Perspective from
March 20, 2018
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USPSTF endorses behavioral counseling to prevent skin cancer

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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.

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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.”

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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.