PerspectiveIn the Journals Plus

USPSTF endorses behavioral counseling to prevent skin cancer

Show Citation

March 20, 2018

John W. Epling Jr.

Clinicians should counsel children, their parents and young adults on the use of sun protective behaviors for the prevention of skin cancer, according to a final recommendation statement from the U.S. Preventive Services Task Force.

The task force recommends that clinicians provide counseling to help reduce the risk for skin cancer among individuals aged 6 months to 24 years with a fair skin type, including parents of young children with a fair skin type (B recommendation). For adults aged 24 years and older with a fair skin type, clinicians should consider the individual’s risks for the disease when deciding to provide counseling (C recommendation).

“Significant exposure to UV rays during childhood and adolescence increases the risk for skin cancer later in life, especially if someone has had repeated sunburns. We found that clinicians can effectively counsel people to better protect themselves from the sun which, in turn, helps reduce the likelihood of skin cancer,” John W. Epling Jr., MD, MSEd, professor of family and community medicine at Virginia Tech Carilion School of Medicine, told HemOnc Today.

Skin cancer is the most common type of cancer in the United States, Epling Jr. said. An extensive population is affected by and at risk for skin cancer.

“Risk factors for skin cancer include having ivory or pale skin, light hair and eye color, freckles, or the tendency to sunburn easily,” Epling Jr. said. “People at higher risk for skin cancer include those who had a high UV ray exposure in childhood or a history of sunburns, those who use tanning beds, those who have had skin cancer before and those who may have disorders of the immune system.”

Therefore, counseling on skin cancer remains a crucial issue for clinicians to consider when caring for their patients.

Counseling interventions aim to encourage people to protect themselves from the sun, Epling Jr. said. Interventions include sunscreen use, wearing protective clothing and avoiding sunlight during peak hours.

“Counseling is more effective if it incorporates longer interactions and multiple different components, such as face-to-face interactions combined with print materials,” Epling Jr. said.

The final recommendation is based on a systematic review performed by Henrikson and colleagues. Researchers searched Cochrane Central Register of Controlled Trials, MEDLINE and PubMed databases for studies published between January 2009 and March 2016 that included care-relevant behavioral interventions focused on improving skin care outcomes, intermediate outcomes, and skin and self-examination behaviors.


Researchers observed the following outcomes in 21 trials from 27 publications:

  • One adult trial promoted skin self-examination but did not find significant difference in patients diagnosed with melanoma in an intervention group vs. a control group at 1-year follow-up;
  • Three trials of children and six adult trials found no consistent improvement in prevention of sunburn;
  • Six trials in pediatric populations and 12 adult trials showed small to moderate increases in sun protection behavior; and
  • Eleven trials indicated a slight increase in skin self-examination in adults.

From these, the USPSTF determined counseling interventions offered a moderate benefit in increasing sun protection behaviors among children, adolescents and young adults with fair skin types, and that behavioral counseling resulted in a small increase in sun protection among adults aged 24 years and older with fair skin types.

“Existing evidence indicates that the net benefit of counseling all adults older than 24 years is small,” the task force wrote in the recommendation statement, adding that the service for this population should be determined on an individual basis.

Consistent with a draft recommendation statement issued in October, the task force again reported insufficient evidence to determine whether benefits outweigh harms from counseling adults about skin self-examinations for the prevention of skin cancer (I recommendation).

The recommendations are proof that progress toward adopting strategies to reduce the burden of skin cancer, as well as the important role that health outcomes research plays in influencing policy, are being embraced, according to Laura K. Ferris, MD, PhD, associate professor in the department of dermatology at University of Pittsburgh Medical Center.

“The new recommendation encourages counseling parents, as well as older children, reflecting newer evidence that interventions targeting parents of young children increases UV radiation-protective behaviors,” Ferris wrote in a related editorial. “Anticipatory guidance is a core aspect of pediatric care, and counseling systems already in place, as well as electronic health record and patient portals, can provide a means to distribute such information at routine visits and provide reminders in summer months when the risk [for] excess exposure is highest.”

Although the recommendations are based on “accurate evaluation,” the task force’s definition of behavioral counseling may be viewed as a “misnomer” to others, according to David B. Buller, PhD, senior scientist and director of research at Klein Buendel, Inc. in Colorado, and colleagues.

“A more accurate term for the services reviewed might be behavioral intervention or behavioral counseling and other interventions,” Buller and colleagues wrote in another editorial. “It would be useful for the task force to add further detail regarding the behavioral counseling approaches used because the approach is likely to be more important than the delivery modality.”


Because self-examination alone is not sufficient, the broader promotion of skin care knowledge and awareness may have a larger impact, Ferris wrote.

