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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

9.4 Skin cancer

Primary prevention is being ‘sun smart’ (refer to Table 9.4.1.2). Everyone, particularly children, should be advised to adopt protective measures when ultraviolet (UV) levels are ≥3. An RCT in Queensland showed that sunscreen applied daily reduces the incidence of melanoma and squamous cell carcinoma (SCC) in adults with a previous history of skin cancer.58,59

Screening of asymptomatic (low-risk) people for melanoma or non-melanocytic skin cancer (NMSC) is not recommended as there is insufficient evidence available to show that this reduces death.60 A skin cancer screening program in one region of Germany reported temporary reductions in melanoma mortality; however, this ecological study may be subject to several biases.61,62

Instead of screening, providing education that raises awareness of the early signs of skin cancer, particularly in people aged >40 years is recommended. Patients can be assessed opportunistically, or when concerned generally, or about a specific skin lesion.

9.4.1 Melanocytic skin cancer

Advise on sun protection and prevention

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

Screen increased-risk and high-risk patients

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

Clinical assessment of future risk of melanoma should take into account:60

  • patient’s age and sex
  • history of previous melanoma or NMSC
  • number of naevi (common and atypical)
  • family history of melanoma
  • skin and hair pigmentation
  • response to sun exposure
  • evidence of actinic skin damage.

There are no sufficiently well-validated risk models to assess the combined effects of all these factors.63

Skin self-examination should be encouraged for high-risk individuals every three months and clinical examination every six months (B).63,64

Table 9.4.1.1. Melanocytic skin cancer: Identifying risk
Who is at risk?What should be done?How often?
Average risk
Medium/dark skin colour and no other risk factors Primary preventive advice (III, B) Opportunistically60
Increased risk
  • • Family history of melanoma in first-degree relative risk [RR] = 1.7)
  • Fair complexion, a tendency to burn rather than tan, the presence of freckles, high naevus count (>100), light eye colour, light or red hair colour
  • Presence of actinic damage (RR = 2)
  • Past history of non-melanocytic skin cancer (NMSC) (<40 years of age higher risk)
  • People with childhood high levels of ultraviolet (UV) exposure and episodes of sunburn in childhood (RR = 2)
Primary preventive advice and examination of skin (III, B) Opportunistically 60, 65
High risk (Risk >6 times normal)
  • Previous history of melanoma (RR >10)
  • >5 atypical (dysplastic) naevi (RR = 6)
Preventive advice, examination of skin (with or without photography) and advice on self-examination (III, C) Every 6–12 months (Practice Point)

Frequency of follow-up examinations for people who have had melanoma is based on disease stage 66-64
RR, relative risk; NMSC, non-melanocytic skin cancer; UV, ultraviolet
Table 9.4.1.2. Melanocytic skin cancer: Preventive interventions
InterventionTechnique
Sun protection advice All people (especially children aged ≤10 years) should be advised to be ‘sun smart’: Adopt protective measures during sun protection times (when ultraviolet [UV] levels are ≥3). These measures include use of shade; broad-brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and sunscreens with a sun protection factor (SPF) ≥30 (which need to be reapplied every two hours) 60, 67

Sun protection times are available from the Bureau of Meteorology. Apps for Apple and Android tablets and smartphones or desktops provide real-time electronic alerts on recommended sun protection times, current and maximum UV levels, and information on recommended exposure for vitamin D. They are adjustable to specific geographic locations around Australia, and is available at SunSmart
Skin examination Before examining the skin, it is worth asking about any new, or changes in old skin lesions. Characteristics of suspicious naevi include asymmetry, border irregularity, variable colour (including a surrounding coloured halo) and diameter >6 mm (mnemonic ‘ABCD’). Naevi that stand out from the others (‘ugly duckling’) are also suspicious. Nodular melanomas (with a much worse prognosis) are characteristically elevated, firm, growing over the past month (mnemonic ‘EFG’)60, 68–70

The 7-point checklist is an alternative method to assess pigmented skin lesions and is the only one to have been validated and shown to improve the identification of melanoma in primary care. A score of >3 is associated with an increased risk of melanoma 71–73

