Position statement - Screening and early detection of skin cancer

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Position statement - Screening and early detection of skin cancer


This position statement is endorsed by the Australasian College of Dermatologists

Key messages

  • Survival from melanoma is strongly associated with depth of invasion; deeper and thicker melanomas are more likely to metastasise and be more difficult to treat. Thus, early detection is important.
  • Population-based screening, however, is not recommended for melanoma or other skin cancers, due to insufficient evidence that it reduces mortality.
  • The majority of melanomas are detected by patients themselves, or their partners. However, melanomas detected by physicians tend to be thinner.
  • Beyond adequate sun protection, competent, whole body skin examination and dermoscopy for suspicious lesions, no examination or technology has proven value for reducing the harm caused by skin cancer.


Recommendations

  • In the absence of sufficient evidence for an associated reduction in mortality from melanomas or other skin cancers, Cancer Council Australia does not recommend population-based screening by a doctor for skin cancer.
  • Cancer Council Australia encourages people to become familiar with their skin, including skin not normally exposed to the sun, and consult a doctor if they notice any change in shape, colour or size of a lesion, or the development of a new lesion.
  • Cancer council Australia recommends that people at high risk of developing skin cancer consult their doctor if they notice any changes and be checked at regular intervals as recommended by their doctor.
  • Cancer Council Australia recommends employers, under work health and safety responsibilities, focus their attention on the introduction and maintenance of effective sun protective control measures, including education and the importance of early detection, over skin cancer screening programs.

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Background

In 2011 there were 1544 Australian deaths from melanoma and 543 deaths from non-melanoma skin cancers (NMSC) such as squamous cell carcinoma and basal cell carcinoma[1]. NMSC is far less likely to be life-threatening than melanoma, with around 400 times the number of cases but only a third the number of deaths.

Survival from melanoma is strongly associated with depth of invasion; deeper and thicker melanomas are more likely to have metastasised and be more difficult to treat. In Australia, five-year survival for melanomas thicker than 4 mm is 55%, compared with almost 100% survival for melanomas 1 mm or less[2]. Earlier diagnosis – i.e. the detection of thinner tumours – is therefore correlated to successful patient outcomes and longer-term survival[3].

The aim of population-based screening programs is to reduce mortality through early detection. However, in the absence of sufficient evidence for an associated reduction in mortality from melanoma or other skin cancers, population-based screening for skin cancer is not recommended.

While screening is not recommended on a population basis, for people at high risk of developing skin cancer, there is evidence to suggest opportunistic screening by general practitioners may be beneficial for people at high risk.

Cancer Council Australia recommends that people get to know their skin, and to consult their doctor if they notice any changes.

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Population-based screening for skin cancer

While there is no organised screening program for skin cancer, screening is being conducted in a significant proportion of the population. Australian studies have demonstrated that anywhere from 10-50% of people participate in skin cancer screening, depending on the definition of skin screening[4][5][6][7][8][9].

Screening for melanoma and NMSC does not meet the World Health Organisation criteria for the implementation of population-based screening[10]. There is currently insufficient evidence that screening for melanoma reduces mortality, and current diagnostic practices for melanoma are not appropriate for screening[11][12]. Screening is unlikely to ever be recommended for NMSC, as long-term illness and death are rare occurrences in relation to incidence. See Principles of screening for more information.

According to current clinical practice guidelines, in the absence of substantive evidence as to its effectiveness in reducing mortality from melanoma, population-based skin screening cannot be recommended[12]. RACGP do not recommend screening for melanoma or other skin cancers for those at average risk[13]. See Early detection in high risk groups for recommendations concerning those at increased risk.

Early evidence from the American Academy of Dermatology skin cancer screening programs showed that melanomas diagnosed through screening were more likely to be thinner than those in population-based registries[14]. Until recently however, no randomised controlled intervention had been conducted to see if whole-body skin examination is effective in reducing mortality from melanoma[12]. In 2012, a German study reported that population-based screening for melanoma by whole-body examination performed by general physicians (who then referred suspicious lesions to a dermatologist) reduced melanoma mortality by 47%[15].

However, more evidence of the mortality benefit of population-based skin cancer screening is required. A randomised trial of a population-based melanoma screening program in Australia involving whole-body clinical skin examinations performed by primary care physicians (with lesions referred to participants’ own doctor) over a period of three years is currently underway[16].

In the absence of sufficient evidence for an associated reduction in mortality from melanoma or other skin cancers, Cancer Council Australia does not recommend population-based screening by a doctor for skin cancer.

For more information, see the Melanoma screening section of the National Cancer Prevention Policy.

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Self versus clinical skin examination

The majority (55-70%) of melanomas are detected by patients themselves, or their partners[17][18][19]. Among melanomas detected by physicians, only 12% are found during a systematic skin examination; most melanomas detected by physicians (51%) are found during routine clinical examinations unrelated to skin cancer[17].

