In July 2016, the U.S. Preventative Services Task Force (USPSTF) published updated skin cancer screening guidelines in JAMA, concluding “current evidence is insufficient” to screen for skin cancer in adults. The guidelines were formulated on a literature review of studies conducted in asymptomatic patients 15 years and older at general risk for skin cancer from 1995-2015; after identifying nearly 13,000 articles spanning two decades of work worldwide, the authors selected 13 studies to answer specified “key questions,” such as whether direct evidence exists that skin cancer screening reduces morbidity and mortality.
One study, the SCREEN trial conducted in Northern Germany, was a population-based skin cancer screening program that included physician training, a public awareness campaign, and a dermatology referral protocol. During a 1-year intervention period (2003 to 2004), 19 percent of the eligible population was screened, the majority were women (73.6 percent) with a mean age of 49.7 years: Of those screened, 39 percent were referred to dermatology and failed to keep the appointment. Regardless, over a 10-year period, age- and sex-adjusted melanoma mortality decreased by 48 percent in the intervention region, although the absolute impact (mortality difference of 0.8 melanoma deaths per 100,000 persons) was small by comparison.
The question of “harms” of skin cancer screening was addressed by the number of excisions required and the cosmetic satisfaction with shave biopsies (physicians were more critical, with 16 percent rating them “poor” vs. 7 percent of patients), and the question of “accuracy” of such screening (primary care physicians vs. dermatologists) was addressed in a separate Australian study, the interpretation of which the authors concluded the “exact number of true-negative and false-negative findings was unknown” and “the screening accuracy of dermatology and primary care clinicians could not be directly compared.”
Moreover, the evidence cited to cast doubt on the importance of skin cancer screening was also scant: The authors identified one Australian study that looked at patients with and without melanoma who recalled a skin exam within three years of a study-assigned reference date. Not surprisingly, patients who had skin exams had thinner melanomas (i.e., the disease was caught sooner) versus those with more advanced disease (in fact, compared to controls, advanced-disease patients were 40 percent less likely to have seen a doctor). The study authors even admitted that “the evidence for an association between skin cancer screening and melanoma mortality is limited,” which is not the same as saying skin cancer screening does not save lives.
As an oncologist devoted to the care of patients with aggressive, often fatal skin cancers, I am deeply troubled by these conclusions and share the concerns expressed by my dermatology colleagues. “Limited” evidence does not mean “no” evidence, and sweeping conclusions were made about skin cancer screening being “ineffective” based on 0.1 percent of the collective data, most of which the authors conceded was insufficient. In sum, it is a public disservice to say to patients (and physicians) that skin cancer screening is not an effective means of prevention.
The greatest oversight of the USPSTF recommendation is the alarming rate at which skin cancers are appearing in our population. Melanoma is the leading cause of cancer death in women aged 25 to 30; not surprisingly, these same women have likely been indoor tanners (the highest rate of use is among Caucasian females age 16 to 29). The National Health Interview Survey estimates 7.8 million women and 1.9 million men in the United States tan indoors each year, and more than 400,000 cases of skin cancer may be related, including basal cell (58 percent), squamous cell (40 percent), and melanoma (<2 percent).
Most worrisome is the significant increase in truncal melanomas in females, which are likely directly related to tanning bed use and are an independent risk factor for more aggressive cancer. While the USPSTF advises physicians to “counsel” patients on sun safety, unless skin cancer risk factors are directly addressed at the clinic visit, an opportunity to catch a cancerous (or precancerous) lesion could be missed by omitting that skin exam.
The “risk factors” for skin cancer are also extremely narrow within the USPSTF guidelines. Epidemiologically, what they also fail to acknowledge are the advances in medicine which unfortunately directly contribute to skin cancer, namely solid organ and bone marrow transplant. While each of these are remarkable lifesaving procedures, these patients are committed to a lifetime of immunosuppression, which dims the natural ability of the immune system to attack and eradicate early cancer lesions.
In fact, squamous cell carcinoma is the most common secondary malignancy seen in both patient populations, and as our transplant care continues to improve, it is extremely likely that these patients will live long enough to develop pre-cancerous or cancerous changes in their skin. This again represents a missed opportunity if the whole body skin exam is skipped.
Even from a general population standpoint, there are reasons for physicians (and patients) to have a heightened awareness of skin cancer: ongoing environmental changes, ozone thinning, and UV exposure have been cited in numerous publications as direct links to rising skin cancer incidence. Unfortunately, I have witnessed this personally, as the patients I see for skin cancer consultation seem younger by the day. It is an indisputable tragedy that a 30-year-old without risk factors dies from melanoma, and while we don’t have “mortality benefit” from randomized controlled trials to support screening, shouldn’t we exercise every preventative measure at our disposal?
As a physician, I am certainly sensitive to the tight constraints of office visits and recognize that time (and dermatology referral pathways) are essential components of an effective skin cancer screening program. In our modern era of high-volume, EMR-saddled clinical duties, perhaps skipping that skin exam on the asymptomatic patient feels better if the USPSTF says it’s OK to do so.
However, as that same physician, I urge my colleagues to think critically about how and whether these recommendations should change our practice, and in the words of Atul Gawande, instead remain a “positive deviant” in steadfast surveillance of all that may ail the patients in our care.
You may very well save someone’s life.
Morganna Freeman is an oncologist. She can be reached on Twitter @docwithacalling.
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