005, based on
the November 2004 submission. Accessed at http://www.seer.cancer.gov/ on
4 December 2008.
7.
Feightner JW. Prevention of skin cancer. In: Canadian Task Force on the
Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care.
Ottawa: Health Canada, 1994; 850-9.
8.
American Academy of Family Physicians. AAFP Policy Action: Summary of Recommendations for Clinical Preventive
Services. Revision 6.3. March 2007. Leawood, KS: American Academy of Family
Physicians; 2007.
9.
National Cancer Institute. Skin Cancer Screening (PDQ). National Cancer
Institute, 2005. Accessed at http://www.cancer.gov/cancertopics/pdq/screening/skin/healthprofessional
on 25 November 2008.
10.
American Cancer Society. Cancer Facts and Figures 2004. Atlanta,
GA: American Cancer Society; 2004. Accessed at http://www.cancer.org/downloads/STT/CAFF_finalPWSecured.pdf
on
25 November 2008.
11.
Ferrini RL, Perlman M, Hill L. American College of Preventive Medicine policy
statement: screening for skin cancer. Am J Prev Med 1998;14:80-2. [PMID: 9476841]
12.
American College of Obstetricians and Gynecologists. ACOG Committee Opinion.
Primary and preventive care: periodic assessments. Obstet Gynecol
2003;102:1117-24. [PMID: 14672497]
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Members of the U.S. Preventive Services Task Force
Members of the U.S. Preventive Services Task Force* are Ned Calonge, MD, MPH, Chair, USPSTF (Colorado Department
of Public Health and Environment, Denver, Colorado); Diana B. Petitti,
MD, MPH , Vice-chair, USPSTF (Arizona State University, Phoenix, Arizona);
Thomas G. DeWitt, MD (Children's Hospital Medical Center, Cincinnati,
Ohio); Leon Gordis, MD, MPH, DrPH (Johns Hopkins Bloomberg School of
Public Health, Baltimore, Maryland); Kimberly D. Gregory, MD, MPH (Department
of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles,
California); Russell Harris, MD, MPH (University of North Carolina School
of Medicine, Chapel Hill, North Carolina); Kenneth W. Kizer, MD, MPH
(National Quality Forum, Washington, DC); Michael L. LeFevre, MD, MSPH
(University of Missouri School of Medicine, Columbia, Missouri); Carol
Loveland-Cherry, PhD, RN (University of Michigan School of Nursing, Ann
Arbor, Michigan); Lucy N. Marion, PhD, RN (School of Nursing, Medical
College of Georgia, Augusta, Georgia); Virginia A. Moyer, MD, MPH (Baylor
College of Medicine, Houston, Texas); Judith K. Ockene, PhD (University
of Massachusetts Medical School, Worcester, Massachusetts); George F.
Sawaya, MD (University of California, San Francisco, California); Albert
L. Siu, MD, MSPH (Mount Sinai Medical Center, New York, New York); Steven
M. Teutsch, MD, MPH (Merck & Company,
Inc., West Point, Pennsylvania); and Barbara P. Yawn, MD, MSPH, MSc (Olmsted
Medical Center, Rochester, Minnesota).
*Members of the Task Force at the time this recommendation was
finalized. For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.
Disclaimer:Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for
Healthcare Research and Quality or the U.S. Department of Health and Human Services.
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Copyright
This document is in the public domain within the United States. For
information on reprinting, contact Randie Siegel, Associate Director, Office of Communications and Knowledge Transfer, Agency for Healthcare Research and Quality,
540 Gaither Road, Rockville, MD 20850.
Requests for linking or to incorporate content in electronic resources
should be sent to: info@ahrq.gov.
Source: U.S. Preventive Services Task Force. Screening for
skin cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2009;150:188-93.
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AHRQ Publication No. 09-05128-EF-2
Current as of February 2009
Internet Citation:
U.S. Preventive Services Task Force. Screening for Skin
Cancer: Recommendation Statement. AHRQ Publication No. 09-05128-EF-2,
February 2009. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/uspstf09/skincancer/skincanrs.htm