Skin Cancer Prevention (PDQ®): Prevention - Health Professional Information [NCI]

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Skin Cancer Prevention

Who is at Risk?

Note: Separate PDQ summaries on Skin Cancer Screening, Skin Cancer Treatment, and Levels of Evidence for Cancer Screening and Prevention Studies are also available.

Individuals whose skin freckles, tans poorly, or burns easily after sun exposure are particularly susceptible to developing skin cancer.[1] Observational and analytic epidemiologic studies have consistently shown that increased cumulative sun exposure is a risk factor for nonmelanoma skin cancer.[1,2] Organ transplant recipients receiving immunosuppressive drugs are at an elevated risk of skin cancer, particularly squamous cell carcinoma (SCC). Arsenic exposure also increases the risk of cutaneous SCC.[3,4] In the case of melanoma, it seems that intermittent acute sun exposure leading to sunburn is more important than cumulative sun exposure;[5] such exposures during childhood or adolescence may be particularly important.[6] Nonmodifiable host factors, such as a large number of benign melanocytic nevi and atypical nevi may also increase the risk of developing cutaneous melanoma.[6]

Factors Associated With an Increased Risk of Nonmelanoma Skin Cancer

Sun and ultraviolet (UV) radiation exposure

Based on solid evidence, sun and ultraviolet radiation exposure are associated with an increased risk of SCC and basal cell carcinoma (BCC).

Magnitude of Effect: Substantial, depending upon amount of exposure.

Study Design: Observational studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.

Factors Associated With an Increased Risk of Melanoma

Sun and UV radiation exposure

Based on fair evidence, intermittent acute sun exposure leading to sunburn is associated with an increased risk of melanoma.

Magnitude of Effect: Unknown.

Study Design: Observational studies.
Internal Validity: Fair.
Consistency: Fair.
External Validity: Poor.

References:

1. Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992.
2. English DR, Armstrong BK, Kricker A, et al.: Case-control study of sun exposure and squamous cell carcinoma of the skin. Int J Cancer 77 (3): 347-53, 1998.
3. Thomas VD, Aasi SZ, Wilson LD, et al.: Cancer of the skin. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Vols. 1 & 2. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2008, pp 1863-87.
4. Le Mire L, Hollowood K, Gray D, et al.: Melanomas in renal transplant recipients. Br J Dermatol 154 (3): 472-7, 2006.
5. Gandini S, Sera F, Cattaruzza MS, et al.: Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer 41 (1): 45-60, 2005.
6. Koh HK: Cutaneous melanoma. N Engl J Med 325 (3): 171-82, 1991.

Interventions With Inadequate Evidence as to Whether They Reduce Risk of Nonmelanoma Skin Cancer

Sunscreen Use and Ultraviolet (UV) Radiation Avoidance

Benefits

The evidence that interventions designed to reduce exposure to UV radiation by the use of sunscreen, protective clothing, or limitation of sun exposure time decrease the incidence of nonmelanoma skin cancer is inadequate. A randomized study suggested a possible reduction in incidence of squamous cell carcinomas (SCCs), but study design and analysis problems complicate interpretation of the results.[1,2]

Magnitude of Benefit: Not applicable (N/A) (inadequate evidence).

Study Design: One randomized controlled trial (RCT) with tumor incidence as the outcome and one RCT with actinic keratosis as the outcome for SCC; cohort studies for basal cell carcinoma (BCC). Other study designs give inconsistent results.
Internal Validity: Poor.
Consistency: Poor.
External Validity: Poor.

Harms

The harms of sunscreen use are poorly quantified but are likely to be small, including allergic reactions to skin creams and lower production of vitamin D by the skin with less sun exposure.

Chemopreventive Agents

Benefits

There is inadequate evidence to determine whether the use of chemopreventive agents reduces the incidence of SCC or BCC of the skin.

Magnitude of Effect: N/A (inadequate evidence).

Study Design: RCTs with tumor incidence as a post-hoc subset.
Internal Validity: Poor.
Consistency: N/A.
External Validity: Poor.

Harms

Beta carotene use has been associated in RCTs with an increased risk of lung cancer incidence and mortality in smokers. Isotretinoin has dose-related skin toxicity. COX-2 inhibitors, such as celecoxib, have been associated with cardiac toxicity in RCTs for the prevention of colorectal cancer.

References:

1. Green A, Williams G, Neale R, 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 354 (9180): 723-9, 1999.
2. van der Pols JC, Williams GM, Pandeya N, et al.: Prolonged prevention of squamous cell carcinoma of the skin by regular sunscreen use. Cancer Epidemiol Biomarkers Prev 15 (12): 2546-8, 2006.

