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Clinical guidelines

Guidelines for preventive activities in general practice 8th edition

9.1 Skin cancer

General population screening for melanoma or non-melanoma skin cancer (NMSC) is not recommended as the prerequisite (evidence to show this reduces death) is not available.471 Providing education that raises awareness of early detection of skin cancer or its prevention is recommended.

Assess people opportunistically or when the patient is concerned (about skin lesions or their skin cancer risk) and plan appropriate strategies for their level of risk. People generally should be encouraged to become familiar with their skin, including skin not normally exposed to the sun, and be alert for new or changing skin lesions, particularly people aged over 40 years.

9.1.1 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 and high risk

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

Skin self-examination should be encouraged for high-risk individuals every 3 months (B).

All people, particularly children, should be advised to adopt protective measures when UV levels are 3 and above (C). Sunscreen may prevent melanoma in adults,472 and generally minimising sun exposure may reduce the risk of melanoma.472-477

Table 9.1.1.1 Melanocytic skin cancer: identifying risk
Who is at risk?What should be done?How often?
Average risk
Light skin without past history of risk
Primary preventive advice (III,B) Opportunistically471
Increased risk
(Risk 2–5 times normal)
  • Family history of melanoma in first-degree relative
  • Fair complexion, a tendency to burn rather than tan, the presence of freckles, light eye colour, light or red hair colour
  • Age over 30 years (over 50 years most at risk)
  • Presence of solar lentigines
  • Past history of NMSC (age <40 years higher risk)
  • People with childhood high levels of UV exposure and episodes of sunburn in childhood
Primary preventive advice and examination of skin (III,B) Opportunistically471,478
High risk
(Risk >6 times normal)
  • Those with multiple atypical or dysplastic naevi and who have a history of melanoma in themselves or in a first-degree relative
Preventive advice, Examination of skin (with or without photography) and advice on self- examination (III,C) Every 3–12 months (Practice Point)479
Table 9.1.1.2 Melanocytic skin cancer: preventive interventions
IndicatorIndicator
Sun protection advice All people (especially children aged ≤10 years) should be advised to adopt protective measures when UV levels are 3 and above. These measures include use of shade; broad-brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and sun protection factor (SPF) 30+ sunscreens, (which need to be reapplied every 2 hours).471,480
Times when the UV is forecast to reach 3 and above and sun protection is recommended are available from the Bureau of Meteorology. ‘SunSmart’ applications for smart phones or desktops provide real-time electronic alerts on recommended sun protection times, maximum UV levels, and information on recommended exposure for vitamin D. They are adjustable to specific geographic locations around Australia at www.sunsmart.com.au
Skin examination Before examining the skin, it is worth asking about any new, or changes in old lesions. Characteristics of suspicious naevi include asymmetry, border irregularity, variable colour (including a surrounding coloured halo) and diameter >6 mm elevation (mnemonic ‘ABCD’). Naevi that stand out from the others (‘ugly duckling’) are also suspicious.471,484-486
Nodular melanomas (with a much worse prognosis) are characteristically elevated, firm, growing over the past month (mnemonic ‘EFG’).
Excision biopsy or referral should be considered. Examination under surface magnification (x 10) (after appropriate training) can assist in diagnosis.
Photography aids in monitoring skin lesions by detecting changes over time, and may reduce the excision rate of benign lesions.481,482
Full body skin examination has been shown in general and dermatology practice, with and without dermatoscopy, to take on average 2–3 minutes.483
Self-examination People should be advised on the specific changes that suggest melanoma, be encouraged to become familiar with their skin, and be alert for new or changing skin lesions. High-risk individuals should be encouraged to perform self-examination, especially of naevi. Those at high risk can benefit from use of self-photography.478,487

Implementation

GPs over-excise pigmented lesions in people who are younger (age <40 years), or female, in whom they excise relatively more benign lesions.482 GPs should be more suspicious of skin lesions in men aged over 50 years.482

