mardi 26 juillet 2016

USPSTF: Not Enough Proof for Visual Skin Ca Screening (CME/CE)

Action Points

  • Note that the U.S. Preventive Services Task Force states that there is insufficient evidence to recommend for or against routine skin cancer screening by primary care physicians.
  • Be aware that this recommendation does not apply to those with suspicious lesions or to the self-directed skin exam.

The evidence for skin cancer screening by visual inspection remains insufficient to assess the benefits and potential harms, the U.S. Preventive Services Task Force (USPSTF) has concluded.

The "I statement" is the third issued on the topic by the USPSTF, following the initial review in 2001 and an update in 2009. The task force panel concluded that visual inspection by primary care physicians has "modest sensitivity and specificity for detecting melanoma." However, the evidence is "more limited and inconsistent" regarding detection of nonmelanoma skin cancers.

The panel found the evidence inadequate to determine whether visual inspection of the skin reduces morbidity or mortality. The review of current literature persuaded panelists that visual inspection of the skin "leads to harms that are at least small," but did not adequately define the "upper magnitude" of the potential harms, as reported online in the Journal of the American Medical Association.

"Evidence to assess the net benefit of screening for skin cancer with a clinical visual skin examination is limited," panel chair Kirsten Bibbins-Dimingo, MD, PhD, of the University of California San Francisco (UCSF), and co-authors concluded in their summary.

"The potential for harm clearly exists, including a high rate of unnecessary biopsies, possibly resulting in cosmetic or, more rarely, functional adverse effects, and the risk of overdiagnosis and overtreatment," they added.

The USPSTF conducted a separate review of skin-self examination for cancer detection and will release recommendations on that issue at a later date.

The American Academy of Dermatology (AAD) expressed disappointment with the USPSTF recommendation, but pointed out that the task force did not specifically discourage skin cancer screening.

"It is important for the public to understand that the USPSTF is not recommending against skin cancer screenings," AAD President Abel Torres, MD, JD, said in a statement. "It means the group did not find conclusive evidence to make a recommendation one way or another. Additionally, the public should know that this recommendation does not apply to individuals with suspicious skin lesions and those with an increased skin cancer risk, and it does not address the practice of skin self-exams."

The authors of an accompanying editorial also emphasized the nuanced language of the USPSTF statement and cautioned against misinterpretation.

'"Insufficient evidence of benefit' is different from 'evidence of no benefit,'" wrote Hensin Tsao, MD, PhD, of Massachusetts General Hospital in Boston and Martin A. Weinstock, MD, PhD, of the Veterans Affairs Medical Center in Providence, R.I. "The public, physicians, and the popular press should avoid this misinterpretation.

"For the scientific community, the I designation should not be viewed as an indictment but rather as an invitation to the public health, medical, and scientific communities to galvanize and to work together in executing well-designed but feasible studies so future recommendations can be of greater public health benefit."

The second update of the USPSTF recommendation statement "identified no completed randomized trials on the topic," authors of a commentary published in JAMA Internal Medicine noted.

"The report should motivate us to improve the evidence base for identifying groups of people in whom the benefits of screening might outweigh the risks. We need high-quality, long-term randomized clinical trials of the effectiveness of screening on skin cancer prevention," wrote Eleni Linos, MD, DrPH, also of UCSF, and co-authors wrote.

The recommendation pertains to asymptomatic healthy adults seen by primary care practitioners, and does not apply to patients with signs and symptoms of skin cancer or who have an increased risk of skin cancer, the authors of a third commentary pointed out.

"The USPSTF does not make recommendations for specialists (eg, dermatologists) who routinely perform targeted screening among high-risk groups," Susan M. Swetter, MD, of Stanford University in Stanford, Calif., and the Palo Alto VA Health Care System, and co-authors wrote.

Increased cooperation between skin cancer specialists and primary care providers, and strengthening healthcare professionals' skin cancer screening skills, are keys to improved early detection and treatment.

"With or without a USPSTF change in skin screening recommendations, dermatologists should build collaborations with primary care colleagues to reduce melanoma deaths, focusing on screening those with highest case-fatality rates ... as well as targeted screening of individuals with the most relevant phenotypic and genotypic melanoma risk factors," Swetter's group concluded in JAMA Dermatology.

The USPSTF is supported by the Agency for Healthcare Research and Quality.

Bibbins-Dimingo and co-authors disclosed no relevant relationships with industry.

Tsao disclosed a relevant relationship with Lubax. Weinstock disclosed no relevant relationships with industry.

Linos and co-authors disclosed no relevant relationships with industry.

Swetter and co-authors disclosed no relevant relationships with industry.

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USPSTF: Not Enough Proof for Visual Skin Ca Screening (CME/CE)

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