Interventions With Inadequate Evidence as to Whether They Reduce Risk of Melanoma

Sunscreen Use and Ultraviolet (UV) Radiation Avoidance

Benefits

There is inadequate evidence to determine whether the avoidance of sunburns or the use of sunscreen alters the incidence of cutaneous melanoma.

Magnitude of Benefit: Unknown.

Study Design: Primarily cohort or case-control studies. A post-hoc analysis of one randomized controlled trial of regular sunscreen use (vs. use at the personal discretion of the control group) suggested a possible decrease in melanoma in the regular sunscreen group that emerged years after the trial period ended. However, the numbers were extremely small, and the confidence intervals were consequently very large.[1]
Internal Validity: Poor.
Consistency: Poor.
External Validity: Not applicable (N/A).

Harms

The harms of sunscreen use are poorly quantified but are likely to be small, including allergic reactions to skin creams and lower production of vitamin D by the skin with less sun exposure.

References:

1. Thomas VD, Aasi SZ, Wilson LD, et al.: Cancer of the skin. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Vols. 1 & 2. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2008, pp 1863-87.

Description of the Evidence

Background

Incidence and mortality

There are three main types of skin cancer:

  • Basal cell carcinoma (BCC).
  • Squamous cell carcinoma (SCC) (together with BCC referred to as nonmelanoma skin cancer [NMSC]).
  • Melanoma.

BCC and SCC are the most common forms of skin cancer but have substantially better prognoses than the less common, generally more aggressive, melanoma.

NMSC is the most commonly occurring cancer in the United States. Its incidence appears to be increasing in some,[1] but not all,[2] areas of the country. Overall U.S. incidence rates have likely been increasing for a number of years.[3] At least some of this increase may be attributable to increasing skin cancer awareness and resulting increasing investigation and biopsy of skin lesions. The total number and incidence rate of NMSCs cannot be estimated precisely, because reporting to cancer registries is not required. However, based on extrapolation of Medicare fee-for-service data to the U.S. population, it has been estimated that the total number of persons treated for NMSCs in 2006 was about 2,152,500.[3] That number exceeds all other cases of cancer estimated by the American Cancer Society for that year, which was about 1.4 million.[4]

Melanoma is a reportable cancer in U.S. cancer registries, so there are more reliable estimates of incidence than is the case with NMSCs. In 2013, it is estimated that 76,690 individuals in the United States will be diagnosed with melanoma and approximately 9,480 will die of the disease.[5]

The incidence of melanoma has been increasing for at least 30 years.[5]

Risk Factors

Epidemiologic evidence suggests that exposure to UV radiation and the sensitivity of an individual's skin to UV radiation are risk factors for skin cancer, though the type of exposure (high-intensity and short-duration vs. chronic exposure) and the pattern of exposure (continuous vs. intermittent) may differ among the three main skin cancer types.[6,7,8] In addition, the immune system may play a role in pathogenesis of skin cancer. Organ transplant recipients receiving immunosuppressive drugs are at an elevated risk of skin cancer, particularly SCC. Arsenic exposure also increases the risk of cutaneous SCC.[9,10]

The visible evidence of susceptibility to skin cancer (skin type and precancerous lesions), of sun-induced skin damage (sunburn and solar keratoses), and the ability of an individual to modify sun exposure provide the basis for implementation of programs for the primary prevention of skin cancer.

Factors associated with increased risk of nonmelanoma skin cancer

Ultraviolet (UV) radiation exposure

Most evidence about UV radiation exposure and the prevention of skin cancer comes from observational and analytic epidemiologic studies. Such studies have consistently shown that increased cumulative sun exposure is a risk factor for NMSC.[7,8] Individuals whose skin tans poorly or burns easily after sun exposure are particularly susceptible.[7]

Factors associated with an increased risk of melanoma

UV radiation exposure

The relationship between UV radiation exposure and cutaneous melanoma is less clear than the relationship between UV exposure and NMSC. In the case of melanoma, it seems that intermittent acute sun exposure leading to sunburn is more important than cumulative sun exposure;[11] such exposures during childhood or adolescence may be particularly important.[6]

Interventions With Inadequate Evidence as to Whether They Reduce Risk of Nonmelanoma Skin Cancer

