Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults about skin self-examination to prevent skin cancer.
Frequency of Service
No information available.
Risk Factor Information
No information available.
This recommendation applies to asymptomatic persons without a history of skin cancer. Because most trials of skin cancer counseling predominantly include persons with fair skin types, the USPSTF limited its recommendation to this population.
Assessment of Risk
Persons with fair skin types (ivory or pale skin, light eye color, red or blond hair, freckles, those who sunburn easily) are at increased risk of skin cancer and should be counseled. Other factors that further increase risk include a history of sunburns, previous use of indoor tanning beds, and a family or personal history of skin cancer. Persons with an increased number of nevi and atypical nevi are at increased risk of melanoma. Persons with a compromised immune system (eg, persons living with HIV, persons who have received an organ transplant) are at increased risk of skin cancer.
Behavioral Counseling Interventions
All studies conducted in children and adolescents focused on sun protection behaviors; most were directed at parents, and some provided child-specific materials or messages. Half of the interventions included face-to-face counseling, and all included print materials. Three studies provided the intervention in conjunction with well-child visits. The majority of studies conducted in young adults and adults focused on improving sun protection behaviors, and 2 studies used “appearance-focused” messages. The mode of delivery varied and included mail-based, face-to-face or telephone counseling, and technology-based (text messages, online programs and modules, personal UV facial photographs) interventions.2
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
Counseling adults about performing skin self-examination appears to result in an increase of such examinations. The potential benefit of behavioral counseling about skin self-examination is uncertain because of the lack of evidence on the link between behavior change and skin cancer or other health outcomes. In addition, there is no evidence about the incremental benefit that might occur with skin self-examination above the benefit from counseling for skin protective behaviors and from current levels of skin examinations being performed by clinicians.
Skin self-examination is performed by the patient and is noninvasive. Psychosocial harms, such as anxiety or cancer worry, are possible. If skin self-examination leads to biopsy, procedural harms such as pain, bleeding, scarring, or infection could occur.7
The frequency of behavioral counseling for skin self-examination in the asymptomatic population is not well known.
Additional Approaches to Prevention
The Community Preventive Services Task Force recommends child care center–based, primary and middle school–based, and multicomponent community-wide interventions for the prevention of skin cancer.8 These interventions combine school- and community-based communications and policy to increase preventive behaviors (eg, covering up, using shade, or avoiding the sun during peak UV hours) among certain populations in specific settings.
The US Food and Drug Administration (FDA) provides information to help guide patients and clinicians regarding sun protection and the use and effectiveness of broad-spectrum sunscreen.9 The FDA has determined that broad-spectrum sunscreens with a sun-protection factor of 15 or greater, reapplied at least every 2 hours, protect against both UVA and UVB radiation and reduce the risk of skin cancer and early skin aging. The FDA also provides consumer education materials on the dangers of indoor tanning.10
The Environmental Protection Agency provides a variety of educational tools regarding sun safety, including state-specific information, and interactive widgets and smartphone applications that forecast UV exposure by zip code or city. It also provides sun safety fact sheets and handouts, including age-appropriate materials.11
The USPSTF has issued a recommendation on screening for skin cancer in adults.12
Skin cancer is the most common type of cancer in the United States and is generally categorized as melanoma or nonmelanoma skin cancer. Melanoma is the fifth-leading type of incident cancer, and 2.2% of adults will be diagnosed with it in their lifetime.1 Although invasive melanoma accounts for 2% of all skin cancer cases, it is responsible for 80% of skin cancer deaths.1 Basal and squamous cell carcinoma, the 2 predominant types of nonmelanoma skin cancer, represent the vast majority of skin cancer cases. There were an estimated 3.3 million new cases of nonmelanoma skin cancer in 2012 and an estimated 91,270 new cases of melanoma skin cancer in 2018.1
Recognition of Risk Status
Exposure to UV radiation during childhood and adolescence increases the risk of skin cancer later in life, especially when more severe damage occurs, such as with severe sunburns. Persons with fair skin types (ivory or pale skin, light hair and eye color, freckles, or those who sunburn easily) are at increased risk of skin cancer. Persons who use tanning beds and those with a history of sunburns or previous skin cancer are also at substantially increased risk of skin cancer. Other factors that further increase risk include an increased number of nevi (moles) and atypical nevi, family history of skin cancer, HIV infection, and history of receiving an organ transplant. Most studies of interventions to increase sun protection behaviors have been limited to persons with fair skin types.2-4
Benefits of Behavioral Counseling Interventions
Behavioral counseling interventions target sun protection behaviors to reduce UV radiation exposure. UV radiation is a known carcinogen5 that damages DNA and causes most skin cancer cases.6 A substantial body of observational evidence demonstrates that the strongest connection between UV radiation exposure and skin cancer results from exposure in childhood and adolescence. Sun protection behaviors include the use of broad-spectrum sunscreen with a sun-protection factor of 15 or greater; wearing hats, sunglasses, or sun-protective clothing; avoiding sun exposure; seeking shade during midday hours (10 am to 4 pm); and avoiding indoor tanning bed use.
The USPSTF found adequate evidence that behavioral counseling interventions available in or referable from a primary care setting result in a moderate increase in the use of sun protection behaviors for persons aged 6 months to 24 years with fair skin types.
The USPSTF found adequate evidence that behavioral counseling interventions available in or referable from a primary care setting result in a small increase in the use of sun protection behaviors for persons older than 24 years with fair skin types.
