DermHelpCentral

Skin Cancer Screening

These are the recommendations of the National Guidelines Clearinghouse taskforce on skin cancer screenings:

Very limited evidence was available to inform the following recommendations on screening. No prospective studies have evaluated the impact of screening on survival, quality of life, or morbidity from treatment for skin cancer nor are there data on the adverse effects of screening for skin cancer. As experts in the treatment and epidemiology of skin cancer, the guideline panel members were aware that some individuals are at increased risk for skin cancer because of personal characteristics or history. They reviewed key papers on risk and identified groups of patients who might be expected to benefit from increased surveillance for skin cancer. Separate recommendations are offered for two groups at increased risk (very high risk and high risk) and the general population.

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 light (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 counselled about skin self-examination and skin cancer prevention by a health care provider (e.g., physician, nurse practitioner, or public health nurse). In 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 counselled 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 skin 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 counselling on skin self-examination by primary care providers is not recommended for individuals at average or low risk for skin cancer.

When is Cancer NOT Cancer?

Gina Kolata, in the 11/23/2011 NY Times, has an  important article which addresses the overdiagnosis of cancer and highlights the dangers of screening. She postulates that "the word 'cancer' is out of date, and all too often it can be unnecessarily frightening." This article needs to be read by physicians, patients and their families.  Although it highlights breast and prostate cancer, it is applicable to skin cancer as well.  Squamous cell carcinoma-in situ, melanoma in-situ, actinic keratoses should not be labeled as "cancer" (or pre-cancer) but as cutaneous dysplasias.  Treatment need not be aggressive.  In my opinion, the whole idea of "screening" needs to be reconsidered. See:  Download ‘Cancer’ or ‘Weird Cells’

Skin Cancer Screening: Update

There is no evidence that the skin cancer screening saves lives.  Yes, screening may pick up some early skin cancers, but they are very, very unlikely to cause death or even suffering.  Screening is a marketing tool for physicians' services and skin cancer screening is no exception.  It brings people into dermatology practices and increases the number of lucrative procedures dermatologists perform.

A spate of recent articles in the press has addressed breast, prostate and cervical screening.  Gina Kolata summarized the data in a recent lucid article: Considering When It Might Be Best Not To Know About Cancer (NY Times, October 29, 2011).  Read this article if you want a good summary of this topic.

One can extrapolate from Kolata's article to skin cancer screening. "The disease [cancer] was defined in 1845 by a German pathologist, Rudolf Virchow, who looked at tumors taken at autopsy and said cancer is an uncontrolled growth that spreads and kills. But, of course, he was looking only at cancers that killed. He never saw the others.

Now we are backing away from that, experts say. In recent years, researchers have found that many, if not most, cancers are indolent. They grow very slowly or stop growing altogether. Some even regress and do not need to be treated — they are harmless."

While this is true for skin cancers as well, dermatologists are still scaring patients.  Isn't it time to stop doing this?  It will be interesting to see if the American Academy of Dermatology and the Canadian Dermatology Association come clean.

The U.S. Preventive Services Task Force's reccomendation on skin cancer screening states: "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."

To Screen or Not to Screen

Cancer screening is a very controversial topic; charged with emotion.  Gilbert Welch, in the NY Times, has an important, lucid opinion piece about mammography and prostate screening that is worth reading. Welch is one of the most respected researchers in health outcomes in the U.S.

 You Have to Gamble on Your Health

"Screening is like gambling:  there are winners and there are losers. And while the few winners win big, there are a lot more losers.

[Are there] some people who have avoided dying from breast or prostate cancer by getting screened?  While there is some debate about whether they really exist, my reading of the data is that they do, but they are few and far between — on the order of less than 1 breast or prostate cancer death averted per 1,000 people screened over 10 years. That’s less than 0.1 percent."