Sunscreen use and UV radiation avoidance

It is not known if interventions designed to reduce exposure to UV radiation through the use of sunscreens and/or protective clothing or through limitation of exposure time reduce the incidence of NMSC in humans. Some studies have used solar keratoses rather than invasive skin cancer as the study endpoint. It is generally felt that half or more of SCCs arise from solar keratoses. However, nearly half of SCCs occur in clinically normal skin.[12] A longitudinal study has shown that the progression rate from solar keratoses to SCC is about 0.075% to 0.096% per year, or less than 1 in 1,000 per year.[12] Moreover, in a population-based longitudinal study, there was an approximately 26% spontaneous regression rate of solar keratoses within 1 year of a screening examination.[13] Therefore, it is likely that solar keratosis is a poor surrogate endpoint in SCC prevention trials.

One very small randomized placebo-controlled study of a sunscreen (sun protection factor [SPF] 29) was conducted in 53 volunteers who had either clinical evidence of solar keratoses or NMSC.[14] Only 37 of the participants returned for the planned 2-year follow-up (attrition rate of 30%). The rate of new solar keratoses was lower after 2 years in the sunscreen group than in the placebo (base-cream) group (estimated 36% reduction in annual rate, P = .001). Another study showed that regular sunscreen use helps reduce the incidence of solar keratoses and increase remission of existing lesions.[15] In Australia, 588 persons aged 40 years and older who attended a free skin cancer screening clinic and had 1 to 30 solar keratoses were enrolled in a randomized controlled trial (RCT) assessing the effect of regular sunscreen (SPF 17) use on solar keratoses; 431 persons completed the study. Individuals in the sunscreen group developed fewer new lesions and had more remissions of existing lesions than those in the base-cream placebo group. There was an increase of 1.0 in the mean number of solar keratoses in the base-cream group versus a decrease of 0.6 in the sunscreen group (difference = 1.53; 95% confidence interval [CI], 0.81–2.25). The rate ratio of new lesions was 0.62 (95% CI, 0.54–0.71). Furthermore, in the sunscreen group, the development of new lesions and the remission of existing lesions were related to the amount of sunscreen used. Such a relationship was not observed in the base-cream group.

However, a different Australian randomized study (the Nambour Skin Cancer Prevention Trial) showed that, after 4.5 years of follow-up, there was no statistically significant difference in the incidence of BCCs or SCCs with regular SPF 16 sunscreen use. This study did not include a sunscreen placebo. Although a secondary subset analysis of the overall number of tumors showed a reduction in the frequency of SCCs on the sites of daily sunscreen application, the validity of the finding is questionable because of the possible effects of extensive multiple statistical testing.[16] An 8-year post-trial observational follow-up demonstrated statistically significant reductions in both the frequency and the overall incidence of SCCs in the regular sunscreen-use arm, but the reliability of these findings is uncertain given their occurrence outside of the controlled-trial environment.[17]

Chemopreventive agents

Beta carotene

In the Physicians' Health Study, 21,884 male physicians with no reported history of BCC or SCC were randomly assigned to take 50 mg doses of daily oral beta carotene versus placebo in a 2 × 2 factorial trial of beta carotene and aspirin.[18] Incidence of NMSCs was a secondary endpoint in the trial. After 12 years of beta carotene or placebo administration, there was no difference in incidence of either BCC or SCC. RCTs of long-term treatment with beta carotene in individuals previously treated for NMSC also showed no benefit in preventing the occurrence of new NMSCs.[16,19]

Isotretinoin

High-dose isotretinoin was found to prevent new skin cancers in individuals with xeroderma pigmentosum.[20] However, a RCT of long-term treatment with isotretinoin in individuals previously treated for BCC showed that this agent did not prevent the occurrence of new BCCs but did produce side effects characteristic of isotretinoin treatment.[21,22]

Selenium

A multicenter, double-blind, randomized, placebo-controlled trial of 1,312 patients with a history of BCC or SCC and a mean follow-up of 6.4 years showed that 200 µg of selenium (in brewer's yeast tablets) did not have a statistically significant effect on the primary endpoint of BCC development and may increase the risk of SCC and total NMSC.[23,24] The cumulative incidence of NMSC was 0.20 versus 0.16 per person year of follow-up in the selenium and placebo groups, respectively (unadjusted relative risk = 1.27; 95% CI, 1.11–1.45).

