Skin Cancer Screening (PDQ®)–Health Professional Version

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Overview

Note: Separate PDQ summaries on Skin Cancer Prevention, Skin Cancer Treatment, Genetics of Skin Cancer, and Levels of Evidence for Cancer Screening and Prevention Studies are also available.

Interventions

The only widely proposed screening procedure for skin cancer is visual examination of the skin, including both self-examination and clinical examination.

Benefits

The evidence is inadequate to determine whether visual examination of the skin in asymptomatic individuals leads to a reduction in mortality from melanomatous skin cancer. Further, in asymptomatic populations, the effect of visual skin examination on mortality from nonmelanomatous skin cancers is unknown.

Magnitude of Effect: Unknown.

  • Study Design: Direct evidence limited to a single ecologic study.
  • Internal Validity: Poor.
  • Consistency: N/A.
  • External Validity: Poor.

Harms

Based on fair, though unquantified evidence, visual examination of the skin in asymptomatic individuals may lead to adverse consequences. These include complications of diagnostic or treatment interventions (such as poor cosmetic or functional outcomes) and the psychological effects of being labeled with a potentially fatal disease. Other harmful consequences are overdiagnosis, leading to the detection of biologically benign disease that would otherwise go undetected, and the possibility of misdiagnosis of a benign lesion as malignant.

Magnitude of Effect: Unknown.

  • Study Design: Case series, ecologic studies.
  • Internal Validity: Fair.
  • Consistency: Fair.
  • External Validity: Fair.

Description of the Evidence

Background

Incidence and mortality

There are three main types of skin cancer:

  • Basal cell carcinoma.
  • Squamous cell carcinoma (together with basal cell carcinoma, this is referred to as nonmelanoma skin cancer).
  • Melanoma.

Basal cell carcinoma and squamous cell carcinoma are the most common forms of skin cancer but have substantially better prognoses than the less common, generally more aggressive melanoma.

Nonmelanoma skin cancer is the most commonly occurring cancer in the United States. Its incidence appears to be increasing in some [1] but not all [2] areas of the United States. Overall U.S. incidence rates have likely been increasing for a number of years.[3] At least some of this increase may be attributable to increasing skin cancer awareness and resulting increasing investigation and biopsy of skin lesions. A precise estimate of the total number and incidence rate of nonmelanoma skin cancer is not possible, because reporting to cancer registries is not required. However, based on Medicare fee-for-service data extrapolated to the U.S. population, it has been estimated that the total number of persons treated for nonmelanoma skin cancers in 2012 was about 3,000,000.[4,5] That number would exceed all other cases of cancer estimated by the American Cancer Society for that year, which was about 1.6 million.[6]

Melanoma is a reportable cancer in U.S. cancer registries, so there are more reliable estimates of incidence than is the case with nonmelanoma skin cancers. In 2016, it is estimated that 76,380 individuals in the United States will be diagnosed with melanoma and approximately 10,130 will die of it. The incidence of melanoma has been increasing for at least 30 years; however, data over the past 5 years indicate that rates are declining or plateauing among individuals younger than 50 years.[5] From 2008 to 2012, incidence rates declined by about 3% per year in both men and women aged 20 to 29 years. In contrast, among adults aged 50 years and older, the incidence rate has increased by 2.6% per year since 1996. Mortality rates have been declining by 2.6% per year since 1986 in individuals younger than 50 years, and mortality rates have been increasing by 0.6% per year since 1990 among individuals 50 years and older.[5]

A study of skin biopsy rates in relation to melanoma incidence rates obtained from the Surveillance, Epidemiology, and End Results Program (SEER) of the National Cancer Institute indicated that much of the observed increase in incidence between 1986 and 2001 was confined to local disease and was most likely caused by overdiagnosis as a result of increased skin biopsy rates during this period.[7] Between 1998 and 2007, a 2.5% relative yearly incidence increase in melanoma among children and adolescents was observed in SEER databases.[8] During that time, the average annual incidence in this group was exceptionally low (5.4 per 1 million), which may have resulted in spurious trends. Nevertheless, similar trends have been seen in Sweden.[8] In the U.S. study of pediatric melanoma, nearly one-half of the patients had local disease (22% of patients had in situ disease and 25% of patients had superficial spreading), and nearly one-half of the patients had disease with a thickness of less than one millimeter. Given that mortality from pediatric melanoma had been fairly stable during those years,[9] it is likely that the increase in incidence could be explained, at least in part, by overdiagnosis.