Evidence including a number of Australian studies shows that melanomas detected by physicians are more likely to be thinner than those detected by patients[17][18][19][20][21]. Whole-body clinical skin examination in particular is associated with diagnosis of thinner melanomas compared with those diagnosed through other means, including incidental diagnosis by a physician[18][20].

Skin cancer clinics are staffed by GPs with a particular interest in skin cancer. In some cases the doctors may have undergone some additional training. Current evidence suggests that general practitioners diagnose skin cancers with equal levels of accuracy as doctors working in primary care skin cancer clinics[22]. However, while overall sensitivity for diagnosing any skin cancer is similar for skin cancer clinic doctors and GPs, sensitivity for melanoma diagnosis is better among skin cancer clinic doctors (60% compared with 29%)[22].

Melanomas diagnosed by dermatologists are thinner than those diagnosed by GPs or other doctors[17][23]. An Australian study found that those visiting both a dermatologist and primary care physician before a melanoma diagnosis were more likely to be diagnosed with a thin melanoma and 34% lower melanoma mortality compared with those without such visits[24].

Cancer Council Australia encourages people to become familiar with their skin, including skin not normally exposed to the sun, and consult a doctor if they notice any change in shape, colour or size of a lesion, or the development of a new lesion.

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Diagnostic technologies

There are various technologies for diagnosing skin cancer, such as the use of dermoscopy, total body photography and sequential imaging.

Dermoscopy improves the clinicians' diagnostic accuracy for melanoma compared with other clinical diagnostic approaches[25][26][27][28][29]. Use of dermoscopy is associated with diagnosis of thinner melanomas[30].

Total body photography is considered a useful tool of the early detection of melanoma in high-risk patients[12].

Beyond adequate sun protection, competent, whole body skin examination and dermoscopy for suspicious lesions, no examination or technology has proven value for reducing the harm caused by melanomas or other skin cancers.

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Early detection in high risk groups

People at high risk for skin cancer include those with:

  • fair skin, a tendency to burn rather than tan, freckles, light eye colour, light or red hair colour;
  • increased numbers of unusual moles (dysplastic naevi);
  • depressed immune systems;
  • a family history of melanoma in a first degree relative; and
  • previous melanoma or NMSC.

Australian clinical practice guidelines recommend that individuals at high risk of melanoma be educated to recognise and document lesions suspicious of melanoma, and to be regularly checked by a clinician with six-monthly full body examination supported by total body photography and dermoscopy as required[12]. High-risk individuals may benefit from regular clinical surveillance for new melanomas and education to self-screen, based on expert opinion[12].

The Royal Australian College of General Practitioners (RACGP) recommend that clinical skin examination is offered opportunistically to those at increased risk of melanoma[13]. For those at highest risk (those with multiple atypical or dysplastic naevi or who have a history of melanoma or other skin cancers in themselves or in a first-degree relative), RACGP recommend clinical skin examination (either with or without photography) every 3-12 months[13]. RACGP recommends this group are given advice on self- examination and note that they may benefit from use of self-photography[13].

As a high number of lesions are not easily visible by the patient[31], people conducting self-checks should be encouraged to ask others to check difficult-to-see areas such as their back, scalp and the back of the neck.

Cancer Council Australia recommends that people at high risk of developing skin cancer are educated to recognise and document lesions suspicious of melanoma, ask others to check difficult-to-see areas such as their back, scalp and the back of the neck, and consult a doctor if they notice any change in shape, colour or size of a lesion, or the development of a new lesion. People at high risk should be regularly checked by a clinician with whole body examinations every 3-12 months.

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Early detection in the workplace

Currently there is no evidence to support skin cancer screening in the workplace. Employers’ legal obligations place a clear emphasis on skin cancer prevention and the implementation of a workplace UV policy.

Cancer Council Australia recommends employers focus on the introduction and maintenance of skin cancer prevention measures, through the reduction of and protection against UV exposure, over skin cancer screening programs.

Outdoor workers are at increased risk of melanoma and other skin cancers, and should be alert for new or changing lesions. Cancer Council Australia encourages people, especially outdoor workers to become familiar with their skin, including skin not normally exposed to the sun, and consult a doctor if they notice any change in shape, colour or size of a lesion, or the development of a new lesion.

See Cancer Council Australia’s position statement on Sun protection in the workplacefor more information.

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Position statement details

This position statement was developed by Cancer Council Australia's National Skin Cancer Committee and endorsed by Cancer Council Australia's principal Public Health Committee. It was published in July 2014.

