In an update to its 2016 recommendations for skin cancer screening, the US Preventive Services Task Force (USPSTF) has once again determined that there is not enough evidence to recommend for or against screening with a visual skin exam in adolescents and adults without symptoms.
This final recommendation applies to the general public and is not meant for those at higher risk, such as people with a family history of skin cancer or who have any signs or symptoms, such as irregular moles.
"The new recommendations are consistent with those from 2016, and we are unable to balance benefits and harms," said Task Force member Katrina Donahue, MD, MPH. "Unfortunately, there is not enough evidence to recommend for or against screening, and healthcare professionals should use their judgment when deciding whether or not to screen."
Donahue told Medscape Medical News that this is a call for more research. "Our recommendations are for patients who present to primary care without symptoms, and after a careful assessment of benefit and harms, we didn't have evidence to push us towards screening as a benefit," said Donahue, professor and vice chair of research in the department of family medicine at the University of North Carolina, Chapel Hill. "We did look at data from two large screening programs, but they were from Europe and not representative of the US population. They also did not show a benefit for reducing melanoma-related mortality."
Skin cancer is the most commonly diagnosed cancer in the United States, but there are different types that vary in their incidence and severity. Basal and squamous cell carcinomas are the most common types of skin cancer, but they infrequently lead to death or substantial morbidity, notes the USPTSF. Melanomas represent about 1% of skin cancer and cause the most skin cancer deaths. An estimated 8000 individuals in the United States will die of melanoma in 2023.
There are racial differences in melanoma incidence; it is about 30 times more common in White vs Black persons, but disease in persons with darker skin color tends to be diagnosed at a later stage. These disparities may be due to differences in risk factors, access to care, and clinical presentation.
In an accompanying editorial, Maryam M. Asgari, MD, MPH, of the Department of Dermatology, Massachusetts General Hospital, Boston, and Lori A. Crane, PhD, MPH, of the Colorado School of Public Health, University of Colorado, Aurora, point out that people with darker skin phenotypes also tend to be affected by skin cancers that are not associated with UV radiation, such as acral melanoma, which arises on the palms and soles, and skin cancers that arise in areas of chronic inflammation, such as wounds.
Thus, differences in anatomical distribution of skin cancers in in the various subpopulations needs to be considered when performing skin screening, they write. "Furthermore, while skin cancer risk is lower among people with darker skin pigmentation, survival is often worse for cancers like melanoma, highlighting the potential need for screening."
"More data are needed, particularly regarding genetic and environmental risk factors for skin cancer in people with darker pigmentation, to help inform guidelines that can be broadly applied to the US population," add Asgari and Crane. "The diversity of the US population extends also to geography, culture, and socioeconomic status, all of which affect skin cancer risk."
Review of Evidence
The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for skin cancer in asymptomatic adolescents and adults, including evidence for both keratinocyte carcinoma (basal cell carcinoma and squamous cell carcinoma) and cutaneous melanoma.
Foundational evidence showed that the sensitivity of visual skin examination by a clinician to detect melanoma ranged from 40% to 70% and specificity ranged from 86% to 98%. Evidence that evaluated the diagnostic accuracy of visual skin examination to detect keratinocyte carcinoma was limited and inconsistent. There were no new studies reporting on diagnostic accuracy for an asymptomatic screening population.
The USPSTF also reviewed 20 studies in 29 articles (n = 6,053,411). This included three nonrandomized studies evaluating two skin cancer screening programs in Germany, but results were inconsistent. In addition, the ecological and nonrandomized design of the studies limited the conclusions that could be drawn and the applicability to a US population was difficult to assess because of differences in population diversity and healthcare delivery in the United States.
Other nonrandomized studies that looked at various outcomes, such as harms, and stage at diagnosis and melanoma or all-cause mortality also did not provide sufficient evidence to support screening.
Research Is Needed
In a second accompanying editorial, published in JAMA Dermatology, Adewole S. Adamson, MD, MPP, of the Division of Dermatology and Dermatologic Surgery at the University of Texas, Austin, pointed out that unlike other cancer screening programs, such as those for breast, colon, and prostate cancer, skin cancer screening programs are somewhat less organized. The other programs focus on defined groups of the population, generally with easily identifiable characteristics such as age, sex, and family history, and importantly, there are always defined ages for initiation and halting of screening and intervals for screening frequency. None of these basic screening parameters have been widely adopted among dermatologists in the United States, he wrote.
"One important reason why skin cancer screening has remained inconsistent is that it is not covered by Medicare or by many commercial insurance companies," Adamson told Medscape Medical News. "The test, in this case the skin exam, is often performed as part of a routine dermatology visit."
Dermatologists should take the lead on this, he said. "Dermatologists should push for a high quality prospective clinical trial of skin cancer screening, preferably in a high-risk population."
Donahue agrees that research is needed, as noted in the recommendation. For example, studies are needed demonstrating consistent data of the effects of screening on morbidity and mortality or early detection of skin cancer, and clearer descriptions of skin color and inclusion of a full spectrum of skin colors in study participants. Clinical research is also needed on outcomes in participants that reflect the diversity of the US population.
"I hope funding agencies will be interested in this area of study," she said. "We put out the whole systematic review and point out the gaps. We need consistent evidence in detecting cancer early and reducing complications from skin cancer."
The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF
None of the USPSTF authors report any disclosures. Asgari reported receiving royalties from UpToDate. Crane did not make any disclosures. Adamson reported serving as an expert reviewer for the US Preventive Services Task Force skin cancer screening report as well as support from the Robert Wood Johnson Foundation, the Dermatology Foundation Public Health Career Development Award, the National Institutes of Health, the American Cancer Society, and Meredith's Mission for Melanoma.
JAMA Dermatol. Published online April 18, 2023. Editorial
Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.
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Image 1: Adewole S. Adamson, MD, MPP
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Cite this: USPSTF Releases Updated Recommendations on Skin Cancer Screening - Medscape - Apr 18, 2023.