Skin cancer screening recommendations by U.S. cancer centers: Inconsistency with national guidelines

Introduction

The U.S. Preventive Services Task Force (USPSTF) has found insufficient evidence to recommend for or against skin cancer screening in asymptomatic, average-risk adults. ¹ With increased skin exams and lower pathologic thresholds for diagnosis, the incidence of melanoma has increased without a commensurate decrease in the incidence of advanced melanoma or melanoma-specific mortality.^2,3 This suggests that recent screening practices have uncovered a subclinical reservoir of disease that may not pose a threat to health, leading to potential harm. ³ In this study, we examined the public recommendations made by U.S. cancer centers on skin cancer screening and their alignment with USPSTF recommendations.

Methods

In this cross-sectional study, two reviewers examined public recommendations for skin cancer screening on the websites of 1113 U.S. cancer centers accredited by the Commission on Cancer, including 66 National Cancer Institute (NCI)-designated centers. Data were extracted from September 2022 to February 2023, and recommendations on screening overall, age, frequency, and self-examination for general and high-risk populations and persons of color were documented. Comparisons utilized two-tailed Fisher's test with α<0.05. This study was deemed exempt from review by the Weill Cornell Institutional Review Board.

Results

For people at average risk of skin cancer, 18% (202) of 1113 cancer centers recommended professional skin cancer screening, 10% (113) recommended discussion with a healthcare professional regarding screening schedule, and 3.4% (38) cited insufficient evidence to recommend for or against screening in alignment with USPSTF guidelines (Figure 1). ¹ The remaining 760 centers (68%) made no screening recommendations. NCI centers were almost twice as likely (31.8%, 21/66) to recommend screening than non-NCI centers (17.3%, 181/1047; p = 0.0049).

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Figure 1.

Screening recommendations for general population.

We also examined recommendations for high-risk adults, defined on websites as having a family or personal history of skin cancer, fair skin, extensive sun exposure, numerous moles, history of sunburns, radiation therapy, and/or immunocompromised status (Table 1). Overall, 49% of NCI centers (32/66) recommended screening compared to 13% of non-NCI centers (135/1047; p = 0.0004); 946 centers (85%) made no recommendations for high-risk individuals. Although the USPSTF also cites insufficient evidence, self-examination was advised by 35.8% (399/1113) of centers (50% of NCI centers vs. 36% of non-NCI centers; p = 0.017).

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Table 1.

Summary of skin cancer screening recommendations by U.S. cancer centers.

Screening age (n = 50)	Begin at age 18–21: 56% (n = 28)
	All ages: 2% (n = 1)
	Other1: 42% (n = 21)
Screening frequency (n = 196)	Annually: 51% (n = 100)
	Regularly: 41% (n = 80)
	Every 3 y until age 39 then annually
	Starting age 40: 6.1% (n = 12)
	Other: 2% (n = 4)2
Screening in high-risk people3 (n = 1113)	Yes: 15% (n = 167); 49% of NCI vs. 13% of non-NCI (p = 0.0004)
	Not specified: 85% (n = 946)
Self-examination (n = 1113)	Yes: 35.8% (n = 399); 50% of NCI vs. 36% non-NCI (p = 0.017)
	Not specified: 64.2% (n = 714)
Age for self-examination (n = 1113)	“All adults”: 0.2% (n = 2)
	Start at age 18–21: 0.9% (n = 10)
	Start at age 35: 0.7% (n = 8)
	Not specified: 98% (n = 1093)
Frequency of self-examination (n = 1113)	“Monthly”: 23% (n = 252)
	“Regularly”: 9% (n = 107)
	“Often,” “every 3 months,” or “annually”: 1% (n = 10)
	Not specified: 67% (n = 744)
Potential harms of screening discussed (n = 1113)	Yes: 0.45% (n = 5)
	No: 99.5% (n = 1108)
Screening in “people of color” discussed4 (n = 1113)	Yes: 3.5% (n = 39)
	Not specified: 96.5% (n = 1074)

¹

Includes “speak with medical professional” (n = 2), “Caucasian individuals at age 50” (n = 1), “age 35” (n = 8), “age 40” (n = 4), “age 50” (n = 1), “age 35–75” (n = 2), “age 60” (n = 1), and “all adults” (n = 2).

²

Includes “every 3 years” (n = 1), “every 3 years from age 20 to 29 and annually starting age 30” (n = 2) and, “occasional” (n = 1).

³

High-risk individuals were defined on websites as those with a family or personal history of skin cancer, fair skin, extensive sun exposure, numerous moles, history of sunburns, radiation therapy, and/or immunocompromised status.

⁴

“People of color” were defined in this study by websites mentioning “African American,” “people of color,” and individuals of “all skin tones.”

Five cancer centers (0.45%) mentioned potential harms of screening, while 39 (3.5%) specifically recommended screening in people of color (“African American,” “people of color,” and people of “all skin tones”), despite a lack of current evidence of benefit ⁴ (Table 1).

Discussion

The increase in melanoma incidence with stable mortality since the 1970s has raised concerns about the overdiagnosis of a subclinical reservoir of the disease. We found that many U.S. cancer centers advise professional skin cancer screening (18%) or self-examination (36%) for average-risk adults, and 3.5% also explicitly recommended screening in people of color, despite insufficient data to recommend for or against these practices per the USPSTF.^1,4 Compared to non-NCI centers, NCI cancer centers were more likely to recommend these practices. Very few centers (0.45%) mentioned the potential harms of screening, which may include unnecessary surgery, scarring, psychological stress, overdiagnosis of indolent disease, and financial costs. ³

One limitation of our study is that recommendations on websites may not reflect the practice of individual physicians among various specialties. Nonetheless, these guidelines inform the public and clinicians seeking guidance on screening.

The variation in recommendations may be due to the ambiguity of the USPSTF guidelines. Previously, we found high alignment with national screening guidelines for cervical cancer (96%) ⁵ and prostate cancer (74%). ⁶ Although national recommendations are limited by inconclusive data, very few cancer center guidelines explicitly address this, indicating a need for stronger evidence supporting specific recommendations, greater public awareness of the potential benefits and harms of routine screening, and shared decision-making between physicians and the public considering skin cancer screening.