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Skin Cancer Screening: 2016 Recommendations

Image from Times article

Should you get screened for skin cancer?
By Nicholas St. Fleur
New York Times, July 26, 2016

In July 2016, the U. S. Prevention Services Force stated that there is no good evidence for the efficacy of skin cancer screening to prevent death or significant disability. This means that the benefits do not outweigh the potential harm of skin cancer screening.

Nonmelanoma skin cancer comprises 98% of skin cancer's and account for only about .1% of all cancer deaths. Melanoma accounts for about 10,000 cancer deaths a year.

If you have a personal or family history of melanoma, and if you have more than 100 moles you should probably consider being screened. But if not, you could safely pass. A large study in Germany found that skin cancer screening can potentially save one life per hundred thousand individuals screened. It is likely that much more harm could be done from over diagnosis and over treatment in a large screen and population.

Screening picks up small very slow growing or not even growing melanomas that are not destined to harm a patient. However, once they are discovered usually aggressive therapy is recommended and the patient is then labeled as a cancer survivor.

Most dermatologists recommend skin screening. In spite of the lack of evidence for its efficacy, it's good business practice for skin doctors. A skillful dermatologist can find something to treat with cryotherapy or a biopsy on most older caucasians, and this provides a good living for these doctors. It's a low risk screening and a high-value return for dermatologists.

The smart patient should avoid skin cancer screenings if they are not at risk. They should specifically avoid the free skin cancer screenings offered by many hospitals and aggressively promoted by the American Academy of Dermatology. They can just say no. If they have risk factors for skin cancer or are worried about specific lesions they can request a complete skin examination. This may be a good way of alleviating anxiety related to specific skin lesions.

The article in July 26, 2016 New York Times is a good overview. It can be accessed at: http://nyti.ms/2albmU/

PSA Update 2016

A recent article by H. Gilbert Welch and Peter Albertsen in the NY Times describes where we are at with PSA testing and prostate cancer screening in 2016.

The case against prostate cancer screening is strong. The heterogeneity underlying cancer can be described through the metaphor of birds, rabbits and turtles. The goal of early detection is not to let any of the animals escape the barnyard and cause a cancer death. But the birds have already flown away. They are the most aggressive cancers, the ones that have already spread by the time they are detectable, the ones that are beyond cure. The rabbits, potentially lethal cancers that might benefit from treatment, are ready to hop out at any time. These are the cancers we hope to control with early detection.

Then there are the turtles — these are nonlethal cancers that aren’t going anywhere. Screening is really good at finding these cancers, and the prostate gland is full of them. Over half of men age 60 and older have small, indolent, nonlethal prostate cancers — many more than those who have harmful ones. That’s why men are much more likely to die with prostate cancer than from it.

It is well worth a careful reading.

Cancer Screening and Easly Diagnosis

The mantra “early diagnosis” is a bit like “free money”—it sounds great, but there’s a complicated catch. Patients will be short changed unless it’s fairly explained. Why are we so reluctant to be upfront about downsides?

Margaret McCartney's editorial in the British Medical Journal is a short, readable introduction in the epidemic of cancer screening: Download Margaret McCartney: Early cancer diagnosis: how low should we go? - bmj.h6442.full

A Simple Test Can save a Baby's Life

A simple test can determine if a newborn has heart defects, yet more than a dozen states still do not require it.  It’s called “Pulse Oximetry” and it’s not a costly, exotic procedure. Most hospitals already have oximeters and use them to monitor infants who suffer complications. You can buy one at units at Walmart for $29.88.

Read: A Simple Test Can save a Baby's Life

More on Sunscreens

The New York Times, today, had an article about new sunscreen regulations.  If one is interested in this topic, it's a good starting point.

Image from Times article

"Experts are urging people to limit their time in the sun, especially at midday, and protect their skin with hats, shirts and cover-ups instead of relying exclusively on sunscreen" See NY Times "New Rules for Sunscreens."

Comment: Please keep in mind that there is controversy as to whether the rising incidence of melanoma referred to in the Times article is related to sun exposure or the result of diagnostic drift.  Pathologists now call lesions melanoma where years ago they would have labeled the same lesions dysplastic moles.  Also, screening tends to increase melanoma incidence (see work of Sam Shuster).  Melanoma incidence is rising, but death rate not nearly as much.  This is a complicated topic that needs to be be addressed. Researchers' conflicts of interests should be clearly noted.  The heavy funding of The Skin Cancer Foundation by "industry" and the grants given to researchers muddy the waters.  "No one should enter the Temple of Science with the soul of a money changer."  Sir Thomas Browne

 

Annual Checkups: Why?

October 23, 2012: The New York Times reports on a recent study "including more than 180,000 subjects, [that has found] found that general health checkups — like annual physicals or other visits to the doctor by asymptomatic people — are ineffective and possibly harmful."

The NY Times article was based on a Danish study, General health checks in adults for reducing morbidity and mortality from disease reported in the prestigious Cochrane Library in October 2012.

Skin Cancer Screening (Australian Recommendations)

In 2010, almost 780 000 skin cancers were diagnosed and treated in Australia. Only 1% of these were invasive melanoma. The vast majority were nonmelanoma skin cancers (NMSCs) in people aged 60 years and over. Nonmelanoma skin cancers in Australia are now nearly seven times more common than all other cancers combined; approximately half of these are removed by general practitioners.

This is a valuable about skin cancer screening from a Professor of Dermatology at the University of Melbourne, Victoria, Australia.

For article with helpful tables:  Download Skin Cancer Screening Sinclair

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."