Clinicians play a vital role in educating patients about skin cancer prevention. Skin cancers are the most common cancers in the United States, affecting an estimated one in five Americans during their lifetime. They are caused by a combination of genetic predisposition and ultraviolet radiation exposure. Fair-skinned individuals are at highest risk. The most common skin cancer is basal cell carcinoma (BCC), followed by squamous cell carcinoma (SCC), and melanoma.
Melanoma.
Although it is the least common skin cancer, melanoma is the most lethal due to its high rate of metastasis and high mortality at advanced stages, causing over 70% of skin cancer deaths. The incidence of melanoma has more than doubled in the past three decades, the most rapid increase of any cancer. Melanoma is now the fifth most frequently diagnosed cancer in men and the seventh most frequently diagnosed in women. In the United States in 2014, the estimated lifetime risk was 1 in 48 for whites (2%), 1 in 200 for Hispanics, and 1 in 1,000 for African Americans.
Ask patients about the melanoma risk factors listed below, and use of the Melanoma Risk Assessment Tool developed by the National Cancer Institute. This tool assesses an individual's 5-year risk of developing melanoma based on geographic location, gender, race, age, history of blistering sunburns, complexion, number and size of moles, freckling, and sun damage. It is applicable up to age 70 years, but is not intended for patients with a family history of melanoma.
Risk Factors for Melanoma
● Personal or family history of previous melanoma
● ≥50 common moles
● Atypical or large moles, especially if dysplastic
● Red or light hair
● Solar lentigines (acquired brown macules on sun-exposed areas)
● Freckles (inherited brown macules)
● Ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths
● Light eye or skin color, especially skin that freckles or burns easily
● Severe blistering sunburns in childhood
● Immunosuppression from human immunodeficiency virus (HIV) or from chemotherapy
● Personal history of nonmelanoma skin cancer
Avoiding Ultraviolet Radiation and Tanning Beds.
Increasing lifetime sun exposure correlates directly with increasing risk of skin cancer. Intermittent sun exposure appears to be more harmful than chronic exposure. The best defense against skin cancers is to avoid ultraviolet radiation exposure by limiting time in the sun, avoiding midday sun, using sunscreen, and wearing sun-protective clothing with long sleeves and hats with wide brims. Advise patients to avoid indoor tanning, especially children, teens, and young adults.Use of indoor tanning beds, especially before age 35 years, increases risk of melanoma by as much as 75%.
In 2009, the International Agency for Research on Cancer classified ultravioletemitting tanning devices as "carcinogenic to humans."Options for tanning include self-tanning products or sprays in conjunction with sunscreen. Targeted patient messages in primary care practices have been shown to amplify these sun-protective behaviors. The U.S. Preventive Services Task Force (USPSTF) has made a grade B recommendation supporting behavioral counseling through minimizing ultraviolet radiation exposure in fair-skinned children, adolescents, and young adults aged 10 to 24 years and cites insufficient evidence, grade I, for counseling adults older than 24 years, but noted no harms associated with counseling.
Regular Use of Sunscreen Prevents Skin Cancer.
There are many myths about sunscreen. A landmark study in 2011 demonstrated that the regular use of sunscreen decreases the incidence of melanoma.This well-designed study showed that when clinicians strongly encouraged use of sunscreen, patients were more likely to use it regularly and melanoma incidence declined. Advise patients to use at least sun protective factor (SPF) 30 and broad-spectrum protection. For water exposure, patients should use water-resistant sunscreens. New U.S. Food and Drug Administration labeling guidelines in 2011 make it easy to see these features on all bottles of sunscreen. Free information about protection and proper use of sunscreen are available from the AAD and the Skin Cancer Foundation.
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