Major features of the lesions (scoring 2 points each):
  • change in size
  • irregular shape
  • irregular colour
Minor features of the lesions (scoring 1 point each):
  • largest diameter 7 mm or more
  • inflammation
  • oozing
  • change in sensation
Excision biopsy or referral should be considered for lesions where there is clear suspicion of melanoma

Training in the use of dermatoscopy and monitoring lesions for three months where there is diagnostic uncertainty can reduce excision rates of benign skin lesions while maintaining sensitivity to detect melanoma

Photography aids in monitoring skin lesions by detecting changes over time, and may reduce the excision rate of benign lesions 74–76
Self-examination Advise patients to be aware of the specific skin changes that suggest melanoma, be encouraged to become familiar with their skin, and be alert for new or changing skin lesions 65, 77

Encourage high-risk individuals to perform self-examination, potentially with the aid of a partner or carer, especially of naevi. Those at high risk may benefit from the use of self-photography. At present, the role of ‘melanoma apps’ on smart phones to support self-monitoring is not advised given uncertainties about their image quality and accuracy78
SPF, sun protection factor; UV, ultraviolet

Implementation

GPs over-excise pigmented lesions in people who are younger (aged <40 years) or female, in whom they excise more benign lesions.75 GPs should be more suspicious of skin lesions in men aged >50 years.75

9.4.2 Non-melanocytic skin cancer (basal cell and squamous cell carcinoma)

Prevention advice

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

Opportunistic case finding

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

High-risk individuals aged ≥40 years should be examined for NMSC opportunistically (B). Skin self-examination should be encouraged for high-risk individuals (B). The most common preventable cause of NMSC is UV exposure. All people, especially children, should be advised to use protective measures when UV levels are ≥3 (A).

An RCT in Queensland showed that sunscreen applied daily reduces the incidence of melanoma and SCC in adults with a previous history of skin cancer.58 In northern Australia and some parts of southern Australia, UV exposure is sufficiently high to require daily use of sunscreen. For daily information about UV levels visit the SunSmart widget

Table 9.4.2.1. Non-melanocytic skin cancer: Identifying risk
Who is at risk?What should be done?How often?
Average risk
Those with fair to lighter than olive skin colour, aged <40 years without any risk factors Preventive advice (III, B) Opportunistically 79
Increased risk
  • Fair complexion, a tendency to burn rather than tan, the presence of freckles, light eye colour, light or red hair colour
  • Aged >40 years
  • Male
  • Presence of multiple solar keratoses
  • People with high levels of ultraviolet (UV) exposure such as outdoor workers
Preventive advice, educate patients to present to their GP if changes occur in a skin lesion, and examination of skin (III, B) Opportunistically79
High risk
  • Previous non-melanocytic skin cancer (NMSC; up to 60% of patients grow another in three years' time)
  • Immunosuppressed (eg post-renal or heart transplant)
  • Past exposure to arsenic
Preventive advice, educate patients to present to their GP if changes occur in a skin lesion, examination of skin, and advice on self- examination (III, B) If initial opportunistic assessment indicates the need. Every 12 months, or when patient develops new skin lesion (Practice Point)80
NMSC, non-melanocytic skin cancer; non-melanocytic skin cancer; UV, ultraviolet
Table 9.4.2.2. Non-melanocytic skin cancer: Preventive interventions
InterventionTechnique
Sun protection advice Advise all people (especially children aged ≤10 years) to adopt protective measures when ultraviolet (UV) levels are ≥3. These measures include use of shade; broad-brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and use of sunscreen with sun protection factor (SPF) ≥30 (which need to be reapplied every two hours)60, 67

Sun protection times are available from the Bureau of Meteorology. ‘SunSmart’ applications for Apple and Android tablets and smartphones or desktops provide real-time electronic alerts on recommended sun protection times, current and maximum UV levels, and information on recommended exposure for vitamin D. They are adjustable to specific geographic locations around Australia, and is available at SunSmart
Skin examination Precede skin examination by enquiring for relevant history (eg of lesions of concern to patient or recent appearance or change in any lesions in the past few months or years). Examination should identify skin lumps, ulcers or scaly patches, particularly growing, scarred or inflamed lesions. Consider incision, shave or excision biopsy for histology (or referral). There are many suitable means to treat non-melanocytic skin cancer (NMSC); these include surgery, cryotherapy, curettage and cytotoxic and immune modulating creams70, 75
Self-examination Advise patients to be alert for skin lesion changes79
SPF, sun protection factor; UV, ultraviolet

