Guidelines for preventive activities in general practice

Cancer

Skin cancer

      1. Skin cancer

Cancer | Skin cancer

Melanocytic and keratinocyte (non-melanocytic) skin cancer  

Case finding age bar 

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 70-74 75-79 ≥80

Australia has the world’s highest incidence of skin cancer.1 Skin cancer incidence and mortality is higher in males than females.2 Melanoma (melanocytic skin cancer) is the third-most common invasive cancer diagnosed in Australia. In 2021, an estimated 16,878 Australians were diagnosed with invasive melanoma and a further 27,585 were diagnosed with a melanoma in situ (stage 0; early form of melanoma).2 Melanoma incidence is similar for males and females up to the age of approximately 45 years but by age 80 years the incidence is twice as high for males than for females. Melanoma incidence increases with age but is disproportionately high among young adults compared to other cancers, and is the most commonly diagnosed cancer for the age group 20–39 years.2 Once a person has developed a melanoma, they are at approximately 5- to 10-times higher risk of developing another primary melanoma, although personal risk varies according to the presence of different risk factors.3 

Keratinocyte cancers (non-melanocytic skin cancers), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are common in the Australian population. It is estimated that over two-thirds of Australians will develop a keratinocyte cancer in their lifetime, and many people develop multiple skin cancers.4 

Skin cancer is highly preventable through sun protection strategies. 

It is estimated that skin cancer–related conditions account for approximately 3% of all health problems managed in Australian general practice (not including primary care skin cancer clinics), and this is higher in regional or remote areas and in areas associated with lower socioeconomic status.5 

Identifying risk of melanoma 

Use one of these validated melanoma risk assessment tools to determine risk level:

The following are considered at high risk of melanoma: 

  • those with previous melanoma. 

The following are considered at very high risk of melanoma: 

  • those with previous melanoma plus any of
    • multiple atypical naevi 
    • multiple primary melanomas 
    • family history of melanoma
  • known carrier of high-risk variant in CDKN2A gene. 

Use the following keratinocyte cancer risk assessment tool to determine risk level:

Refer to the Resources section for further information on these tools.

Screening 

Recommendation  Grade How often References
For individuals at average/below average risk of developing melanoma or keratinocyte cancer, regular skin checks are not recommended.  
 
Generally not recommended N/A 6,7,8

Case finding 

Recommendation  Grade How often References
Opportunistic examination of the skin is recommended for individuals at  above-average risk of developing melanoma or keratinocyte cancer. Conditionally recommended Opportunistically (usually no more than once every 12 months). 6,7
Regular skin checks are recommended for individuals at high risk of developing melanoma or keratinocyte cancer. Conditionally recommended At least every 12 months. 6,7
Individuals at very high risk of developing a new primary melanoma should be checked regularly by a clinician with six-monthly full skin examination supported by total body photography and dermoscopy. They and their partner or carer should be educated to recognise and document lesions suspicious of melanoma.  Practice point Six-monthly 6

Preventive activities and advice 

Recommendation  Grade How often References
Everyone regardless of their risk category should be: 
  • provided with education that raises awareness of the early signs of skin cancer 
  • be encouraged to be familiar with their skin and get any suspicious new or changing spots checked by a doctor 
Conditionally recommended N/A 6,7
The most common preventable cause of skin cancer is ultraviolet (UV) radiation exposure. All people (especially children, adolescents, young adults) should be advised to be ‘sun smart’ – broad-brimmed hat, covering clothing, sunscreen, sunglasses and shade.
Every morning sunscreen should be applied to the head, neck, arms and hands. It should be reapplied after heavy sweating, bathing or long sun exposure, especially if outdoors when the UV Index is ≥3.
Recommended (Strong) N/A 9,10
GPs should strongly counsel patients against personal home use of sunbeds or sunlamps for cosmetic tanning purposes. Practice Point N/A 11
Patients should be advised to avoid getting sunburnt, especially to the point of blistering and skin peeling, because multiple episodes have been shown to increase the risk of developing melanoma. Practice Point N/A 12,13

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 ultraviolet (UV) levels, and information on recommended exposure for vitamin D. They are adjustable to specific geographic locations around Australia and internationally, available at SunSmart Global UV

Most Australian adults will maintain adequate vitamin D levels from sun exposure during typical day-to-day outdoor activities. There is little evidence to suggest that sunscreen increases risk of vitamin D deficiency.14 

Relevant validated risk tools (calculators) for the Australian population available to help individuals assess risk

Each risk tool provides a valid assessment of personal risk, but they have been developed and presented differently depending on the population for whom they are intended (ie people with or without a previous melanoma) and because there is little evidence guiding optimal risk category classification and cut-points. The risk tools have been comprehensively developed but some rare risk factors may be missing, such as immunosuppression (eg among organ transplant recipients). 