Risk Factors

Epidemiologic evidence suggests that exposure to UV radiation and the sensitivity of an individual’s skin to UV radiation are risk factors for skin cancer, although the type of exposure (high-intensity and short-duration vs. chronic exposure) and pattern of exposure (continuous vs. intermittent) may differ among the three main types of skin cancer.[10-12] In addition, the immune system may play a role in pathogenesis of skin cancers. Organ-transplant recipients receiving immunosuppressive drugs are at elevated risk of skin cancers, particularly squamous cell cancers (SCC). Arsenic exposure also increases the risk of cutaneous SCC.[13,14]

The incidence of melanoma rises rapidly in Caucasians after age 20 years. Fair-skinned individuals exposed to the sun are at higher risk. Individuals with certain types of pigmented lesions (dysplastic or atypical nevi), with several large nondysplastic nevi, with many small nevi, or with moderate freckling have a twofold to threefold increased risk of developing melanoma.[15] Individuals with familial dysplastic nevus syndrome or with several dysplastic or atypical nevi are at high (>fivefold) risk of developing melanoma.[15]

Accuracy of Making a Clinical Diagnosis of Melanoma

A systematic review of 32 studies that compared the accuracy of dermatologists and primary care physicians in making a clinical diagnosis of melanoma concluded that there was no statistically significant difference in accuracy. However, the results were inconclusive, owing to small sample sizes and study design weaknesses.[16] In addition, differentiating between benign and malignant melanocytic tumors during histologic examination of biopsy specimens has been shown to be inconsistent even in the hands of experienced dermatopathologists.[17] This fact undermines results of studies examining screening effectiveness and also may undermine the effectiveness of any screening intervention. Furthermore, this suggests that requesting a second opinion regarding the pathology of biopsy specimens may be important.[17]

Evidence of Benefit Associated With Screening

More than 90% of melanomas that arise in the skin can be recognized with the naked eye. Very often there is a prolonged horizontal growth phase during which time the tumor expands centrifugally beneath the epidermis but does not invade the underlying dermis. This horizontal growth phase may provide lead time for early detection. Melanoma is more easily cured if treated before the onset of the vertical growth phase with its metastatic potential.[18]

The probability of tumor recurrence within 10 years after curative resection is less than 10% with tumors less than 1.4 mm in thickness. For patients with tumors less than 0.76 mm in thickness, the likelihood of recurrence is less than 1% in 10 years.[19]

A systematic review of skin cancer screening examined evidence available through mid-2005 and concluded that direct evidence of improved health outcomes associated with skin cancer screening is lacking.[20] An updated review published in 2016 found limited evidence that skin cancer screening reduces melanoma mortality.[21,22]

No randomized trials evaluating the efficacy of skin cancer screening on mortality have been completed. A population-based trial (using cluster randomization) to determine the effect of skin cancer screening on melanoma mortality was initiated in Queensland, Australia, but lost its funding after the initial pilot phase, and no health outcomes were ever reported.[23]

The highest level of direct evidence available is an ecologic study comparing melanoma mortality rates across different regions of northern Germany (the SCREEN study). One region that conducted a population-based skin cancer awareness campaign, clinician education and training, and one-time clinical visual screening exams was compared with four nearby regions that did not have similar interventions available.[24,25] The two-stage skin cancer screening program began with a total-body visual examination of the skin by a general practitioner; if skin cancer was suspected, the patient was re-examined by a dermatologist. Nineteen percent of all those eligible were screened. The melanoma mortality rates were decreased in the years after the screening program in the screened region (1.7 per 100,000 in 1998–1999 to 0.9 per 100,000 in 2008–2009, or about one fewer melanoma death per 100,000 screened participants), whereas the melanoma mortality rates either stayed the same or increased in the comparison regions. This study has important methodological limitations such as the lack of randomization, lack of an internal control group, and lack of individual-level data to assess outcomes, as well as a low participation rate (19%) and high loss to follow-up rate (37%). Further, an independent analysis of the SCREEN study population found that the observed modest mortality reduction did not persist with longer-term follow-up; after 5 additional years, death rates from melanoma returned to baseline rates observed before the screening intervention was initiated.[26]

