PracticalDermatology

The United States Preventive Services Task Force (USPSTF) has once again waded into issues of skin cancer counseling and screening and once again drawn criticism from dermatologists. Their latest recommendations—for primary care practice—are puzzling. They may be particularly mystifying if not considered in context.

The Messenger

USPSTF recommendations periodically garner the attention of dermatologists. The group’s recommendations tend to be widely reported in the media and may influence perceptions and behaviors. It bears noting, however, that despite its official sounding name, USPSTF does not make recommendations on behalf of the US government. As the organization website states, recommendations, “should not be construed as an official position of the Agency for Healthcare Research and Quality or the US Department of Health and Human Services.” Additionally, the Task Force states that it does not consider the costs of preventive service in determining recommendation grades. Nonetheless, it is conceivable that government payors and independent insurers could point to USPSTF recommendations to justify non-payment for services that the task force deems unnecessary or minimally beneficial.

USPSTF was created in1984, “as an independent, volunteer panel of national experts in prevention and evidence-based medicine.” The Task Force says its mission is to make “evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.” The Taskforce recommendations (See Grading Scale, next page) are in no way binding, nor have they been suggested to establish standards of care.

Task Force recommendations tend to be directed to primary care. At times, the nuance of recommendation audience has shed light on the recommendations themselves. As previously addressed in this column, USPSTF has recommended against routine skin exams by primary care physicians. The data showing benefit for such exams by PCPs are not as robust as those for dermatologists, which influenced the Task Force determination. The current recommendations on behavioral counseling for skin cancer are also directed at PCPs. This may bear on the Task Force recommendation regarding skin self-examination, as addressed below.

The Recommendations

The Task Force determined that evidence is insufficient to assess the balance of benefits and harms of PCPs routinely recommending skin self-exams to adults. The “I” rating indicates that “Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.” Although the USPSTF notes that counseling adults about performing skin self-exams appears to result in an increase in such exams (most dermatologists would argue this is good), the group suggests that there is no evidence of incremental benefit that might occur from skin self-examinations above the benefit from skin-protective behaviors or skin exams by physicians.

Evidence shows that dermatologists as specialists are more adept at spotting likely skin cancers than PCPs, which makes sense given our training and clinical experience. However, we also see referrals from PCPs for assessment of suspicious lesions that, in very many cases, may warrant biopsy or surveillance. Furthermore, it seems misguided to assume that if PCPs cannot assess lesions with the same specificity and sensitivity as dermatologists that they also cannot advise patients on identifying suspicious lesions that should be evaluated by a physician—preferably a dermatologist. The ABCDE guidelines are fairly straightforward and well-vetted. Especially in light of the emphasis on E for evolution, PCPs should be equipped to efficiently educate patients on what to look for during self-examinations.

Were the Task Force to argue that patients might over-rely on self-exam to the point of missing out on a professional diagnosis, one might concede the point. However, the Task Force ultimately seems to suggest the opposite. They write that a downside of self-exams is the fact that exams may lead to biopsy, which itself has associated risks. “If skin self-examination leads to biopsy, procedural harms such as pain, bleeding, scarring, or infection could occur,” the Task Force states.

While it is certainly true that there are risks associated with skin biopsy, these risks are quite low in dermatology practice and far outweigh the risks of undiagnosed skin cancers.

Clearly, not every lesion brought to the attention of a physician requires biopsy. The Task Force seems to disregard the fact that patients who find suspicious lesions during self-exam must then present to a physician to assess that lesion and determine the need to biopsy. Hopefully, that physician will be a dermatologist. Additionally, the recommendation makes no allowance for non-invasive assessment tools, such as dermatoscopes, or the role of photo surveillance, which reduce the need for unnecessary biopsies.

The Task Force rightly notes that self-exams could lead to, “psychosocial harms, such as anxiety or cancer worry.” This is certainly a risk, and may depend greatly on individual patient personalities, but a physician can effectively counsel patients that the goal of self-exam is to identify skin cancers early, when the chance for cure is very good and much higher than for many other cancers.

To Be Fair

The USPSTF gives a grade B recommendation in favor of “counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons aged six months to 24 years with fair skin types to reduce their risk of skin cancer.” At first glance, this seems reasonable, but why limit the recommendation based on skin type?

The Task Force provides a “C” recommendation regarding whether “clinicians selectively offer counseling to adults older than 24 years with fair skin types about minimizing their exposure to UV radiation to reduce risk of skin cancer.” They note that, “existing evidence indicates that the net benefit of counseling all adults older than 24 years is small.”

Certainly, patients with fair skin are at higher risk for developing skin cancers, but to limit counseling to fair-skinned adults seems absurd. The time and energy needed to educate patients about UV avoidance is minimal within the context of a primary care visit.

Absent from the USPSTF recommendations is consideration of other, well-established risk factors for developing skin cancer. High risk factors include a family history of skin cancer, presence of atypical moles, and multiple blistering sun burns—especially before adulthood. Individuals with these risk factors should surely be examined on a consistent basis for the presence of new or changing lesions. If they cannot see a dermatologist directly, the PCP is an important partner in their assessment and, if needed, referral.

More concerning than the recommendations is the discussion of potential harm attributed to screenings. The USPSTF writes:

Potential harms of interventions promoting sun protection behaviors include skin reactions to sunscreen lotion, vitamin D deficiency, reduced physical activity due to avoiding the outdoors, and a paradoxical increase in sun exposure from a false reassurance of protection from sunscreen use.

Dermatologists have for years been fighting these very misconceptions in the lay public. All the while, our peers in the medical community apparently require similar education.

Without diving into all the available data, it is worth noting that, while patients can develop allergic contact dermatitis to sunscreens, there exists on the market such a breadth of formulations and sunscreening chemicals that any patient should be able to find and use a formulation that will not cause a reaction.

Vitamin D concerns have been addressed multiple times in multiple venues. No sunscreen completely blocks UV. Patients can surely acquire sufficient UV exposure to synthesize vitamin D while still practicing UV safety. Additionally, vitamin D supplements are widely available.

The issue of “paradoxical increase in sun exposure” seems to be in itself clear evidence of the need for better and more widespread patient counseling.

Plus, does the recommendation to counsel only fair-skinned adults not potentially support a “paradoxical increase in sun exposure” among patients with darker skin? Patient with lighter skin types may have a higher risk for developing skin cancer, but patients with darker skin tones are shown to have worse prognosis.

Advice of Counsel

Skin cancer is at epidemic proportions. Dermatologists are the specialists best trained to diagnose and treat the condition. The USPSTF recommendations do not assess, nor do they weigh on, our ability as specialists to educate and counsel patients about UV avoidance and conduct of skin self-exams.

There are only about 11,000 dermatologists in the US, compared to more than 200,000 PCPs. Clearly, dermatologists cannot and will not be the first line of identification of all suspicious lesions. Patients must take an active role in protecting their skin and in identifying suspicious lesions as early as possible to optimize the likelihood of effective treatment.

PCPs are in the best position to educate the most patients about UV exposure risks, safe UV practices, and the conduct of skin self-examinations. Given that there may be miseducation and misunderstanding in the public, patients are at increased need for education about sunscreen selection and use, as well as its role within a broader UV safety strategy.

Dermatologists can collaborate with our peers in primary care to help them augment their care in this regard. The AAD for its part offers public education that also helps to support healthy behaviors among all Americans.