Genetic risk assessment 

Individuals with or at risk of a mutation in the CDKN2A gene or at high risk for new primary melanoma 

In individuals with a strong family history of melanoma (ie three or more cases in first- or second-degree relatives) considered where predictive features are present, such as multiple primary melanoma, early age of onset, pancreatic cancer, or multiple other cancers, clinical genetic testing for CDKN2A or other high-risk mutations and genetic counselling should be undertaken.6 

Cancer Institute NSW eviQ guidelines provide information on risk assessment and clinical genetic testing for CDKN2A.15

Aboriginal and Torres Strait Islander people are usually at lower risk of skin cancer, but their actual risk will depend on the presence of risk factors including the level of skin pigmentation. When Aboriginal and Torres Strait Islander people are diagnosed with skin cancer, they generally experience poorer outcomes. Thus, it is important that they are provided with education that raises awareness of the early signs of skin cancer, and are encouraged to be familiar with their skin and get any suspicious new or changing spots checked by a doctor. It is also important to note that the acral lentiginous subtype of melanoma, which accounts for approximately 1% of melanomas diagnosed in Australia, is the most frequently diagnosed melanoma in persons with darker skin colour, is not related to sun exposure, and often has a poor prognosis.16
 
For specific recommendations for Aboriginal and Torres Strait Islander people, please refer to the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.

Immunosuppression is also a strong risk factor for skin cancer, and organ transplant recipients are at very high (very much above average) risk of keratinocyte cancers.7

 
 

Educational tools and resources for health professionals to provide messages about skin cancer prevention, vitamin D and the early detection and management of skin cancer:

Resources for health professionals | SunSmart
Sunscreen for skin cancer prevention, Handbook of non-drug interventions (HANDI) | RACGP

 
 
  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68(6):394–424.
  2. Australian Institute of Health and Welfare. Cancer data in Australia. Cat. no. CAN 122. AIHW, 2022 [Accessed 11 May 2023].
  3. Cust AE, Badcock C, Smith J, et al. A risk prediction model for the development of subsequent primary melanoma in a population-based cohort. Br J Dermatol 2020;182(5):1148–57. doi: 10.1111/bjd.18524.
  4. Olsen CM, Pandeya N, Green AC, Ragaini BS, Venn AJ, Whiteman DC. Keratinocyte cancer incidence in Australia: A review of population-based incidence trends and estimates of lifetime risk. Public Health Res Pract 2022;32(1):e3212203.
  5. Reyes-Marcelino G, McLoughlin K, Harrison C, et al. Skin cancer-related conditions managed in general practice in Australia, 2000–2016: A nationally representative, cross-sectional survey. BMJ Open 2023;13:e067744. doi: 10.1136/bmjopen-2022-067744.
  6. Cancer Council Australia. Clinical practice guidelines for the diagnosis and management of melanoma. Cancer Council Australia, 2019.
  7. Cancer Council Australia. Clinical practice guidelines for keratinocyte cancer > 3. Early detection of keratinocyte cancers. Cancer Council Australia, 2019.
  8. US Preventive Services Task Force; Mangione CM, Barry MJ, et al. Screening for skin cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2023;329(15):1290–95. doi: 10.1001/jama.2023.4342. PMID: 37071089.
  9. US Preventive Services Task Force; Grossman DC, Curry SJ, et al. Behavioral counseling to prevent skin cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2018;319(11):1134–42. doi: 10.1001/jama.2018.1623. PMID: 29558558.
  10. The Royal Australian College of General Practitioners. Handbook of non-drug interventions (HANDI). Sunscreen for skin cancer prevention. RACGP, 2014 [Accessed 8 April 2024].
  11. Cancer Council Australia. Clinical practice guidelines for keratinocyte cancer > 2.1 Strategies for protection from excessive exposure to ultraviolet radiation. Cancer Council Australia, 2019.
  12. Australian Institute of Health and Welfare 2016. Skin cancer in Australia. Cat. no. CAN 96. AIHW, 2016 [Accessed 6 March 2024].
  13. Cancer Council Victoria; Department of Health Victoria. Optimal care pathway for people with melanoma. 2nd edn. Cancer Council Victoria, 2021 [Accessed 6 March 2024].
  14. Australian Skin and Skin Cancer Research Centre. Position statement: Balancing the harms and benefits of sun exposure. ASSC, 2023 [Accessed 8 April 2024].
  15. Cancer Institute NSW eviQ. CDKN2A – Genetic testing. Cancer Institute NSW eviQ, 2022 [Accessed 16 May 2023].
  16. Chakera AH, Read RL, Stretch JR, Saw RPM. Diverse presentations of acral melanoma. Aust Fam Physician 2015;44(1–2):43–45.
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