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Draft Recommendation Statement

Skin Cancer: Screening

October 25, 2022

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This topic is being updated. Please use the link(s) below to see the latest documents available.

Recommendation Summary

Population Recommendation Grade
Asymptomatic adolescents and adults The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adolescents and adults. See the Practice Considerations section for additional information regarding the I statement. I

Additional Information

Tools
Related Resources
  • Screening for Skin Cancer: Understanding Task Force Draft Recommendations | Link to File

Full Recommendation:

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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Skin cancer is the most commonly diagnosed cancer in the United States.1 There are different types of skin cancer varying in disease incidence and severity. Basal and squamous cell carcinomas are the most common types of skin cancer but infrequently lead to death or substantial morbidity.2 Melanomas represent about 1% of skin cancer and cause the most skin cancer deaths.3 An estimated 7,650 Americans will die from melanoma in 2022.4

Melanoma is nearly 40 times more common in White persons than in Black persons.5 However, persons of color are often diagnosed at later stages when skin cancer is more difficult to treat.6 Several factors may contribute to these disparities, including differences in risk factors, access to care, and clinical presentation.7,8

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The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient, and the balance of benefits and harms for visual skin examination by a clinician to screen for skin cancer in asymptomatic adolescents and adults cannot be determined.

Go to the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.9

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Patient Population Under Consideration

This recommendation applies to asymptomatic adolescents and adults who do not have a history of premalignant or malignant skin lesions. It does not apply to patients who present with a suspicious skin lesion or who are already under surveillance because of a high risk of skin cancer, such as those with a familial syndrome (e.g., familial atypical mole and melanoma syndrome).

Definitions

Keratinocyte carcinoma, previously referred to as nonmelanoma skin cancer, consists of basal and squamous cell carcinomas.2

Screening Tests

A visual skin examination is the most commonly proposed method for skin cancer screening and includes a survey of the body for skin lesions. A common technique used by clinicians to assess a potential melanoma is the “ABCDE” rule, which looks for lesions with the following characteristics: asymmetry, border irregularity, nonuniform color, diameter greater than 6 mm, and evolution over time. Another approach for visual skin examination is the “ugly duckling” sign, in which the clinician identifies pigmented lesions that look different than other moles on the patient. Visual skin examination can be performed with either the naked eye or a magnifying device called a dermatoscope. Biopsy of a suspicious lesion is needed to definitively diagnose skin cancer.8

Treatment

Melanoma is generally treated by surgically removing the primary tumor and surrounding normal tissue, and possibly taking a biopsy of the sentinel lymph node to determine stage. Immunotherapy and targeted therapy are also used to treat advanced melanoma. There are several treatments for keratinocyte carcinoma, including surgical excision, Mohs micrographic surgery, radiation therapy, electrodessication and curettage, and photodynamic therapy, among others.8

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Skin cancer is the most commonly diagnosed cancer in the United States. Melanoma, which constitutes 1% of skin cancer, causes the most skin cancer deaths compared with keratinocyte carcinoma. An estimated 100,000 new cases of melanoma will be diagnosed in the United States in 2022, with 7,650 associated deaths. Estimated 5-year survival for melanoma ranges from 99.5% for localized stage disease to 31.9% for distant stage disease.4 Because keratinocyte carcinoma is common and usually curable, it is not monitored by cancer registries and reliable epidemiologic data are not available. There is emerging evidence that mortality data for squamous cell carcinoma may be underestimated.2,8

Exposure to ultraviolet radiation (UVR) from sun exposure, indoor tanning beds, and other UVR-emitting devices is the major environmental risk factor for skin cancer. History of frequent sunburns, older age, and male sex are associated with increased risk for skin cancer. Exposure to UVR from the use of indoor tanning beds is an important risk factor in adolescents. Incidence of melanoma is higher among White persons compared with persons of other races and ethnicities. This disparity likely reflects traits associated with increased melanoma risk such as fair skin (which is more susceptible to sunburning), light-colored eyes, and red or blond hair being more common among White persons compared with persons of other races and ethnicities. Other melanoma risk factors include higher numbers of moles on the skin (especially ones that are atypical), as well as a personal and family history of skin cancer.8

Potential Harms

Trial evidence on harms of skin cancer screening is limited. Potential harms include cosmetic harms (e.g., scarring) from diagnostic workup, psychosocial harms (e.g., worry) from the screening process, and overdiagnosis leading to overtreatment. Treatment harms vary in frequency and severity depending on treatment type. Harms tend to be infrequent and less severe for local excisional treatments, whereas systemic treatments like chemotherapy or immunotherapy have the potential for more common and severe harms.8