Celecoxib

The use of celecoxib as a chemopreventive agent for actinic keratosis was assessed in a double-blind, randomized, placebo-controlled trial. Two hundred forty high-risk men and women (each with 10–40 actinic keratoses and a history of previous skin cancer) received 200 mg doses of celecoxib twice daily or a placebo for 9 months with an additional 2-month follow-up. No difference was found in the incidence of actinic keratosis, but a post-hoc analysis revealed a statistically significant difference in the mean number of NMSCs per patient (rate ratio = 0.43; 95% CI, 0.24–0.75; absolute difference, 0.2 lesions per patient). The ultimate utility of celecoxib in preventing NMSCs remains unclear, given the exploratory nature of the analysis, the challenge of interpreting benefits in fractions of lesions, and the potential for serious adverse cardiovascular effects associated with long-term use of nonsteroidal anti-inflammatory drugs. However, the unexpected finding of the lack of effect of celecoxib on actinic keratosis but apparent effect on SCC and BCC incidence raises questions about the use of actinic keratosis as an intermediate endpoint for SCC and BCC and our understanding of the natural history of NMSCs.[25]

Alpha-difluoromethylornithine

Alpha-difluoromethylornithine (DFMO), an ornithine decarboxylase inhibitor used in intravenous form to treat African trypanosomiasis and in topical form to treat female hirsutism, was investigated as a chemopreventive agent in patients with prior NMSCs.[26] After a 4-week placebo run-in period, 291 volunteers who took at least 80% of their placebos were randomly assigned to oral DFMO (500 mg/m2 /day) versus placebo for up to 5 years (average 4 years). At baseline, the placebo group had a higher mean number of prior NMSCs than the DFMO group (4.9 vs. 4.2; P = .1), and a longer history of NMSC (P = .002), possibly favoring the DFMO group. The primary endpoint of the study was the number of new NMSC events, and the rate was 0.44 new cancers per year in the DFMO group versus 0.61 in the placebo group (P = .07). In a subset analysis, there was a statistically significant difference in BCC events favoring the DFMO group (0.28 vs. 0.40 per year; P = .03) and no difference in SCC rates. DFMO is known to have ototoxicity, and the average hearing loss of audiograms was greater in the DFMO group, which was about 4 dB versus 2 dB (P = .003). In the DFMO group,10.8% discontinued the study drug because of a greater than 15 dB hearing loss, compared with a 4.5% discontinuation in the placebo group (P = .06). DFMO hearing loss is usually reversible. In summary, the efficacy of DFMO for skin cancer prevention is unclear, and it remains investigational for this indication.

Interventions With Inadequate Evidence as to Whether They Reduce Risk of Melanoma

Sunscreens

Results from a collaborative European case-control study and one animal study suggest that sunscreens that protect against sunburn may not protect against UV radiation–associated cutaneous melanoma.[27,28] Nonmodifiable host factors, such as propensity to burn, a large number of benign melanocytic nevi, and atypical nevi may also increase the risk of developing cutaneous melanoma.[6]

A post hoc analysis of the Nambour Skin Cancer Prevention Trial (discussed above) examined the incidence of melanoma at a median of 14.2 person-years of follow-up. In the trial, participants were randomly assigned to daily or discretionary sunscreen use from 1992 to 1996. Follow-up continued until 2006 via either active participation, in which subjects completed periodic questionnaires about new skin cancers and relevant sun behaviors, or passive participation, in which subjects' medical records were reviewed for skin cancer diagnoses; 52% of the trial participants were actively participating as of 2006. Eleven melanomas were diagnosed in the daily sunscreen arm versus 22 in the discretionary-use arm (hazard ratio [HR] = 0.5; 95% CI, 0.24–1.02), of which 3 versus 11 were invasive, respectively (HR = 0.27; 95% CI, 0.08–0.97). There was no difference in the rates of melanoma on prescribed sunscreen application sites between the two groups. This study has several important limitations: melanoma was not a planned outcome of the original trial; the CIs of the outcome estimates are very wide, indicating substantial uncertainty of the magnitude of the effect; and there is potential for the introduction of confounding with the widespread use of the passive participant option during the follow-up phase of the study.[29]

A meta-analysis of 18 studies that explored the association between melanoma risk and previous sunscreen use illustrates widely differing study qualities and suggests little or no association.[30]

