USPSTF Updates Skin Cancer Prevention Counseling Guidelines

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November 8, 2011 — To reduce risk for skin cancer, the US Preventive Services Task Force (USPSTF) recommends counseling persons aged 10 to 24 years with fair skin to minimize exposure to ultraviolet (UV) radiation, according to a USPSTF recommendation statement. However, the USPSTF concluded that current evidence is insufficient to weigh the benefits versus the risks of counseling adults older than 24 years of age.

This evidence-based recommendation statement is an update to the previous 2003 USPSTF recommendations about skin cancer counseling by primary care doctors. At that time, the Task Force concluded that there was no evidence for the benefit of counseling in any age group.

"Skin cancer is the most common malignancy in American populations, and is diagnosed in more than 2 million Americans each year," the USPSTF writes. "Convincing evidence relates UV radiation exposure during childhood and youth to a moderately increased risk of skin cancer later in life; for adults, adequate evidence links UV radiation exposure to a small increase in the subsequent risk of skin cancer.…Individuals with a fair skin type are at greatly increased risk of skin malignancy."

Rationale for Behavioral Counseling

The goal of behavioral counseling is to increase sun-protective behaviors shown to be effective in reducing UV radiation exposure from the sun and from indoor tanning. Recommended interventions include using effective sunscreen, wearing hats or other shade-protective clothing, reducing outdoor activities during midday hours, and avoiding the use of indoor tanning.

Risk for skin cancer is greatly increased among persons with a fair skin type, defined as light pigmentation, light hair and eye color, freckles, and a tendency to sunburn easily. Most studies of interventions to increase sun-protective behaviors have enrolled only persons with a fair skin type.

Adequate evidence suggests that for persons aged 10 to 24 years, counseling interventions available in or referable from primary care can moderately increase the use of sun-protective behaviors. However, evidence is inadequate to assess the effect of counseling on the use of sun-protective behaviors by adults older than 24 years of age.

Evidence is adequate that no appreciable harms are associated with counseling or sun-protective behaviors in youth or adults. Little evidence supports theoretical concerns about sun-protective behaviors increasing the risk for vitamin D deficiency in adults living in northern latitudes.

The USPSTF therefore concluded with moderate certainty that there is a moderate net benefit of counseling for persons aged 10 to 24 years with fair skin. However, the balance of benefits and harms cannot be determined for adults older than age 24 years, because evidence is sparse and of unknown clinical significance.

Specific USPSTF Recommendations

Specific USPSTF recommendations regarding behavioral counseling to prevent skin cancer are as follows:

• To reduce risk for and prevent incidence of skin cancer, the USPSTF recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to UV radiation (grade B recommendation).
• The USPSTF concludes that current evidence is insufficient to determine the balance of benefits and harms of counseling adults older than age 24 years about minimizing their risks to prevent skin cancer (I statement).

Overall, these recommendations are consistent with those of other professional societies. The American Cancer Society recommends protecting children from the sun because severe sunburns in childhood increase the risk for skin cancer. The American Academy of Family Physicians is updating its recommendations about counseling to prevent skin cancer, although previous statements have been consistent with those of the USPSTF.

The American Academy of Pediatrics has issued comprehensive guidelines to protect children from UV radiation exposure and recommends that pediatricians include sun safety advice in health maintenance visits at least annually.

Clinical Implications

• The USPSTF recommendation applies only to asymptomatic persons with no history of skin cancer.
• The recommendation for counseling persons aged 10 to 24 years is limited to those with a fair skin type because most trials of skin cancer counseling enrolled only persons with that skin type.
• Counseling adults is of uncertain potential benefit because of the unknown effectiveness of counseling interventions to change behavior and because the association between behavior change in adulthood and skin cancer risk is not well demonstrated. The authors suggest that UV exposure after 35 years of age may contribute much less to lifetime skin cancer risk compared with exposure earlier in life.
• Effective interventions are typically of low intensity and can be carried out during the primary care visit. Messages targeting appearance are most effective in late-adolescent females, with techniques including self-guided booklets, a video on photoaging, 30-minute peer counseling sessions, and UV facial photography to demonstrate the extent of skin damage from UV exposure.

"Further randomized, controlled trials are needed to develop effective interventions for infants and small children," the USPSTF concludes. "In addition, a better understanding of the impact of UV exposure during adulthood, in terms of risk of skin malignancies, would be valuable to address the key evidence gap around counseling for that age group. Research is also needed to further develop technologies and vehicles for administering relevant interventions for behavior change."

By: Laurie Barclay, MD