9.1.2 NMSC (basal cell and squamous cell carcinoma)

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

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

High-risk individuals from age 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 or above (A). Use of sunscreen helps prevent squamous cell skin cancer (B).488

Table 9.1.2.1 NMSC: identifying risk
Who is at risk?What should be done?How often?
Average risk
  • Those with fair to lighter than olive skin colour, under age 40 years without any risk factors
Preventive advice (III,B) Opportunistically489
Increased risk
  • Fair complexion, a tendency to burn rather than tan, the presence of freckles, light eye colour, light or red hair colour
  • Family history of skin cancer
  • Age over 40 years
  • Male sex
  • Presence of multiple solar keratoses
  • People with high levels of UV exposure such as outdoor workers
Preventive advice, education to present if changes occur in a skin lesion, and examination of skin (III,B) Opportunistically489
High risk
  • Fair complexion, a tendency to burn rather than tan, the presence of freckles, light eye colour, light or red hair colour
  • Age over 40 years
  • Previous NMSC (up to 60% grow another in 3 years)
  • Past exposure to arsenic
  • Immunosuppressed (e.g. post-renal or heart transplant)
Preventive advice, education to present 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)490
Table 9.1.2.2 Non-melanocytic skin cancer: preventive interventions
InterventionTechnique
Sun protection advice All people (particularly children) should be advised to adopt protective measures when UV levels are 3 or above, especially between the hours of 10 am and 3 pm. These measures include use of shade; broad-brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and SPF 30+ sunscreens (which need to be reapplied every 2 hours).491
Skin examination Skin examination should be preceded by enquiry for relevant history (e.g. 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. Incision, shave or excision biopsy for histology (or referral) should be considered. There are many suitable means to treat NMSC; these include the use of surgery, cryotherapy, curettage and cytotoxic and immune modulating creams.  Examination under magnification can assist in diagnosis. Full body skin examination has been shown to take on average 2–3 minutes in general and dermatology practice, with and without dermatoscopy.482,486
Self-examination People should be advised to be alert for skin lesion changes.489

References

  1. Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical Practice Guidelines for the Management of Melanoma in Australian and New Zealand. Wellington: New Zealand Guidelines Group, Sydney and New Zealand Guidelines Group, Wellington, 2008
  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. Gefeller O, Pfahlberg A. Sunscreen use and melanoma: a case of evidence-based prevention? Photodermatol Photoimmunol Photomed 2002;18(3):153–6
  4. Marks R. Photoprotection and prevention of melanoma. Eur J Dermatol 1999;9(5):406–12
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  6. English DR, Milne E, Simpson JA. Sun protection and the development of melanocytic nevi in children. Cancer Epidemiol Biomarkers Prev 2005;14(12):2873–6
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  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. NZDS, 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. Hanrahan P, D’Este CA, Menzies 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
  12. 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):16–9
  13. Smith W. Skin cancer in Australia and the case for screening in general practice. Brisbane: University of Queensland, 2003
  14. Kelly J, Chamberlain AJ, Staples MP, McAvoy B. Nodular melanoma. No longer as simple as ABC. Aust Fam Physician 2003;32(9):706–9
  15. Scope A, Dusza SW, Halpern AC, Rabinovitz H. The ‘ugly duckling’ sign: agreement between observers. Arch Dermatol 2008;144(1):58–64
  16. 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
  17. 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
  18. Green A, Williams G, Neale R, Hart V, Leslie D, Parsons P, 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):723–9
  19. National Health and Medical Research Council. Clinical practice guidelines non-melanoma skin cancer: Guidelines for treatment and management in Australia. Canberra: NHMRC, 2002
  20. Czarnecki D, Mar A, Staples M, Giles G, Meehan C. The development of non-melanocytic skin cancers in people with a history of skin cancer. Dermatology 1994;189(4):364–7
  21. Canadian Task Force on Periodic Health Examination. The Canadian guide to clinical preventive health care. Ottawa: CTFPHE, 2000
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