For further information

Cancer Council Australia – http://www.cancer.org.au

Cancer Council Helpline – 13 11 20

The Australasian College of Dermatologists – http://www.dermcoll.asn.au

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References

  1. Australian Institute of Health and Welfare. ACIM (Australian Cancer Incidence and Mortality) books. Canberra: AIHW; 2014 Feb 13 Available from: http://www.aihw.gov.au/acim-books/.
  2. Australian Institute of Health and Welfare. Cancer survival and prevalence in Australia: period estimates from 1982 to 2010. Cancer Series no. 69. Cat. no. CAN 65. Canberra: AIHW; 2012 Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737422721.
  3. Balch CM, Soong SJ, Atkins MB, Buzaid AC, Cascinelli N, Coit DG, et al. An evidence-based staging system for cutaneous melanoma. CA Cancer J Clin 2004 May;54(3):131-49; quiz 182-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15195788.
  4. Janda M, Elwood M, Ring IT, Firman DW, Lowe JB, Youl PH, et al. Prevalence of skin screening by general practitioners in regional Queensland. Med J Aust 2004 Jan 5;180(1):10-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14709121.
  5. Borland R, Meehan JW. Skin examination for signs of cancer. Aust J Public Health 1995 Feb;19(1):85-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7734602.
  6. Balanda KP, Lowe JB, Stanton WR, Gillespie AM. Enhancing the early detection of melanoma within current guidelines. Aust J Public Health 1994 Dec;18(4):420-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7718657.
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  10. Wilson JMG, Jungner G. Principles and practices of screening for disease. Geneva, Switzerland: World Health Organization; 1968. Report No.: Public Health Papers No. 34. Available from: http://whqlibdoc.who.int/php/WHO_PHP_34.pdf.
  11. U.S. Preventative Services Task Force. Screening for Skin Cancer: Clinical Summary of U.S. Preventative Services Task Force Recommendation. USPSTF; 2009 Feb. Report No.: AHRQ Publication No. 09-05128-EF-3.
  12. 12.0 12.1 12.2 12.3 12.4 12.5 Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group. Clinical Practice Guidelines of the Management of Melanoma in Australian and New Zealand. Wellington: Australian Cancer Network Melanoma Guidelines Revision Working Party; 2008 Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp111.pdf.
  13. 13.0 13.1 13.2 13.3 The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice, 8th edition. Melbourne: RACGP; 2012.
  14. Geller AC, Zhang Z, Sober AJ, Halpern AC, Weinstock MA, Daniels S, et al. The first 15 years of the American Academy of Dermatology skin cancer screening programs: 1985-1999. J Am Acad Dermatol 2003 Jan;48(1):34-41 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12522368.
  15. Katalinic A, Waldmann A, Weinstock MA, Geller AC, Eisemann N, Greinert R, et al. Does skin cancer screening save lives?: an observational study comparing trends in melanoma mortality in regions with and without screening. Cancer 2012 Nov 1;118(21):5395-402 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22517033.
  16. Aitken JF, Elwood JM, Lowe JB, Firman DW, Balanda KP, Ring IT. A randomised trial of population screening for melanoma. J Med Screen 2002;9(1):33-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11943795.
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  21. Kantor J, Kantor DE. Routine dermatologist-performed full-body skin examination and early melanoma detection. Arch Dermatol 2009 Aug;145(8):873-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19687416.
  22. 22.0 22.1 Youl PH, Baade PD, Janda M, Del Mar CB, Whiteman DC, Aitken JF. Diagnosing skin cancer in primary care: how do mainstream general practitioners compare with primary care skin cancer clinic doctors? Med J Aust 2007 Aug 20;187(4):215-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17708723.
  23. Haenssle HA, Hoffmann S, Holzkamp R, Samhaber K, Lockmann A, Fliesser M, et al. Melanoma thickness: the role of patients' characteristics, risk indicators and patterns of diagnosis. J Eur Acad Dermatol Venereol 2014 Mar 19 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24646029.
  24. Roetzheim RG, Lee JH, Ferrante JM, Gonzalez EC, Chen R, Fisher KJ, et al. The influence of dermatologist and primary care physician visits on melanoma outcomes among Medicare beneficiaries. J Am Board Fam Med 2013 Nov;26(6):637-47 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24204060.
  25. Vestergaard ME, Macaskill P, Holt PE, Menzies SW. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol 2008 Sep;159(3):669-76 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18616769.
  26. Ahnlide I, Bjellerup M. Accuracy of clinical skin tumour diagnosis in a dermatological setting. Acta Derm Venereol 2013 May;93(3):305-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23538779.
  27. Rosendahl C, Tschandl P, Cameron A, Kittler H. Diagnostic accuracy of dermatoscopy for melanocytic and nonmelanocytic pigmented lesions. J Am Acad Dermatol 2011 Jun;64(6):1068-73 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21440329.
  28. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002 Mar;3(3):159-65 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11902502.
  29. Bafounta ML, Beauchet A, Aegerter P, Saiag P. Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the evaluation of diagnostic tests. Arch Dermatol 2001 Oct;137(10):1343-50 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11594860.
  30. Salerni G, Terán T, Puig S, Malvehy J, Zalaudek I, Argenziano G, et al. Meta-analysis of digital dermoscopy follow-up of melanocytic skin lesions: a study on behalf of the International Dermoscopy Society. J Eur Acad Dermatol Venereol 2013 Jul;27(7):805-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23181611.
  31. Koh HK, Miller DR, Geller AC, Clapp RW, Mercer MB, Lew RA. Who discovers melanoma? Patterns from a population-based survey. J Am Acad Dermatol 1992 Jun;26(6):914-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1607408.

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