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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
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