Cutaneous malignancies are not only the most common malignancy in the world, but the incidence of both melanoma and non-melanoma skin cancers (NMSCs) have continued to rise in an unabated fashion for the last few decades.^1-3 In Australia, they have seen a tripling in incidence of NMSC over the last twenty years, while in the United States, melanoma incidence has increased by nearly 200% over the past four decades, and looks to double 2010 levels by 2030. ^4-7 Furthermore, national treatment costs for skin cancer have also risen substantially, with an average treatment cost of $8.1 billion each year, for the 5 million adults being treated annually in the U.S. ⁶

While clearly a major public health problem, in the U.S. the US Preventive Services Task Force has recommended against skin screening for the general population. ⁸ They cite insufficient evidence that early detection of skin cancer through visual skin examination by a clinician reduces morbidity and mortality as well as insufficient data regarding the potential magnitude of the harms of early detection. ⁹ This was substantiated by a recent Cochrane systematic review, supporting the conclusion that general population screening (specifically for melanoma) was not supported by current evidence, ¹⁰ and underscores the challenge of conducting a randomized control trial assessing the implementation of a skin screening program.

Screening for skin cancers is arguably the safest, easiest, and most cost-effective screening test in medicine, and involves a total body skin examination (TBSE) with inspection of the entire skin surface, including the scalp, hair, and nails.^11,12  However, it is not usually part of the general physical exam performed by primary care providers (PCP)s or non-dermatology specialists. ¹³ In fact, a review of the National Health Interview Survey data suggested only 8% of patients who were seen by a PCP or obstetrician in the last 12 months had received a skin exam, and only 24% of “high-risk” individuals reported having undergone a TBSE at least once in their lifetime. ^14-5 While the reason for this may be partially due to time constraints, greater emphasis on skin cancer screening education within medical schools and continued medical education courses may address some of these gaps.

This was demonstrated in a study at the University of Pittsburgh, whereby combining a campaign promoting annual skin cancer screening, training of PCPs, with electronic health record prompting  facilitated the identification of thinner melanomas in the screened cohort compared with an unscreened cohort. ¹⁶ Whether population-level screening leads to improved survival remains controversial. Most notably, in 2003-2004, the Skin Cancer Research to provide Evidence for Effectiveness of Screening in North Germany enrolled 19% of eligible citizens in Schleswig-Holstein with TBSE.¹⁷ While initial reports suggested a decline in mortality compared with adjacent non-screened regions,¹⁸ when skin screening was extended to the rest of Germany in 2008, melanoma mortality in Germany did not differ with those of surrounding countries, and melanoma mortality rates in Schleswig-Holstein returned to pre-screening rates as well. ¹⁹ Multiple non-randomized or controlled trials and case-control studies have also demonstrated reduced melanoma thickness in screened populations, despite lack of differences in survival. ^20-3

Currently, Germany is the only country that offers whole-population skin cancer screening for adults over the age of 35 years every two years, and more frequently for higher-risk patients.²⁴ Other countries, including Australia, New Zealand, Netherlands, and the UK recommend screening subsets of high-risk patients, though definitions vary. ²⁵  Taking all this together, the Melanoma Prevention Working Group, consisting of a diverse group of melanoma experts, developed data-driven recommendations for which patients should undergo annual skin cancer screening (TABLE 1).

Table 1: Melanoma Prevention Working Group’s Recommended 2017 Guidelines in Response to the 2016 USPSTF Findings

While up to 85% of skin cancers occur in the head and neck region,²⁶ as Head and Neck Surgeons, our involvement typically resides in locally advanced skin cancers, or those requiring regional disease management. As a result, patients who we encounter are likely to be at higher risk for developing new skin cancers and ongoing skin cancer screening is paramount in their surveillance. Being attentive to patient risk factors and incorporating a comprehensive head and neck skin exam to our practice may aid this burgeoning health care problem.

