Screening

Is Screening for Skin Melanoma Useful?

The working group is of the opinion that routine checking for pigmented lesions warrants recommendation in cases with a known familial increased risk of melanoma. One check-up every 6 to 12 months is considered sufficient.

According to the working group, increased attentiveness is advisable for individuals with a combination of risk factors resulting in a substantially increased risk of melanoma.

The working group is of the opinion that population-based screening for melanoma is not warranted in the Netherlands.

Population Based Whole-Body Skin Screening for Melanoma

C - In the absence of substantive evidence as to its effectiveness in reducing mortality from melanoma, population-based skin screening cannot be recommended.

Identification and Management of High-Risk Individuals

Family History of Melanoma

B - Clinical assessment of future risk of melanoma take into account:

• Person's age and sex
• History of previous melanoma or non-melanoma skin cancer
• Number of naevi (common and atypical)
• Family history of melanoma
• Skin and hair pigmentation
• Response to sun exposure
• Evidence of actinic skin damage

Management of High-Risk Individuals

C - Individuals at high risk of melanoma and their partner or carer should be educated to recognise and document lesions suspicious of melanoma, and to be regularly checked by a clinician with six-monthly full body examination supported by total body photography and dermoscopy as required.

GPP - Prophylactic removal of nonsuspicious lesions is not recommended since it is unlikely to increase survival and therefore may incur unnecessary procedures and give false reassurance as many new melanomas in high-risk individuals will occur outside pre-existing naevi.

Genetic Risk Factors and Testing

C - Screening for a mutation such as the CDKN2A gene should be contemplated only after a thorough clinical risk assessment (the patient is at personal high risk of melanoma), confirmation of a strong family history of melanoma (there is a significant probability of a family mutation), and appropriate genetic counselling.

Very High Risk of Skin Cancer

Individuals with any of the following risk factors have a very high risk of skin cancer (approximately 10 or more times the risk of the general population):

• On immunosuppressive therapy after organ transplantation
• A personal history of skin cancer
• Two or more first-degree relatives with melanoma
• More than 100 nevi in total or 5+ atypical nevi
• Have received more than 250 treatments with psoralen-ultraviolet A radiation (PUVA) for psoriasis
• Received radiation therapy for cancer as a child

Individuals at very high risk should be identified by their primary health care provider and offered total body skin examination by a dermatologist or a trained health care provider on a yearly basis. They should also be counseled about skin self-examination and skin cancer prevention by a health care provider (e.g., physician, nurse practitioner, or public health nurse). In the case of childhood cancer survivors, the site of radiation therapy should be monitored.

High Risk of Skin Cancer

Individuals with two or more of the main identified susceptibility factors are at a high risk for skin cancer (roughly 5 times the risk of the general population):

• A first-degree relative with melanoma
• Many (50-100) nevi
• One or more atypical (dysplastic) nevi
• Naturally red or blond hair
• A tendency to freckle
• Skin that burns easily and tans poorly or not at all

Other factors that may influence the risk of skin cancers that are environmental include an outdoor occupation, a childhood spent at less than latitude 35°, the use of tanning beds during teens and twenties, and radiation therapy as an adult.

Individuals at high risk should be identified by their primary health care provider and counseled about skin self-examination (specifically focused on the site of radiation for those having had therapeutic radiation) and skin cancer prevention by a health care provider (e.g., physician, nurse practitioner, or public health nurse). High risk individuals should be seen once a year by a health care provider trained in screening for cancers.

The General Population Not at Increased Risk of Skin Cancer

• There is at this time no evidence for or against skin cancer screening of the general population at average risk of developing skin cancer.
• Based on the limited evidence available at present, routine total body skin examination by primary care providers is not recommended for individuals at average or low risk for skin cancer (i.e., those not included in the increased risk groups described above).
• Based on the limited evidence available at present, routine counseling on skin self-examination by primary care providers is not recommended for individuals at average or low risk for skin cancer.

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. This is an I statement.

Clinical Considerations

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.

No recommendations offered

Prevention

B - Sunburn be avoided and UV protection (physical methods complemented by sunscreens) adopted.

C - Sunscreens should be used to complement but not to replace physical methods of UV protection.

C - Risks associated with exposure to tanning booths and sunbeds should be explained.

C - As brief sun exposures are needed to maintain vitamin D levels, total lack of sun exposure is not advised without vitamin D supplementation.

No recommendations offered

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 (www.ahrq.gov/clinic/prevenix.htm). 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 (www.thecommunityguide.org).

No recommendations offered

Prevention

C - Risks associated with exposure to tanning booths and sunbeds should be explained.

