What Can We Do to Promote Skin Cancer Awareness?

May is Skin Cancer Awareness Month. Guest blogger R. Logan Jones, MD writes about what physicians and other healthcare providers can do to properly educate patients about skin cancer prevention. 

There are many great things about spring. The world is waking up from the slumber of winter, the flowers are blooming, and the sun is shining longer and longer. The month of May – in addition to being home for National Sea Monkey day and National Chicken Dance Day – is also National Skin Cancer Awareness Month. Just in time, too, as many people in the United States start to spend more and more time outdoors in the warm sunshine.

Skin cancer is a big deal. First and foremost, skin cancers are the most commonly diagnosed cancers in the United States. One in five Americans will develop skin cancer during their lives¹, and the annual cost of treating skin cancers in the United States is estimated at $8.1 billion: about $4.8 billion for nonmelanoma skin cancers and $3.3 billion for melanoma.² Of the three general categories of skin cancer, basal cell carcinoma (BCC) is the most common type and affects around 3 million people each year in the United States.³ The next most common skin cancer, squamous cell carcinoma (SCC), is diagnosed and treated in approximately 1 million Americans annually – not including the 58 million individuals with the precancerous lesion actinic keratosis.³ The third category, melanoma, may not be as prevalent as BCC or SCC, but it carries a much more serious prognosis. Approximately 85,000 new cases of invasive melanoma are diagnosed each year in the United States, and this number is growing. An estimated 9,730 people in the United States will die in 2017 from melanoma – about one person each hour.⁴

As clinicians, what can and should we be doing to promote our patients’ integumentary health? In July 2016, the United States Preventative Services Task Force (USPSTF) updated its recommendation on screening for skin cancer. Ultimately, their analysis of the data was INCONCLUSIVE that the benefits of routine clinician screening outweighed the potential harms resulting from screening asymptomatic adults without a high risk for skin cancer or a personal history of a premalignant or malignant skin lesions.⁵ One of the most robust sources that the USPSTF cited was the Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany (SCREEN) study. The SCREEN study was a fair-quality ecologic study but had poor participation, with a screening penetration rate of only 19% in the target population in Germany. This study indicated that the screening intervention would, at most, result in 1 less death due to melanoma per 100,000 persons over a decade,⁶ hardly a strong case for routine asymptomatic screening. Nevertheless, this recommendation applies only to asymptomatic screening, so should a patient present with concerns over a skin lesion, don’t forget your ABCs (or ABCDEs): asymmetry, border irregularity, nonuniform color, diameter greater than 6 mm, and evolving over time.

Without asymptomatic clinical visual screening, clinicians must rely on patient counseling to help them mitigate their skin cancer risks. The USPSTF recommends that persons aged 10-24 years with fair skin be counseled about minimizing exposure to UV radiation.⁵ One of the greatest risks observed is from indoor tanning – those who have ever tanned indoors have a 67% increased risk of developing SCC and a 29% of BCC;⁷ indoor tanning before the age of 35 increases risk for melanoma by 75%.⁸ While indoor tanning has tremendous risk for cutaneous cancers, UV radiation from the sun is also a concern for genomic damage. Surprisingly, research has indicated that chronic low-dose exposure to solar UV radiation does not seem to increase the risk of melanoma; it may even be somewhat protective.⁹ Evidence suggests that the largest risk for melanoma lies in acute UV radiation exposure that leads to sunburns. This should be cause for concern for clinicians offering advice, as most people in the United States obtain their UV radiation in bursts during the summer when the risk for sunburns are highest. Further, most of the evidence that sunscreen helps prevent cutaneous melanoma has only been demonstrated in daily use of sunscreen, not intermittent use.¹⁰

Thus, in the spirit of National Skin Cancer Awareness Month, consider the following skin cancer prevention tips as you and your patients enjoy the springtime sunshine.

Skin Cancer Prevention Recommendations

• Use a broad-spectrum UVA/UVB sunscreen EVERY DAY – SPF 15 or higher
• Avoid tanning and UV tanning beds
• Seek shade – especially between 10 AM and 4 PM
• Cover up – with clothing, a broad-brimmed hat, and UV-blocking sunglasses
• For fun in the sun, use water-resistant SPF 30 or higher sunscreen – apply this 30 minutes before going outside, and reapply every 2 hours or immediately after swimming or sweating
• DO NOT use sunscreen to prolong time spent in the sun – this increases the risk of sunburns, and sunscreen should not be considered a substitute for clothing or hats
• Perform self-skin checks – aim for monthly and head-to-toe
• Keep newborns out of the sun – infants older than six months should use sunscreen
• DO NOT BURN – if skin becomes uncomfortable or red, get out of the sun immediately to reduce the risk of sunburn

1. Robinson JK. Sun exposure, sun protection, and vitamin D. JAMA. 2005;294(12):1541-1543. [PubMed]
2. Guy GP Jr, Machlin SR, Ekwueme DU, Yabroff KR. Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med. 2015;48(2): 183-187. [PubMed]
3. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the US population, 2012. JAMA Dermatol. 2015;151(10):1081-1086. [PubMed]
4. American Cancer Society. Cancer Facts & Figures 2017. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2017/cancer-facts-and-figures-2017.pdf. Accessed May 4, 2017.
5. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for skin cancer: US Preventative Services Task Force Recommendation Statement. JAMA. 2016;316(4):429-435. [PubMed]
6. Katalinic A, Waldmann A, Weinstock MA, et al. Does skin cancer screening save lives?: an observational study comparing trends in melanoma mortality in regions with and without screening. Cancer. 2012;118(21):5395-5402. [PubMed]
7. Colantonio S, Bracken MB, Beecker, J. The association of indoor tanning and melanoma in adults: systematic review and meta-analysis. J Am Acad Dermatol. 2014;70(5):847-857.e1-18. [PubMed]
8. International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer. 2007;120(5):1116-1122. [PubMed]
9. Radespiel-Tröger M, Meyer M, Pfahlberg A, Lausen B, Gefeller O. Outdoor work and skin cancer incidence: a registry-based study in Bavaria. Int Arch Occup Environ Health. 2009;82(3):357-363. [PubMed]
10. Planta MB. Sunscreen and melanoma: is our prevention message correct? J Am Board Fam Med. 2011;24(6):735-739. [PubMed]
11. Skin Cancer Foundation. Prevention guidelines. http://www.skincancer.org/prevention/sun-protection/prevention-guidelines. Accessed May 9, 2017.

About the Author

R. Logan Jones recently graduated with his MD from the University of Nebraska Medical Center in Omaha, NE and will be starting his Internal Medicine residency at Oregon Health & Science University this summer in Portland, OR. He has a strong interest in medical education, healthcare policy, and health informatics and has served in many committee and leadership positions to explore those passions. Logan also has a strong interest in Antimicrobial Stewardship and plans on pursuing a career in Infectious Diseases. He enjoys spending his free time cooking, maintaining his wellness through exercise and yoga, and listening to NPR and his favorite podcasts.