This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations for screening for skin cancer and supporting scientific evidence, and it updates the 1995 recommendations contained in the Guide to Clinical Preventive Services, second edition.₁ Explanations of the ratings and of the strength of overall evidence are given in Appendix A and in Appendix B, respectively. The complete information on which this statement is based, including evidence tables and references, is available in the article Screening for Skin Cancer ₂ and in the Systematic Evidence Review ₃ on this topic, which can be obtained through the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm), through the National Guideline Clearinghouse (http://www.guideline.com), or in print through the AHRQ Publications Clearinghouse (1-800-358-9295).

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Agency for Healthcare Research and Quality

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US Department of Health and Human Services

Summary of Recommendations

• The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for skin cancer using a total-body skin examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer. I recommendation.

Evidence is lacking that skin examination by clinicians is effective in reducing mortality or morbidity from skin cancer. The USPSTF could not determine the benefits and harms of periodic skin examination. (See Clinical Considerations for discussion of selected populations at high risk.)

Other strategies to prevent skin cancer, such as counseling to reduce risky health behaviors and performance of skin self-examination, will be addressed in a separate recommendation.

Clinical Considerations

• Benefits from screening are unproven, even in high-risk patients.

Clinicians should be aware that fair-skinned men and women aged > 65, patients with atypical moles, and those with >50 moles constitute known groups at substantially increased risk for melanoma.

• 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 >6 mm (“A,” “B,” “C,” “D”), or rapidly changing lesions are features associated with an increased risk of malignancy. Suspicious lesions should be biopsied.

• The USPSTF did not examine the outcomes related to surveillance of patients with familial syndromes, such as familial atypical mole and melanoma (FAM-M) syndrome.

Scientific Evidence

Epidemiology and Clinical Consequences

Accuracy and Reliability of Screening Test

Yield of Screening Test

Effectiveness of Early Detection

Potential Adverse Effects of Screening

Recommendations of Others

The Canadian Task Force on Preventive Health Care concluded that the evidence was insufficient to recommend for or against skin cancer screening for the general population, but suggests that regular total-body skin examination may be prudent for a subgroup of very high-risk individuals.₄ The American Cancer Society recommends skin examination as part of a cancer-related checkup every 3 years for people aged between 20 and 40, and on a yearly basis for anyone aged > 40.₅ The American College of Preventive Medicine recommends total-body skin examination in high-risk individuals, including those with a family or personal history of skin cancer, predisposing phenotypic characteristics, and increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions (e.g., dysplastic or congenital nevi), but does not recommend routine screening.₆ The American College of Obstetricians and Gynecologists recommends yearly, or as appropriate, skin examination of women aged ≥ 13 based on risk factors (increased recreational or occupational exposure to sunlight; family or personal history of skin cancer; clinical evidence of precursor lesions).₇ A National Institutes of Health (NIH) Consensus Panel recommends screening for melanoma as part of routine primary care.₈ The Australian National Health and Medical Research Council does not recommend mass screening or screening of high-risk people for melanoma.₉ All of these organizations advise public or patient education to change behaviors that may increase the risk of skin cancer, including sun avoidance, sun protection and skin self-examination.

Discussion

Periodic total-body skin examination can increase the detection of thin (earlier stage) melanoma; however, controlled studies are needed to determine whether early detection would actually have an important effect on mortality. Additional questions remain about the ability of primary care clinicians to perform adequate examinations in the context of usual care. Studies of skin health behaviors and studies of factors associated with advanced melanoma suggest that older persons are at high risk and are unlikely to benefit from existing skin cancer prevention efforts such as public education and clinician education efforts regarding sun avoidance and/or sun protection. While it is unproven, skin cancer screening (using a risk assessment strategy with examination or referral of high-risk patients) is the most promising strategy for addressing the excess burden of disease in older persons. Since most elderly individuals consult a clinician at least yearly, case finding by clinicians focusing on the elderly may reach vulnerable individuals who may not benefit from other approaches.

Members of the U.S. Preventive Services Task Force are:

Alfred O. Berg, MD, MPH, Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, PhD, RN, CS, Vice-chair, USPSTF (Dean and Professor, School of Nursing, University of Texas Health Science Center, San Antonio, TX); Paul S. Frame, MD (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, MD, MPH (Executive Director, National Initiative for Children’s Healthcare Quality, Boston, MA); Tracy A. Lieu, MD, MPH (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, MD, MSc (Professor of Medicine, University of Texas Health Science Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX); C. Tracy Orleans, PhD (Senior Scientist, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, MD, MPH (Director of Research, Women and Infants’ Hospital, Providence, RI); Nola J. Pender, PhD, RN (Professor and Associate Dean for Research, School of Nursing, University of Michigan, Ann Arbor, MI); Harold C. Sox, Jr., MD (Professor and Chair, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH); Steven M. Teutsch, MD, MPH (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, MD, MSc (Associate Professor of Obstetrics, Gynecology and Public Health, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY); and Steven H. Woolf, MD, MPH (Professor of Family Medicine, Department of Family Practice, Medical College of Virginia, Fairfax, VA).

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations for screening for skin cancer and supporting scientific evidence, and it updates the 1995 recommendations contained in the Guide to Clinical Preventive Services, second edition.1 Explanations of the ratings and of the strength of overall evidence are given in Appendix A and in Appendix B, respectively. The complete information on which this statement is based, including evidence tables and references, is available in the article Screening for Skin Cancer2 and in the Systematic Evidence Review3 on this topic, which can be obtained through the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm), through the National Guideline Clearinghouse (http://www.guideline.com), or in print through the AHRQ Publications Clearinghouse (1-800-358-9295).

Address correspondence to:

David Atkins, MD, MPH, Chief Medical Officer, U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, Center for Practice and Technology Assessment, 6010 Executive Boulevard, Suite 300, Rockville, MD 20852. tel (301) 594-4016, fax (301) 594-4027, datkins@ahrq.gov

Reprints are available from the AHRQ Web site at http://www.ahrq.gov/clinic/uspstfix.htm, through the National Guideline Clearinghouse (http://www.guideline.gov), or in print through the AHRQ Publications Clearinghouse (1-800-358-9295).

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U.S. preventive services task force recommendations and ratings

The Task Force grades its recommendations according to one of 5 classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms):

A.The USPSTF strongly recommends that clinicians routinely provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B. The USPSTF recommends that clinicians routinely provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C. The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D. The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I.The USPSTF concludes that the evidence is insufficient to recommend for or against routinelyproviding [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

U.S. preventive services task force Strength of Overall Evidence

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):

Good: Evidence includes consistent results from well-designed, well-conducted studies inrepresentative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Correspondence to

Alfred O. Berg, MD, MPH, Chair, U.S. Preventive Services Task Force, c/o David Atkins, MD, MPH, Coordinator for Clinical Preventive Services, U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, Center for Practice and Technology Assessment, 6010 Executive Boulevard, Suite 300, Rockville, MD 20852. (301) 594-4016, fax (301) 594-4027, E-mail: datkins@ahrq.gov.