Current Practice

Contemporary data on clinician practice patterns related to skin cancer screening are limited. Available studies show that the majority of melanomas are detected either by the patient discovering the lesion and reporting it to their clinician or by the clinician finding it incidentally.10 In one study, survey data showed that dermatologists perform more skin examinations than family practice clinicians or internists (552 [81.3%] dermatologists vs. 333 [59.6%] family practice clinicians vs. 243 [56.4%] internists).11

Additional Tools and Resources

The Community Preventive Services Task Force recommends interventions for skin cancer prevention in child care centers; primary and middle schools; outdoor occupational, recreational, and tourism settings; and communities (www.thecommunityguide.org).12

The Centers for Disease Control and Prevention’s Melanoma Dashboard provides state and local data for melanoma incidence and mortality, UVR levels, and other risk factors. These geographic-specific data can help communities better meet their unique melanoma prevention needs (https://ephtracking.cdc.gov/Applications/melanomadashboard).13

Other Related USPSTF Recommendations

In a separate recommendation, the USPSTF recommends counseling all young adults, adolescents, children, and parents of young children about minimizing exposure to UVR for persons ages 6 months to 24 years with a fair skin type to reduce their risk of skin cancer (B recommendation), and selectively offering counseling (based on risk factors) to adults older than age 24 years with a fair skin type (C recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults about skin self-examination for skin cancer prevention (I statement).14

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Scope of Review

The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for skin cancer in asymptomatic adolescents and adults.8 The review included evidence for both keratinocyte carcinoma and cutaneous melanoma. The USPSTF used foundational evidence from previous reviews to assess diagnostic accuracy of visual skin examination by a clinician for detecting skin cancer.

Accuracy of Screening Tests and Risk Assessment

Based on foundational evidence, the sensitivity of visual skin examination by a clinician (e.g., primary care clinician, dermatologist, or plastic surgeon) in detecting melanoma ranged from 40% to 70%, and specificity ranged from 86% to 98%. Evidence evaluating the diagnostic accuracy of visual skin examination to detect keratinocyte carcinoma was limited and inconsistent.15 No new studies from the current review reported diagnostic accuracy for an asymptomatic screening population.8

Benefits of Early Detection and Treatment

The USPSTF reviewed three ecological studies evaluating two skin cancer screening programs in Germany. One fair-quality study (SCREEN; n=360,288 screened) included in the previous review measured melanoma mortality in one region of Germany after implementing a population-based skin cancer screening program. The screening program consisted of clinician education and training, a public awareness campaign, and clinical skin examinations for 1 year. At the 5-year followup, melanoma mortality declined 49% in the screening region compared with surrounding areas without a screening program. However, this mortality benefit attenuated at the 10-year followup, with melanoma mortality returning back to similar rates as at program initiation.16,17

Following the initial positive outcomes from the SCREEN trial, Germany implemented a nationwide routine skin cancer screening program covered by statutory health insurance. This program included provider education and free total skin examinations every 2 years by either a participating primary care clinician or dermatologist. One fair-quality study (n not reported) compared melanoma mortality between Germany and 22 other European countries and found that the annual melanoma mortality rate increased, not decreased, prior to and after implementation of the German national screening program. The mean unadjusted melanoma mortality rate per 100,000 population in Germany increased from 2.7 deaths to 3.4 deaths after initiation of the national screening program. Melanoma mortality rates increased in other European countries throughout the same time period but not as much as in Germany. These data suggested that there is no observable melanoma mortality benefit from a national skin cancer screening program.16

Another nonrandomized but good-quality study (n=1,431,327) from the German national skin cancer screening program found a higher proportion of melanoma deaths in the unscreened group compared with the screened group during a 4-year observation period (171 deaths [9.5% of the screened group] vs. 154 deaths [22.8% of the unscreened group]; unadjusted hazard ratio, 0.37; p<0.05). However, this difference was attenuated on multivariate analysis and after adjustment for lead time bias.18

The ecological and nonrandomized design of the German screening studies limits the conclusions that can be drawn about the effectiveness of clinical skin cancer screening on melanoma mortality. No included studies reported outcomes for keratinocyte carcinoma mortality or all-cause mortality. The applicability to U.S. settings is also difficult to assess because the population diversity and healthcare delivery in the United States differs from the characteristics in available studies.8