The USPSTF found insufficient evidence regarding the benefits of counseling adults about skin self-examination to prevent skin cancer.
Harms of Behavioral Counseling Interventions
The USPSTF found adequate evidence that the harms related to behavioral counseling interventions and sun protection behaviors in young persons or adults are small. The USPSTF found inadequate evidence regarding the harms of counseling adults about skin self-examination.
The USPSTF concludes with moderate certainty that behavioral counseling interventions have a moderate net benefit for young adults, adolescents, and children aged 6 months to 24 years with fair skin types.
The USPSTF concludes with moderate certainty that behavioral counseling interventions have a small benefit in adults older than 24 years with fair skin types.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults about skin self-examination.
Implementation Interventions included tailored mailings, print materials, and in-person counseling by health professionals. Interventions for children were directed mostly toward parents; some materials were child-specific. Counseling interventions for children, their parents, or both provided messages focused on increasing sun protection behaviors (eg, using sunscreen, avoiding midday sun, wearing sun-protective clothing). Some print-based interventions included materials tailored to the child’s risk level, barriers to change, self-efficacy, or other factors. Health professionals providing in-person counseling included primary care clinicians and health educators. One trial of an intervention involving children 3 years and younger used clinician counseling and print materials for parents promoting child sun protection with sun protection aids (sunscreen samples and hat).13 Several trials in children aged 3 to 10 years used standard or tailored mailings over 1 to 36 months.14-17 One study also included a DVD in addition to a standard mailing promoting sun protection. One trial used a 1-day, in-person parent education session with a children's video, print materials, and sun protection aids (shirt, hat, and sunscreen). For the single study in adolescents, clinicians directly counseled participants, with 4 follow-up telephone counseling sessions by a health educator over 18 months; mailed materials and sunscreen samples were also used. In the 16 trials among adults, interventions included a variety of messages and components, conducted in a range of settings.2, 4 Technology-based interventions included an interactive web program and tailored text messages on sun protection, as well as appearance-focused print materials. The web program study reported reduced sunburns after the intervention, which provided information on topics such as indoor tanning, UV radiation exposure and health, skin cancer, sunscreen, and skin examination. Each module took about 10 minutes to complete and included a goal-setting section. Other interventions that increased sun protection behaviors in adults included mailed print materials containing personalized risk feedback and recommendations, self-monitoring aids for UV exposure, and skin cancer prevention and detection information; individualized computer reports; and an interactive educational computer program on skin cancer prevention that provided individual feedback on personal risk of skin cancer. Research Needs and Gaps A better understanding of the effectiveness of counseling on the use of sun protection behaviors in adults 25 years and older is needed to address the key evidence gap on counseling for this age group. Research that evaluates the association between UV exposure during adulthood and skin cancer risk would also be valuable. In addition, studies regarding the effectiveness of counseling persons without a fair skin type are lacking. Ideally, research studies would provide measurements of sun exposure, sunburn, precursor skin lesions, and cancer among large trial populations, with an emphasis on behaviors and health outcomes among persons who receive an intervention focused on sun protection behaviors. Such studies would also assess whether these behaviors continue after trial completion. These cohorts should include populations with diverse skin colors and should include adolescents, young adults, and preschool-aged children and their parents. These studies may be used to further develop technologies and vehicles for administering relevant interventions for behavior change in the primary care setting, especially among nonwhite persons, young adults, and persons who practice indoor or outdoor tanning. Further evidence is needed to assess the balance of benefits and harms of counseling adults about skin self-examination to prevent skin cancer and premature death. The US Surgeon General,40 American Cancer Society,41 American College of Obstetricians and Gynecologists,42 American Academy of Pediatrics,43 Royal Australian College of General Practitioners,44 and the World Health Organization’s International Agency for Research on Cancer45 endorse the involvement of clinicians in counseling patients about skin cancer prevention. The Community Preventive Services Task Force recommends education and policy approaches to encourage sun protection behaviors in child care centers, schools, recreational sites, and occupational settings. In addition, it recommends community-wide interventions that may or may not involve health care settings to increase protection behavior from UV radiation. Interventions include mass media campaigns and environmental and policy changes across multiple settings within a defined geographic area or an entire community.8 The American Academy of Dermatology encourages everyone to perform skin self-examination to check for signs of skin cancer.46 The American Cancer Society47 and the Skin Cancer Foundation48 recommend monthly skin self-examination. This recommendation replaces the 2012 USPSTF recommendation on counseling about skin cancer prevention19 and the skin self-examination portion of the 2009 USPSTF recommendation on screening for skin cancer.20 In this updated recommendation, the USPSTF expanded the age range for behavioral counseling interventions to include persons aged 6 months to 24 years with fair skin types (the previous recommendation applied to persons aged 10 to 24 years, based on the evidence available at that time). Recent studies in children younger than 10 years resulted in the USPSTF extending the lower end of the age range to 6 months, the minimum age recommended for sunscreen use. Based on additional evidence since the prior recommendation, the USPSTF now also recommends that clinicians consider selectively offering counseling to adults older than 24 years with fair skin types. As in 2012, the evidence on persons without a fair skin type remains insufficient for this population to be included in the recommendation statement. The evidence continues to be insufficient to assess the balance of benefits and harms of counseling adults about skin self-examination to prevent skin cancer, as it was in 2009.