Lastly, new technologies are emerging to aid both patients and health practitioners improve diagnostic accuracy. Firstly, with dermoscopy (epiluminescene microscopy), users can study microscopic skin structures that are illuminated from noninvasive polarized light that can penetrate up to 1mm of the superficial epidermis and superficial dermis. In skilled hands, this has been shown to improve their sensitivity in melanoma diagnosis.²⁷  Several companies have developed software based on dermoscopic images to follow skin lesions over time.²⁸ Artificial intelligence systems have also emerged as another adjunct to improving diagnostic accuracy, with a convolutional neural network trained on over 129,000 images matching the performance of experienced dermatologists. ²⁹

IN CONCLUSION:

• Melanoma and non-melanoma skin cancers represent a burgeoning public health problem with continued increasing incidence.
• Skin cancer screening has been demonstrated to identify skin cancers at earlier stages, but not found to have a mortality benefit. Currently, there is insufficient evidence for skin cancer screening in the general population. However, patients with high risk features (Table 1) may benefit.
• Head and neck skin cancer patients are at higher risk for developing additional skin cancers and should be offered total body skin examinations by either their PCP or dermatology.

REFERENCES:

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• Cutaneous malignancies: melanoma and nonmelanoma types. Netscher DT, Leong M, Orengo I, Yang D, et al. Plast Reconstr Surg. 2011; 127(3): 37-56e.
• Glazer AM, Winkelymann RR, Farberg AS, Rigel DS. Analysis of trends in US melanoma incidence and mortality. JAMA Dermatol. 2017; 153:225-6.
• Staples MP, et al. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985. Med J Aust. 2006; 184:6-10.
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• National Cancer Institute Surveillance, Epidemiology, and End Results Program. SEER Stat Fact Sheets: Melanoma of the Skin. http://seer.cancer.gov/statfacts/html/melan.html
• Rahib L, Smith BD, Aizenberg R, Rosenzweigh AB, et al. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver and pancreas cancers in the United States. Cancer Res. 2014; 74(11):2913-21.
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• US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et a. Screening for skin cancers: US Preventive Services Task Force recommendation statement. JAMA. 2016; 316: 429-35.
• Johansson M, Brodersen J, Gotzsche PC, Jorgensen KJ. Screening for reducing morbidity and mortality in malignant melanoma. Cochrane Database of Systematic Reviews. 2019 (6): CD012352. DOI: 10.1002/14651858.CD012352.pub2
• Losina E, Walensky RP, Geller A, et al. Visual screening for malignant melanoma: a cost-effectiveness analysis. Arch Dermatol. 2007; 143(1):21-8
• American Academy of Dermatology. Learning module: the skin exam. https://aad.org/education/basic-derm-curriculum/suggested-order-of-modules/the-skin-exam
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• Boniol M, Autier P, Gandini S. Melanoma mortality following skin cancer screening in Germany. BMJ open. 2015; 5:e008158.
• Schenider Js, Moore DH 2^nd, Mendelsohn ML. Screening program reduced melanoma morality at the Lawrence Livermore National Laboratory, 1984 to 1996. J Am Acad Dermatol. 2008; 58:741-9.
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• Aitken JF, Elwood M, Baade PD, et al. Clinical whole-body skin examination reduces the incidence of thick melanomas. In J cancer. 2010; 126:450-8.
• Kovalyshyn I, Dusza SW, et al. The impact of physician screening on melanoma detection. Arch Dermatol. 2011; 147:1269-75.
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• Johnson MM, Leachman SA, Cranmer LD, et al. Skin cancer screening: recommendations for data-driven screening guidelines and a review of the US Preventive Services Task Force controversy. Melanoma Manag. 2017; 4(1):13-37.
• Staples MP, et al. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985. Med J Aust. 2006; 184:6-10.
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• Del Rosario F, Farahi JM, Drendel J, et al. Performance of a computer-aided digital dermoscopic image analyzer for melanoma detection in 1,076 pigmented skin lesion biopsies. J Am Acad Dermatol. 2018; 78 (5): 927-34.
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Christopher Yao, MD FRCSC

Christopher MKL Yao, MD, FRCSC is an Assistant Professor in the Division of Head and Neck Surgery at Fox Chase Cancer Center. He completed his medical school and Otolaryngology residency program at the University of Toronto, followed by a two-year Head and Neck Surgical Oncology and Microvascular Reconstruction fellowship at the University of Texas MD Anderson Cancer Center. His research interests primarily focus on clinical outcomes, and quality of care in head and neck, skin and thyroid cancers.

Latest posts by Christopher Yao, MD FRCSC (see all)

• What is the current role for screening for Skin Cancers? - May 31, 2021