“Better educating patients on what is concerning is likely an important component to improving early self-detection,” she wrote.

Buller and colleagues deemed the task force’s conclusion on self-examination “disappointing.”

“This conclusion appears to rest on the lack of evidence that self-examination is an effective secondary prevention practice,” Buller and colleagues wrote. “However, it can be difficult to measure skin self-examination to determine its effectiveness, and some ongoing studies show promise,” they wrote, adding that behavioral counseling appears to increase an individual’s use of self-examination.

“If evidence emerges that skin self-examination is beneficial, behavioral counseling interventions may be an effective way of promoting it,” Buller and colleagues wrote.

The task force is calling for more research on counseling people with other skin types and the benefits and harms of providing counseling about skin self-examination, according to a press release.

“Anyone who is concerned about their risk for skin cancer or who has questions about skin cancer prevention should discuss their concerns with their clinician,” Epling Jr. said. – by Melinda Stevens


References :

Buller DB, et al. JAMA Dermatol. 2018;doi:10.1001/jamadermatol.2018.0325.

Ferris LK. JAMA Oncol. 2018;doi:10.1001/jamaoncol.2018.0469.

Henrikson NB, et al. JAMA. 2018;doi:10.1001/jama.2017.21630.

US Preventive Services Task Force. JAMA. 2018;doi:10.1001/jama.2018.1623.


For more information:

John W. Epling, Jr., MD, MSEd, can be reached at USPSTF, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857.


Disclosures: Epling Jr. and other task force members report no relevant financial disclosures. Ferris reports a consultant role with Derm Tech. Buller and colleagues report no relevant financial disclosures.

itj+ Infographic

itj+ Perspective

Author Name

The USPSTF reviews and helps us better define high-risk groups of patients based on their skin type and how we should screen and counsel them to prevent sun damage and skin cancer.

There are three main recommendations:

  • Children and young adults aged 6 months to 24 years with fair skin should receive counseling about decreasing exposure to UV radiation;
  • Clinicians should selectively offer counseling for adults with fair skin types to decrease exposure to UV radiation to reduce skin cancer; and
  • Patients and clinicians should consider the presence of risk factors for skin cancer.

The task force did not find enough current evidence to recommend routine counseling on self-skin examination to prevent skin cancer for everyone.

One of the most interesting points in this article is the discussion on how clinicians and patients report, identify and define high-risk groups of patients, where terms like “fair skin type” may not be enough or may be misleading. There is a suggestion that terms like “sunburn easily” are an important step to identify high-risk groups of patients who may benefit more from closer surveillance and counseling.

The task force has done a nice job in defining and identifying ways that clinicians and patients can better understand “sun-sensitive skin” and creating pathways and steps to improve how we counsel, teach and educate these patients on sun safety.

Jeffrey M. Farma, MD, FACS

Fox Chase Cancer Center

Disclosure: Farma reports no relevant financial disclosures.


Author Name

Most skin cancers, including melanoma — responsible for the majority of skin cancer deaths — are caused by UV radiation. Most melanomas are potentially preventable by minimizing sun exposure and avoiding indoor tanning. Nonetheless, people are often not adequately protected from UV radiation.

The USPSTF found behavioral counseling provides moderate benefit in increasing sun protection behaviors among children, adolescents and young adults with fair skin types, and to a lesser extent for adults aged older than 24 years. As they did not find consistent evidence that such interventions reduced sunburns and found only minimal evidence on skin cancer outcomes, it is unlikely that such interventions in isolation will achieve durable clinical impact.

Recent data from the United States and Australia demonstrating reduced melanoma incidence rates among young adults support that multicomponent approaches targeting behavioral change through public policy initiatives — eg, restricting use of indoor tanning devices by minors — and/or other approaches, such as school-based programs, can have a real clinical impact. Through both behavioral counseling and youth education, we have an opportunity to greatly reduce the cumulative lifetime risk for skin cancer. Programs such as The University of Texas MD Anderson Cancer Center’s Ray and the Sunbeatables — a sun safety program for children in preschool, kindergarten and first grade — can serve as a complement to a multicomponent approach to reduce melanoma risk.

By widely implementing behavioral counseling aimed at minimizing UV radiation exposure, together with multicomponent initiatives to restrict indoor tanning for minors and educational initiatives spanning early childhood throughout adulthood, there is significant opportunity to improve preventive efforts to reduce the burden of skin cancer, including melanoma. 

Jeffrey E. Gershenwald, MD

The University of Texas MD Anderson Cancer Center

Disclosure: Gershenwald reports no relevant financial disclosures.