Evidence of Harms Associated With Screening

Harms have not been well studied or reported in quantitative terms, but the potential for adverse consequences from skin cancer screening exists. In the SCREEN study, 4.4% of all screened participants underwent a skin excision for a suspicious lesion, but the majority of biopsies did not result in a cancer diagnosis. The detection rate was especially affected by age. One case of melanoma was detected per 28 excisions overall (for both men and women), while 52 skin excisions were required to detect one melanoma in men aged 20 to 34 years.[27]

Visual examination of the skin in asymptomatic individuals may lead to cosmetic or functional complications of diagnostic or treatment interventions and the psychological effects of being labeled with a potentially fatal disease, although robust data on the frequency of such events are lacking. Other harmful consequences are overdiagnosis, leading to the detection of biologically benign disease that would otherwise go undetected,[7] and the possibility of misdiagnosis of a benign lesion as malignant. (Refer to the Accuracy of Making a Clinical Diagnosis of Melanoma section of this summary for more information.)

References
  1. Athas WF, Hunt WC, Key CR: Changes in nonmelanoma skin cancer incidence between 1977-1978 and 1998-1999 in Northcentral New Mexico. Cancer Epidemiol Biomarkers Prev 12 (10): 1105-8, 2003. [PUBMED Abstract]
  2. Harris RB, Griffith K, Moon TE: Trends in the incidence of nonmelanoma skin cancers in southeastern Arizona, 1985-1996. J Am Acad Dermatol 45 (4): 528-36, 2001. [PUBMED Abstract]
  3. Rogers HW, Weinstock MA, Harris AR, et al.: Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 146 (3): 283-7, 2010. [PUBMED Abstract]
  4. Rogers HW, Weinstock MA, Feldman SR, et al.: Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012. JAMA Dermatol 151 (10): 1081-6, 2015. [PUBMED Abstract]
  5. American Cancer Society: Cancer Facts and Figures 2016. Atlanta, Ga: American Cancer Society, 2016. Available online. Last accessed July 11, 2016.
  6. American Cancer Society: Cancer Facts and Figures 2012. Atlanta, Ga: American Cancer Society, 2012. Available online. Last accessed July 19, 2016.
  7. Welch HG, Woloshin S, Schwartz LM: Skin biopsy rates and incidence of melanoma: population based ecological study. BMJ 331 (7515): 481, 2005. [PUBMED Abstract]
  8. Austin MT, Xing Y, Hayes-Jordan AA, et al.: Melanoma incidence rises for children and adolescents: an epidemiologic review of pediatric melanoma in the United States. J Pediatr Surg 48 (11): 2207-13, 2013. [PUBMED Abstract]
  9. Lewis KG: Trends in pediatric melanoma mortality in the United States, 1968 through 2004. Dermatol Surg 34 (2): 152-9, 2008. [PUBMED Abstract]
  10. Koh HK: Cutaneous melanoma. N Engl J Med 325 (3): 171-82, 1991. [PUBMED Abstract]
  11. Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992. [PUBMED Abstract]
  12. English DR, Armstrong BK, Kricker A, et al.: Case-control study of sun exposure and squamous cell carcinoma of the skin. Int J Cancer 77 (3): 347-53, 1998. [PUBMED Abstract]
  13. Thomas VD, Aasi SZ, Wilson LD, et al.: Cancer of the skin. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Vols. 1 & 2. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2008, pp 1863-87.
  14. Le Mire L, Hollowood K, Gray D, et al.: Melanomas in renal transplant recipients. Br J Dermatol 154 (3): 472-7, 2006. [PUBMED Abstract]
  15. Gandini S, Sera F, Cattaruzza MS, et al.: Meta-analysis of risk factors for cutaneous melanoma: I. Common and atypical naevi. Eur J Cancer 41 (1): 28-44, 2005. [PUBMED Abstract]
  16. Chen SC, Bravata DM, Weil E, et al.: A comparison of dermatologists' and primary care physicians' accuracy in diagnosing melanoma: a systematic review. Arch Dermatol 137 (12): 1627-34, 2001. [PUBMED Abstract]
  17. Farmer ER, Gonin R, Hanna MP: Discordance in the histopathologic diagnosis of melanoma and melanocytic nevi between expert pathologists. Hum Pathol 27 (6): 528-31, 1996. [PUBMED Abstract]
  18. Friedman RJ, Rigel DS, Kopf AW: Early detection of malignant melanoma: the role of physician examination and self-examination of the skin. CA Cancer J Clin 35 (3): 130-51, 1985 May-Jun. [PUBMED Abstract]
  19. Blois MS, Sagebiel RW, Abarbanel RM, et al.: Malignant melanoma of the skin. I. The association of tumor depth and type, and patient sex, age, and site with survival. Cancer 52 (7): 1330-41, 1983. [PUBMED Abstract]
  20. Wolff T, Tai E, Miller T: Screening for skin cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 150 (3): 194-8, 2009. [PUBMED Abstract]
  21. Wernli KJ, Henrikson NB, Morrison CC, et al.: Screening for Skin Cancer in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 316 (4): 436-47, 2016. [PUBMED Abstract]
  22. Bibbins-Domingo K, Grossman DC, Curry SJ, et al.: Screening for Skin Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 316 (4): 429-35, 2016. [PUBMED Abstract]
  23. Aitken JF, Elwood JM, Lowe JB, et al.: A randomised trial of population screening for melanoma. J Med Screen 9 (1): 33-7, 2002. [PUBMED Abstract]
  24. 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 118 (21): 5395-402, 2012. [PUBMED Abstract]
  25. Breitbart EW, Waldmann A, Nolte S, et al.: Systematic skin cancer screening in Northern Germany. J Am Acad Dermatol 66 (2): 201-11, 2012. [PUBMED Abstract]
  26. Boniol M, Autier P, Gandini S: Melanoma mortality following skin cancer screening in Germany. BMJ Open 5 (9): e008158, 2015. [PUBMED Abstract]
  27. Waldmann A, Nolte S, Geller AC, et al.: Frequency of excisions and yields of malignant skin tumors in a population-based screening intervention of 360,288 whole-body examinations. Arch Dermatol 148 (8): 903-10, 2012. [PUBMED Abstract]

