NO USE OF SKIN CANCER SCREENING

There is "insufficient" evidence to recommend that primary care physicians perform visual skin cancer screenings in asymptomatic adults, according to final recommendations from the US Preventive Services Task Force (USPSTF).

The influential organization placed its "I" statement tag on the new report, which appears in the July 26 issue of JAMA.

The assessment means that the evidence is lacking, of poor quality, or is conflicting, and the balance of benefits and harms cannot be determined.

This is the same statement grade and determination made by the USPSTF 7 years ago, in its 2009 recommendation.

However, the new guidance does not completely dismiss visual examinations.

"Clinicians should understand the evidence but individualize decision making to the specific patient or situation," write the report authors, led by Kirsten Bibbins-Domingo, PhD, MD, of the University of California, San Francisco.

That evidence is fully described in an additional article in JAMAthat contains the updated systematic review.

Other major organizations have no specific formal guidance, say the report's authors. These include the American College of Physicians, the American College of Preventive Medicine, and the American Academy of Dermatology. However, the American Cancer Society recommends that adults undergo skin examination as part of a general cancer-related checkup.

The new recommendations should not be viewed negatively, suggest two experts in an accompanying editorial in JAMA.

" 'Insufficient evidence of benefit' is different from 'evidence of no benefit': the public, physicians, and the popular press should avoid this misinterpretation," write Hensin Tsao, MD, PhD, from the Massachusetts General Hospital in Boston, and Martin A. Weinstock, MD, PhD, from Brown University, Providence, Rhode Island.

Although still insufficient, the evidence for primary care screening has evolved. "Evidence regarding benefits has improved since the last evidence review closed a decade ago," the pair write.

The editors at JAMA obviously believe that the subject of skin cancer and its screening is very important. In addition to the essay from Dr Tsao and Dr Weinstock in JAMA, they commissioned three additional editorials about the subject for three other JAMA-based journals.

One editorial defies the USPSTF guidance and calls for routine exams, whereas the other two make important points about the necessity of some skin cancer exams and the ongoing need for prevention.

In an editorial appearing in JAMA Dermatology, three experts emphasize that the new recommendations apply only to asymptomatic adults being seen in primary care.

"The USPSTF statement does not apply to those with concerning signs or symptoms or to individuals at high risk for skin cancer based on family or personal history, atypical mole phenotype, or other factors," write these editorialists, led by Susan M. Swetter, MD, of Stanford University in California.

The new guidance also does not apply to dermatologists, they point out. "The USPSTF does not make recommendations for specialists (eg, dermatologists) who routinely perform targeted screening among high-risk groups."

US healthcare must be proactive about skin cancer screening of these high-risk groups, these editorialists believe.

They argue that educational media campaigns are needed to drive high-risk groups to undergo screening (eg, white men aged ≥50 years and individuals with an atypical mole phenotype and/or family history of melanoma).

Follow-up studies could then take place. "Studies must assess whether media campaigns alone can contribute to reducing the incidence of thicker melanoma," write Dr Swetter and her colleagues.

A media-based approach should include public promotion of self-screening to identify atypical moles, they suggest; they point out that this is not included the current USPSTF guidelines. This is known as "lesion-directed skin screening" and was recently reported on positively by Belgian researchers (JAMA Dermatol. 2016;152:27-34).

Best Evidence of Benefit From Germany

Another trio of experts, writing an editorial in JAMA Internal Medicine, says that the new recommendations from the USPSTF may lead to physicians and patients being "confused."

"Several organizations have encouraged screening; skin cancer seems easy to detect early because it is visible; skin examinations are neither painful nor invasive; and melanoma thickness at the time of diagnosis predicts mortality," observe these editorialists, led by Eleni Linos, MD of the University of California, San Francisco.

But they acknowledge that there are no completed randomized clinical trials on the effectiveness of screening.

To date, the most impressive results come from an "ecologic" study, Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany (SCREEN), conducted in a single German state during 2003-2004.(J Am Acad Dermatol. 2012;66:201-211).

This multiaudience project showed a 48% relative reduction in melanoma mortality in the state by 2009 after initiation of a population-based skin cancer awareness campaign, clinician education and training, and screening of nearly 20% of eligible adults aged ≥20 years with a single clinical visual skin examination.

But a subsequent nationwide program of clinical visual skin examinations has not yet shown a mortality benefit after 5 years of follow-up. Furthermore, several major methodologic concerns about SCREEN have been raised, say these editorialists.

There is also a need for new skin cancer prevention efforts in the United States, Dr Linos and colleagues comment.

The trio emphasizes avoidance of tanning beds and protection from the sun, citing Australia's SunSmart program as effective (slip on clothing, slop on sunscreen, slap on a hat, seek shade, and slide on sunglasses). The Australian program has been linked to a decrease in the incidence of skin cancer in young adults, they say.

A Declaration for Routine Screening

One last trio of experts, writing an editorial in JAMA Oncology, is fearful that the new USPSTF guidance "may lead physicians and patients to avoid total-body skin examinations (TBSEs)."

The superiority of TBSEs over lesion-directed examinations has been studied and proven, say the editorialists, led by Vinayak K. Nahar, MD, of the University of Mississippi in Jackson.

"Lesion-directed examinations focus on only 1 patient-detected lesion and are not successful in diagnosing early skin cancers that are unbeknownst to the patient," they write.

Furthermore, a study from the United Kingdom found that more than one third of melanomas are detected as incidental lesions and would be missed without a TBSE (Acta Derm Venereol. 2013;93:689-692).

This trio of experts is the only set of editorialists who defy the USPSTF recommendations and call for routine screening in asymptomatic adults.

There is now a "decades-long" increase in melanoma incidence and "slow-to-stabilize" mortality, they argue. It is estimated that in 2016, 76,400 American adults will develop melanoma and that 10,100 will die from the disease.

"Therefore, a recommendation stronger than 'I' is needed to emphasize screening as part of regular physical examinations. An age and/or sex-targeted recommendation may be best," they write.

Yes, questions remain about melanoma screening, they agree, but they argue that the "current mortality from melanoma cannot be ignored."

This research was funded by the Agency for Healthcare Research and Quality. The editorialists have disclosed no relevant financial relationships.

JAMA. 2016;316:429-435. Full text