Given the limitations in studies evaluating the direct effect of skin cancer screening on mortality, the USPSTF reviewed evidence for an indirect pathway that evaluated if screening is associated with earlier detection of skin cancer or precancerous lesions, and whether earlier detection reduces melanoma and all-cause mortality. The USPSTF reviewed six nonrandomized observational studies (n= 2,947,595) assessing the effectiveness of skin cancer screening on earlier detection (measured by cancer stage or lesion thickness). Results were either inconsistent or showed no association between routine clinician skin examination and increased detection of keratinocyte carcinoma, melanoma, or skin cancer precursor lesions compared with usual care or lesion-directed examination.8

The USPSTF reviewed nine nonrandomized studies (n=1,326,051) assessing the association between stage at diagnosis and melanoma or all-cause mortality. Results showed that there is a strong, consistent positive association between advancing stage at melanoma detection and increasing melanoma and all-cause mortality risk.8 For example, one good-quality U.S.-based study (n=185,219) showed that compared with in situ disease at detection, the adjusted hazard ratios for melanoma mortality were 5.8 (95% CI, 5.3 to 6.3) for localized stage, 31.5 (95% CI, 28.9 to 34.2) for regional stage, and 169.6 (95% CI, 154.2 to 186.6) for distant stage. Regarding all-cause mortality, the same pattern was observed; the adjusted hazard ratios for all-cause mortality was 1.5 (95% CI, 1.5 to 1.5) for localized stage, 3.9 (95% CI, 3.8 to 4.1) for regional stage, and 15.8 (95% CI, 14.9 to 16.7) for distant stage, compared with in situ melanoma at detection.19 U.S.-based studies also showed higher melanoma mortality risk at all stages among men compared with women, and at stage 1 among Black, Asian American, Native American, and Hispanic adults compared with White adults. No evidence was available assessing the association between stage at keratinocyte carcinoma detection and skin cancer or all-cause mortality.8

Harms of Screening and/or Treatment

The USPSTF reviewed two small fair-quality nonrandomized studies evaluating the harms of skin cancer screening. A fair-quality study (n=45) in Germany described patient-reported cosmetic acceptance of deep shave excisions after 6 months. Patients judged 7% of shave sites as having poor cosmetic outcomes.20 A fair-quality U.S.-based study (n=187) used various scales to estimate patient-reported psychological harms (e.g., anxiety, depression, and physical and social consequences) and health-related quality of life at 5 and 8 months after screening with visual examination and subsequent diagnostic biopsy as indicated. Scores in both the screened and unscreened groups were within the normal range on all measures, indicating there were no significant psychological effects.21,22

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Studies are needed that provide the following information.

  • Consistent data showing the effects of screening on morbidity and mortality or early detection of skin cancer, particularly melanoma.
  • Morbidity and mortality outcomes in participants reflective of a U.S. population with a diversity of skin tones.
  • The effectiveness of screening in primary care settings applicable to U.S. healthcare delivery where access to care varies.
  • Clearer descriptions of skin color and inclusion of a full spectrum of skin colors in study participants.
  • The effectiveness of screening for reducing morbidity and mortality of acral lentiginous melanoma, which is more commonly diagnosed in darker-skinned persons.
  • Validated risk assessment tools to identify persons at highest risk for skin cancer and who might benefit from screening.
  • The impact of social determinants of health (e.g., outdoor occupational exposure, geographic exposure differences, and access to quality care) on skin cancer risk, prevention, screening, and treatment.
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Currently, no professional organizations in the United States recommend clinical visual examination for skin cancer screening. Although the American Academy of Dermatology does not have formal guidelines on clinician-performed skin cancer screening, it does encourage and provide resources for its clinician members to hold free skin cancer screening events for the public.8,23

