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March 22, 2018

How early should counseling begin on skin cancer prevention? At 6 months old, says USPTF

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    Children and young adults with fair skin should receive counseling on how to avoid ultraviolet radiation that can cause skin cancer, according to recommendations from the U.S. Preventive Services Task Force (USPSTF) published Tuesday in JAMA.

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    About skin cancer

    USPSTF wrote that skin cancer is the most common form of cancer diagnosed in the United States, with an estimated 3.3 million cases of non-melanoma skin cancer and more than 90,000 cases of melanoma skin cancer diagnosed in 2012. Invasive melanoma accounted for just 2% of all skin cancer cases but led to 80% of all skin cancer deaths in 2012, according to USPSTF.

    The task force wrote that "a substantial body of observational evidence demonstrates that the strongest connection between ultraviolet radiation exposure and skin cancer results from exposure in childhood and adolescence."

    Recommendation details

    USPSTF based its new recommendations on a review of 21 studies published from 2009 to 2016 on behavioral interventions for preventing skin cancer. USPSTF found that of the six studies that focused specifically on children and adolescents, five found statistically significant improvement in sun-protection behaviors among those who received counseling. Further, of the three trials that focused on young adults, USPSTF found that two reported counseling on preventing skin cancer was effective. In addition, USPSTF found that six of the 12 trials that involved adults ages 24 and older reported an increase in sun protection behavior among those that received such counseling.

    As such, USPSTF's new recommendations endorse counseling on sun-protection behaviors for parents of children with fair skin as young as six months, as well as adolescents and young adults up to age 24 who have fair skin. The task force said such counseling should include information on:

    • Avoiding indoor tanning;
    • Avoiding sun exposure during the brightest times of day;
    • Sunscreen use; and
    • Using protective clothing, hats, and sunglasses.

    USPSTF said its new recommendations update the task force's 2012 recommendations by moving up the age at which it endorses behavioral counseling. USPSTF's 2012 recommendations applied to children with fair skin beginning at age 10, compared with the new recommendations' call for behavioral counseling beginning at age six months.

    USPSTF also suggested that clinicians offer counseling to adults with fair skin older than age 24 on a case-by-case basis depending on such individuals' risk factors for skin cancer. Such factors include:

    • An increased number of nevi;
    • Atypical nevi;
    • Family history of skin cancer;
    • Having received an organ transplant;
    • History of indoor tanning;
    • History of sunburn; and
    • HIV infection.

    USPSTF said the benefits of counseling for individuals with skin types other than fair was insufficient. USPSTF also said there was not sufficient evidence to determine whether the benefits of counseling adults about skin self-examination as a tool to prevent skin cancer outweighed associated harms.


    Sharon Manne of the Rutgers Cancer Institute of New Jersey and colleagues in an editorial published in JAMA Dermatology wrote, "It was disappointing to learn that the task force still considers the evidence insufficient to determine whether behavioral counseling for skin self-examination among adults will prevent skin cancer." They added, "This conclusion appears to rest on the lack of evidence that skin self-examination is an effective secondary prevention practice. However, it can be difficult to measure skin self-examination to determine its effectiveness, and some ongoing studies show promise."

    However, June Robinson, a researcher at the Northwestern University Feinberg School of Medicine, and colleagues in an editorial published in JAMA wrote that self skin-examiniations "may make some people unduly anxious and result in needless skin biopsies." Robinson instead suggested training individuals at a high risk for melanoma on skin examinations. "People who need to be trained are melanoma survivors and their family members, and people who had many sunburns," Robinson said, adding, "Skin self-exam does not replace physician examination but it does help the person to determine when to seek the care of a doctor."

    Robert Sidbury of the Seattle Children's Hospital in an editorial published in JAMA Pediatrics praised the recommendations for touting methods other than sunscreen use to prevent skin cancer. Sidbury wrote that a significant challenge to protecting patients against ultraviolet radiation is "the notorious inadequacy of sunscreen as sole defense against photodamage." He continued, "Comprehensive sun protection efforts include not only sunscreen but also appropriate clothing, eye protection, and prudent exposure," adding, "Unfortunately most people, particularly children, consider sunscreen the beginning, middle, and end of photoprotection, if they make any effort at all" (Minerd, MedPage Today, 3/20; Rapaport, Reuters, 3/20).

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