Identification and Management of High-Risk Individuals

Management of High-Risk Individuals

Regular skin examination can be done by the person himself or herself, perhaps aided by a partner or carer, or by a clinician. Both of these can be aided by total body photography, which provides a baseline that may aid recognition of new and changing lesions. The clinician examination can be aided by dermoscopy and short-term digital monitoring, in which suspicious lesions are photographed and reviewed at three months. In individuals with multiple naevi there is no evidence that prophylactic removal of lesions that are not clinically suspicious reduces prospective risk of melanoma.

C - Individuals at high risk of melanoma and their partner or carer should be educated to recognise and document lesions suspicious of melanoma, and to be regularly checked by a clinician with six-monthly full body examination supported by total body photography and dermoscopy.

Very High Risk of Skin Cancer

Individuals at very high risk should be counseled about skin self-examination and skin cancer prevention by a health care provider (e.g., physician, nurse practitioner, or public health nurse). In the case of childhood cancer survivors, the site of radiation therapy should be monitored.

High Risk of Skin Cancer

Individuals at high risk should be identified by their primary health care provider and counseled about skin self-examination (specifically focused on the site of radiation for those having had therapeutic radiation) and skin cancer prevention by a health care provider (e.g., physician, nurse practitioner, or public health nurse).

The General Population Not at Increased Risk of Skin Cancer

Based on the limited evidence available at present, routine counseling on skin self-examination by primary care providers is not recommended for individuals at average or low risk for skin cancer.

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. This is an I statement.

The type of supporting evidence is not specifically stated.

Designations of Levels of Evidence According to Type of Research Question

Note: Explanatory notes for this table are outlined in the methods handbook available on request from the Australian Cancer Network or the New Zealand Guidelines Group.

Recommendation Grades

Good Practice Points

Good practice points are used when the conventional grading of evidence is not possible – these points represent the views of the Guideline Development Group.

The recommendations are based on evidence-based practice guidelines, one case-control study, and two comparative studies

What the USPSTF Grades Mean and Suggestions for Practice

USPSTF Levels of Certainty Regarding Net Benefit

Definition: The U.S. Preventive Services Task Force defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

All four groups performed searches of electronic databases to collect the evidence; ACN/NZGG and PEBC also conducted hand-searches of published literature (both primary and secondary sources), and USPSTF conducted hand-searches of published secondary sources. A targeted review of the literature was prepared by the Agency for Healthcare Research and Quality (AHRQ) for use by USPSTF in the development of its guideline. PEBC, USPSTF and ACN/NZGG provide details regarding the search strategies employed, including the names of databases searched, the date range, search terms used, and inclusion/exclusion criteria. ACCC does not provide this information.

To assess the quality and strength of the evidence, PEBC and USPSTF employed expert consensus. ACCC and ACN/NZGG used weighting according to a rating scheme, but ACCC, in contrast to ACN/NZGG, does not provide the scheme. With regard to methods used to analyze the evidence, all of the groups, with the exception of ACCC, performed a systematic review (ACN/NZGG's systematic review incorporated evidence tables). In addition, a review of published meta-analyses was conducted by PEBC and ACN/NZGG. ACCC performed a review to analyze the evidence.

All of the groups employed expert consensus to formulate the recommendations and provide a description of the process; USPSTF also utilized balance sheets. The strength of the recommendations was graded by USPSTF and ACN/NZGG, and both provide the rating scheme.

ACN/NZGG was the only group to perform a cost analysis and to review published cost analyses. PEBC, USPSTF, and ACN/NZGG all employed both internal and external peer review to validate their guidelines and provide a description of the validation process; USPSTF also performed a comparison with guidelines from other groups. ACCC does not state if any method of guideline validation was used.

Association of Comprehensive Cancer Centres

New Zealand Guidelines Group

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

United States Government

• Improved quality of care in patients with melanoma
• Better results from treatment
• Decreased metastases
• Decreased mortality

Appropriate prevention, diagnosis, and management of melanoma

• The pilot phase of a randomized trial demonstrated the feasibility of implementing a screening program consisting of community education, general practitioner education and screening clinics to promote self-screening and whole-body screening by general practitioners. Early results detected an increase in the percentage of subjects reporting whole-body skin examination by a physician.
• The randomized trial and a work-place screening study both found that people were more likely to perform skin self-examination if they had undergone a whole-body skin examination by a physician.
• A case-control study detected a reduced risk of melanoma and reduced mortality from melanoma associated with skin self-examination.

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.

No screening-related harms are provided.

Not stated

Not stated

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.