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  1. Centers for Disease Control and Prevention. Skin Cancer. Last reviewed April 18, 2022. Accessed September 22, 2022. https://www.cdc.gov/cancer/skin/index.htm
  2. American Society of Clinical Oncology. Skin Cancer (Non-Melanoma): Introduction. Published 2022. Accessed September 22, 2022. https://www.cancer.net/cancer-types/skin-cancer-non-melanoma/introduction  
  3. American Cancer Society. Key Statistics for Melanoma Skin Cancer. Last Revised January 12, 2022. Accessed September 22, 2022. https://www.cancer.org/cancer/melanoma-skin-cancer/about/key-statistics.html  
  4. National Cancer Institute; Surveillance, Epidemiology and End Results Program. Cancer Stat Facts: Melanoma of the Skin. Accessed September 22, 2022. https://seer.cancer.gov/statfacts/html/melan.html  
  5. National Cancer Institute; Surveillance, Epidemiology and End Results Program. SEER*Explorer. Recent Trends in SEER Age-Adjusted Incidence Rates, 2000-2019. Accessed September 22, 2022. https://seer.cancer.gov/explorer/application.html?site=53&data_type=1&graph_type=2&compareBy=age_range&chk_age_range_1=1&chk_age_range_9=9&chk_age_range_141=141&chk_age_range_157=157&rate_type=2&sex=2&race=1&stage=101&advopt_precision=1&advopt_show_ci=on&advopt_display=2
  6. American Academy of Dermatology Association. Skin Cancer: Incidence Rates. Accessed September 22, 2022. https://www.aad.org/media/stats-skin-cancer
  7. American Cancer Society. Risk Factors for Melanoma Skin Cancer. Accessed September 22, 2022. https://www.cancer.org/cancer/melanoma-skin-cancer/causes-risks-prevention/risk-factors.html
  8. Henrikson NB, Ivlev I, Blasi PR, Nguyen M, Senger CA, Perdue, LA, Lin JS. Screening for Skin Cancer: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 225. AHRQ Publication No. 22-05297-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2022.
  9. U.S. Preventive Services Task Force. Procedure Manual. Updated August 2022. Accessed September 22, 2022. www.uspreventiveservicestaskforce.org/uspstf/procedure-manual
  10. Epstein DS, Lange JR, Gruber SB, Mofid M, Koch SE. Is physician detection associated with thinner melanomas? JAMA. 1999;281(7):640-643.

  11. Oliveria SA, Heneghan MK, Cushman LF, Ughetta EA, Halpern AC. Skin cancer screening by dermatologists, family practitioners, and internists: barriers and facilitating factors. Arch Dermatol. 2011;147(1):39-44.
  12. Community Preventive Services Task Force. The Community Guide. Accesssed September 22, 2022. www.thecommunityguide.org
  13. Centers for Disease Control and Prevention. Melanoma Dashboard. Accessed September 22, 2022. https://ephtracking.cdc.gov/Applications/melanomadashboard
  14. US Preventive Services Task Force. Behavioral counseling to prevent skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(11):1134-1142.
  15. US Preventive Services Task Force. Screening for skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(4):429-435.
  16. Kaiser M, Schiller J, Schreckenberger C. The effectiveness of a population-based skin cancer screening program: evidence from Germany. Eur J Health Econ. 2018;19(3):355-367.
  17. Katalinic A, Eisemann N, Waldmann A. Skin cancer screening in Germany. Documenting melanoma incidence and mortality from 2008 to 2013. Dtsch Arztebl Int. 2015;112(38):629-634.
  18. Datzmann T, Schoffer O, Meier F, Seidler A, Schmitt J. Are patients benefiting from participation in the German skin cancer screening programme? A large cohort study based on administrative data. Br J Dermatol. 2022;186(1):69-77.
  19. Ward-Peterson M, Acuña JM, Alkhalifah MK, et al. Association between race/ethnicity and survival of melanoma patients in the United States over 3 decades. Medicine (Baltimore). 2016;95(17):e3315.
  20. Gambichler T, Senger E, Rapp S, Alamouti D, Altmeyer P, Hoffmann K. Deep shave excision of macular melanocytic nevi with the razor blade biopsy technique. Dermatol Surg. 2000;26(7):662-666.
  21. Matthews NH, Risica PM, Ferris LK, et al. Psychosocial impact of skin biopsies in the setting of melanoma screening: a cross-sectional survey. Br J Dermatol. 2019;180(3):664-665.
  22. Risica PM, Matthews NH, Dionne L, et al. Psychosocial consequences of skin cancer screening. Prev Med Rep. 2018;10:310-316.
  23. American Academy of Dermatology Association. Free Skin Cancer Screenings. Accessed September 22, 2022. https://www.aad.org/public/public-health/skin-cancer-screenings

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Rationale Assessment
Detection The USPSTF found adequate foundational evidence that visual skin examination by a clinician has modest sensitivity and specificity for detecting melanoma. However, skin cancer has primarily been studied in persons with fair skin, so the evidence may not be applicable to all skin colors. Evidence is limited regarding the accuracy of the clinical visual skin examination for detecting keratinocyte carcinoma.
Benefits of early detection and intervention and treatment The USPSTF found inadequate evidence that screening for skin cancer through visual skin examination by a clinician reduces morbidity or mortality.
Harms of early detection and intervention and treatment The USPSTF found inadequate evidence of the harms of skin cancer screening and diagnostic followup.

USPSTF assessment

Due to a lack of available data applicable to a U.S. population, the USPSTF found that evidence is insufficient, and the balance of benefits and harms for visual skin examination by a clinician to screen for skin cancer in asymptomatic adolescents and adults cannot be determined.

Abbreviation: USPSTF=U.S. Preventive Services Task Force

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