Changes to This Summary (12/01/2016)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Overview

Revised text to describe the evidence of benefits of visual examination of the skin, including magnitude of effect, study design, and external validity.

Revised text to add poor cosmetic or functional outcomes as examples of complications of diagnostic or treatment interventions.

Revised text to describe the evidence of harms of visual examination of the skin, including study design and consistency.

Description of the Evidence

Added text to state that an updated review published in 2016 found limited evidence that skin cancer screening reduces melanoma mortality (cited Wernli et al. as reference 21 and Bibbins-Domingo et al. as reference 22).

Added text to state that no randomized trials evaluating the efficacy of skin cancer screening on mortality have been completed. Also revised text to state that a population-based trial to determine the effect of skin cancer screening on melanoma mortality was initiated in Queensland, Australia, and no health outcomes were ever reported (cited Aitken et al. as reference 23).

Added text to state that the highest level of direct evidence available is an ecologic study comparing melanoma mortality rates across different regions of northern Germany (the SCREEN study). Also revised text to describe the screening interventions provided in one region that conducted a population-based skin cancer awareness campaign from the SCREEN study. Also revised text to add that there was about one fewer melanoma death per 100,000 screened participants in the years after the screening program in the screened region. Also revised text to add that low participation rate and high loss to follow-up rate were important methodological limitations of the SCREEN study. Also added that an independent analysis of the SCREEN study population found that the observed modest mortality reduction did not persist with longer-term follow-up (cited Boniol et al. as reference 26).

Revised text to state that harms have not been well studied or reported in quantitative terms, but the potential for adverse consequences from skin cancer screening exists. Also added text to describe the findings from the SCREEN study, including the rate of skin excision of all screened participants. Also added that one case of melanoma was detected per 28 excisions overall (for both men and women), while 52 skin excisions were required to detect one melanoma in men aged 20 to 34 years (cited Waldmann et al. as reference 27).

This summary is written and maintained by the PDQ Screening and Prevention Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about skin cancer screening. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Screening and Prevention Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

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  • be discussed at a meeting,
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  • replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

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Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Screening and Prevention Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

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The preferred citation for this PDQ summary is:

PDQ® Screening and Prevention Editorial Board. PDQ Skin Cancer Screening. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: http://www.cancer.gov/types/skin/hp/skin-screening-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389300]

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  • Updated: December 1, 2016

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