References

  1. Green A, Williams G, Neale R, et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: A randomised controlled trial. Lancet 1999;354(9180):723–29.
  2. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: Randomised trial follow-up. J Clin Oncol 2011;29(3):257–63.
  3. Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical practice guidelines of the management of melanoma in Australian and New Zealand. Wellington: Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group, 2008.
  4. Boniol M, Autier P, Gandini S. Melanoma mortality following skin cancer screening in Germany. BMJ Open 2015;5(9):e008158.
  5. 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):5395–402.
  6. Usher-Smith JA, Emery J, Kassianos AP, Walter FM. Risk prediction models for melanoma: A systematic review. Cancer Epidemiol Biomarkers Prev 2014;23(8):1450–63.
  7. Watts CG, Dieng M, Morton RL, Mann GJ, Menzies SW, Cust AE. Clinical practice guidelines for identification, screening and follow-up of individuals at high risk of primary cutaneous melanoma: A systematic review. Br J Dermatol 2015;172(1):33–47.
  8. MacKie R, McHenry P, Hole D. Accelerated detection with prospective surveillance for cutaneous malignant melanoma in high-risk groups. Lancet 1993;341(8861):1618–20.
  9. New Zealand Dermatological Society. New Zealand guidelines on the general management of malignant melanoma New Zealand. Palmerston North, NZ: NZ Dermatological Society, 2004.
  10. Baade PD, Balanda KP, Stanton WR, Lowe JB, Del Mar CB. Community perceptions of suspicious pigmented skin lesions: Are they accurate when compared to general practitioners? Cancer Detect Prev 2005;29(3):267–75.
  11. Kelly J, Chamberlain AJ, Staples MP, McAvoy B. Nodular melanoma. No longer as simple as ABC. Aust Fam Physician 2003;32(9):706–09.
  12. Scope A, Dusza SW, Halpern AC, Rabinovitz H. The ‘ugly duckling’ sign: Agreement between observers. Arch Dermatol 2008;144(1):58–64.
  13. Zalaudek I, Kittler H, Marghoob AA, Balato A. Time required for a complete skin examination with and without dermoscopy: A prospective, randomized multicenter study. Arch Dermatol 2008;144(4):509–13.
  14. National Institute for Health and Care Excellence. Suspected cancer: Recognition and referral. London: NICE, 2015.
  15. Walter FM, Prevost AT, Vasconcelos J, et al. Using the 7-point checklist as a diagnostic aid for pigmented skin lesions in general practice: A diagnostic validation study. Br J Gen Pract 2013;63(610):e345–53.
  16. Walter FM, Morris HC, Humphrys E, et al. Effect of adding a diagnostic aid to best practice to manage suspicious pigmented lesions in primary care: Randomised controlled trial. BMJ 2012;345:e4110.
  17. Hanrahan P, CAD’Este SW, Plummer T, Hersey P. A randomised trial of skin photography as an aid to screening skin lesions in older males. J Med Screening 2002;9(3):128–32.
  18. English D, Del Mar C, Burton R. Factors influencing the number needed to excise: Excision rates of pigmented lesions by general practitioners. Med J Aust 2004;180(1):16–19.
  19. Menzies SW, Emery J, Staples M, et al. Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: A sequential intervention trial. Br J Dermatol 2009;161(6):1270–77.
  20. Kanzler M, Mraz-Gernhard S. Primary cutaneous malignant melanoma and its precursor lesions: Diagnostic and therapeutic overview. J Am Acad Dermatol 2001;45(2):260–76.
  21. Kassianos AP, Emery JD, Murchie P, Walter FM. Smartphone applications for melanoma detection by community, patient and generalist clinician users: A review. Br J Dermatol 2015;172(6):1507–18.
  22. National Health and Medical Research Council. Clinical practice guidelines non-melanoma skin cancer: Guidelines for treatment and management in Australia. Canberra: NHMRC, 2002.
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