My wife Elie recently noted a small bump on my forehead just at the hairline. Of course, if you look at my photo that accompanies this article, you will realize that my hairline is actually a theoretical entity. In any event, listening to my better half, I went to a dermatologist who diagnosed an actinic keratosis and froze it off. I was then offered a total body skin examination. On one hand, it does reinforce the general recommendation that you always should don clean underwear every morning as you never know what the day will bring. But what to do?

I am now addressing the issue of skin cancer screening for average-risk individuals, not those at high risk for skin cancer. By having an actinic keratosis, for example, I have already placed myself in a high-risk group for skin cancer, along with those who have fair skin and a history of unusual sun exposure. Nonetheless, it is interesting and important to refer to the recommendations of my favorite source for unbiased guidelines, the U.S. Preventive Services Task Force (USPSTF). In rendering their opinions, they do not allow specialists on their committees from the disease under consideration, as they will possibly reflect biases on the issues at hand.

So let us skip to the conclusion—the USPSTF did not find adequate evidence to recommend that asymptomatic average-risk adults should undergo visual skin examination by a clinician to screen for skin cancer. The regular readers of this column will recall that the basis for the recommendation of a screening test is not that it leads to an increase in the diagnosis of the cancer, but that it leads to a significant reduction in severe morbidity or mortality, and that this be achieved at a reasonable cost-benefit. Apparently the USPSTF did not find evidence to support these criteria for skin cancer screening.

The most prominent study they found was one conducted in Germany. A pilot study was reported in 2003 in which total body skin screening was introduced in one state of Germany (Schleswig-Holstein) and it appeared that the melanoma mortality rate was subsequently decreased by this intervention. Based on this preliminary evidence, a total body visual skin examination was made available on a national basis to all members of the German nationalized healthcare system who were 35 years of age or older on an every-two-year basis. This program was initiated in 2008, and there was an immediate 28% increase in the diagnosis of melanoma, as would be expected when new screening modalities are introduced. However, by 2013, a study was published that there had been no reduction in the mortality rate from melanoma. Some argued that the follow-up period was too short, but when further follow-up was published, it did not change these findings.

A similar study was later conducted in the U.S., specifically in Pittsburgh within the University of Pittsburgh Medical Center health care system. Primary care physicians were trained in the proper conduct of skin exams, and then they offered these exams to patients 35 years of age and older who attended their primary care practices. Between 2014 and 2018, of 595,799 eligible patients, 144,851 (24.3%) underwent at least one total body skin examination. After adjustment for age, sex and race, the screened patients were more likely than those not screened to be diagnosed with melanomas, and the diagnosed melanomas were more likely to be thinner and more superficial, i.e., a better stage. Whether this represented a real screening improvement or overdiagnosis remained moot. However, more importantly, there was certainly no evidence of a mortality benefit.

For now, the USPSTF guidelines must remain paramount. Clearly what is necessary for reaching firm conclusions in this important clinical arena is a randomized clinical trial. To date, none has been conducted. One had been planned for quite some time in Australia, where skin cancer rates are high, but it was sidetracked because of the COVID-19 pandemic. I believe that indications are that plans for this trial are being reactivated at the present time. Undoubtedly that would provide us with some concrete answers on this important question.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: [email protected].

This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.