To Screen or Not to Screen (for Skin Cancer) – Reframing the Question

July 29, 2016
Louise M. Perkins, Ph.D.
MRA Chief Science Officer

To screen or not to screen actually isn’t the question screen

While an adaptation of Hamlet’s famous phrase may capture the headlines on whole-body skin checks, a deeper dive gets us closer to questions of life and death. In fact, there is no question that skin cancer screening is important!  The real question is when, how and for whom does skin cancer screening fit as a means to protect yourself from the deadliest of skin cancers, melanoma.

Just the facts

An independent body of medical experts called the U.S. Preventive Services Task Force (USPSTF) recently published their findings on the recommendation for whole-body skin examinations for the early detection of skin cancer. With a focus on primary care physicians and the total universe of potential patients, they concluded that there is not enough evidence to weigh the balance of benefits against possible harms in making this a universal practice.

This doesn’t mean screening is ineffective or unimportant for certain individuals – just that the jury is still out on screening for the general population.  Where a clear verdict can be delivered, is the importance of skin checks for those at higher risk for melanoma:  if you have a history of sunburns or UV exposure, family history of skin cancer, more than 50 moles, or fair skin, light eyes and/or red or blonde hair, you should discuss the benefits of regular skin exams with your doctor.  Everyone can use the ABCDE system for a monthly skin check to help identify suspicious moles and bring them to your doctor’s attention.

Here are some more details

What’s new – the 2016 USPSTF recommendation

On July 26, 2016, the USPSTF published a recommendation that there is not sufficient evidence to weigh the benefits of visual skin cancer screening by primary care providers (PCPs) against potential harms for symptom-free individuals who are not at increased risk for melanoma.

That’s a pretty dense sentence so let’s break it down a bit.

Who is the USPSTF?

The USPSTF is a volunteer panel of medical experts who are, despite the name, independent of the U.S. government and provide recommendations about prevention and evidence-based medicine to primary care physicians. This is an influential group whose determinations can have wide-ranging impact on medical practice not only by non-specialist physicians but can also affect health coverage.

What did the USPSTF study?

The task force gathered evidence from the scientific literature to measure if there is enough information of sufficient quality that related to the potential benefit and potential harms of a universal skin screening program.

What is skin screening?

Skin screening involves having a clinician examine the skin for suspicious spots.  A thorough total body exam includes looking on the scalp, between toes, and all points in between.  So, yes, you need to be out of your clothes for it, and it may take you more time to undress and dress for the exam than the exam itself!

What kind of evidence might’ve convinced USPSTF otherwise? Help me understand benefit and harms.

The USPSTF could have recommended that PCPs perform total body skin screens on everyone if robust evidence existed to support it.  A convincing study might have shown that skin screens performed on the general population by PCPs led to decreased deaths from melanoma – and there were not too many biopsies of suspicious lesions that turned out not to be skin cancer – or too much unnecessary anxiety produced by that screening.  At the present time, however, there simply is not enough evidence like this, hence the USPSTF “I” rating for insufficient evidence.

An analogy might be useful here. Broad screening would be like having your mechanic check your car once a year for rust whether or not you have a ding on its body.  With no dings, dents or scratches, the likelihood of rust is next to nil, and the regular checks become just a burden of time and resources; and for the overly anxious person – a bit of non-productive anxiety. Those would be harms. But if your car ran years and years because of this inspection, that would be a benefit. 

So, skin screening is a big waste of time and I should skip it, right?

Wrong. What the USPSTF found is that there’s just not sufficient evidence to recommend for or against PCP screening for the adult general population. However, “insufficient evidence of benefit” is different from “evidence of no benefit.” We know that when caught early, melanoma is highly treatable with surgery. But once it spreads throughout the body (metastasizes), it can be deadly. So, detecting melanoma at its earliest stages is very important. Keep in mind that adults with concerning skin symptoms or who are at higher-risk for skin cancer were not included in the USPSTF’s evaluation. Nor was screening by the skin specialists – the dermatologists – or even skin screening by individuals themselves considered (that evidence will be looked at by USPSTF later).

Um – okay.  So, when it comes to screening, what should I do?

First of all, everyone should check their own skin monthly using the ABCLayout 1DE system. If you’re at higher risk for melanoma, discuss the benefits of regular skin exams with your doctor.  How do you know if you’re at risk? Risk factors include:

  • Fair skin
  • Red or blonde hair
  • Light eyes
  • More than 50 moles
  • History of sunburn or excessive UV exposure
  • Personal or family history of skin cancer
  • Weakened immune system

About half of melanomas are found initially by the patient themselves.  So, for now, take charge of your own skin using the ABCDEs.

If you have something on your skin that looks suspicious, bring it to your doctor’s attention and s/he may refer you for further testing.

What is MRA doing?

The USPSTF conclusion on skin screening means that more research needs to be done on the benefits and potential harms of skin cancer screening. In 2014, MRA funded an interdisciplinary team of researchers to study melanoma skin screening in the primary care setting.  That work is just starting to yield results with a paper published recently.  One of the key components of their approach is a training system that MRA funded in 2009 called INFORMED and is used to teach PCPs skin screening.  We’ve worked with numerous allies to advocate for melanoma awareness and to spread the word that exposure to ultraviolet light (UV) from the sun and tanning beds is the most preventable risk factor for melanoma.

So, learn as much as you can, avoid tanning beds, use sun-safe practices and check your skin and you can decrease your risk of this deadly disease.