Behavioral Interventions to Change Sun-Protective Practices

As noted previously, direct evidence that interventions, such as sunscreen or protection from UV light exposure, decrease the risk of skin cancer is sparse. However, given the association between UV light exposure and subsequent risk of skin cancer, counseling interventions aimed at increasing sun-protective behaviors have been examined. The U.S. Preventive Services Task Force (USPSTF) commissioned a systematic review of this evidence. Although the USPSTF review found no randomized trials directly linking counseling strategies to skin cancer reduction, it found 11 trials, rated as fair in quality, that tested the effect of interventions on sun-protective behaviors.[31] Several trials of behavioral interventions in adults, sometimes as part of an intervention addressing multiple health-related behaviors, such as smoking and nutrition, showed a short-term increase in self-reported sun-protective behaviors. However, the effect sizes were small to modest, without clear evidence that the differences were clinically meaningful.[32,33,34,35,36] Likewise, appearance-based behavioral interventions in young women have had a favorable impact on self-reported indoor tanning behavior, but no long-term follow-up or health outcomes were reported.[37,38,39] A randomized, primary care office–based counseling intervention in adolescents showed an increase in self-reported midday sun avoidance and sunscreen use in the intervention group for up to 24 months.[40] A randomized trial of a provider-based sun protection promotion counseling program for parents for their infant children showed a small increase in sun-protective actions, of questionable clinical importance according to the researchers.[41]

Nevertheless, studies of intervention strategies for reducing UV radiation exposure suggest that the best approach is education about the risks associated with sun exposure and sunburn and education about sun-protection strategies.[42,43] In one study, an educational intervention at the time of treatment for skin cancer—a time when an individual may have heightened awareness of his or her susceptibility to skin cancer—seemed to have the greatest effect.[42] However, even in such a high-risk group, it was difficult for many individuals to maintain sun-protective behaviors. In a community skin cancer screening study, researchers found that, although regular use of sunscreens was not related to personal or family history of skin cancer, it was more common among persons who perceived themselves to be at moderate or high risk of developing melanoma.[43]

Sun-protective strategies may include avoiding sun exposure at times of the day when the exposure is more intense and wearing clothing that protects skin from sun exposure. Self-examination for skin-pigmentary characteristics associated with melanoma (e.g., freckling status) may be a useful way to identify individuals at an increased risk of developing melanoma.[44] Skin type (propensity to burn after sun exposure and tanning ability), alone or with other physical characteristics, such as hair color, has been used as a measure of sun sensitivity in epidemiologic studies.[45]

In summary, a number of randomized trials and other studies have suggested that counseling or health information may have an effect on sun- or UV-protective behaviors. However, in addition to lack of information on health outcomes and relatively short follow-up times, most of the studies suffer from important methodologic problems, including the possibility of self-reporting inaccuracy, high study attrition rates, and lack of information about sustainability of the interventions.

References:

1. Athas WF, Hunt WC, Key CR: Changes in nonmelanoma skin cancer incidence between 1977-1978 and 1998-1999 in Northcentral New Mexico. Cancer Epidemiol Biomarkers Prev 12 (10): 1105-8, 2003.
2. Harris RB, Griffith K, Moon TE: Trends in the incidence of nonmelanoma skin cancers in southeastern Arizona, 1985-1996. J Am Acad Dermatol 45 (4): 528-36, 2001.
3. Rogers HW, Weinstock MA, Harris AR, et al.: Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 146 (3): 283-7, 2010.
4. American Cancer Society.: Cancer Facts and Figures 2006. Atlanta, Ga: American Cancer Society, 2006. Also available online. Last accessed February 15, 2013.
5. American Cancer Society.: Cancer Facts and Figures 2013. Atlanta, Ga: American Cancer Society, 2013. Available online. Last accessed March 13, 2013.
6. Koh HK: Cutaneous melanoma. N Engl J Med 325 (3): 171-82, 1991.
7. Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992.
8. English DR, Armstrong BK, Kricker A, et al.: Case-control study of sun exposure and squamous cell carcinoma of the skin. Int J Cancer 77 (3): 347-53, 1998.
9. Thomas VD, Aasi SZ, Wilson LD, et al.: Cancer of the skin. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Vols. 1 & 2. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2008, pp 1863-87.
10. Le Mire L, Hollowood K, Gray D, et al.: Melanomas in renal transplant recipients. Br J Dermatol 154 (3): 472-7, 2006.
11. Gandini S, Sera F, Cattaruzza MS, et al.: Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer 41 (1): 45-60, 2005.
12. Marks R, Rennie G, Selwood TS: Malignant transformation of solar keratoses to squamous cell carcinoma. Lancet 1 (8589): 795-7, 1988.
13. Marks R, Foley P, Goodman G, et al.: Spontaneous remission of solar keratoses: the case for conservative management. Br J Dermatol 115 (6): 649-55, 1986.
14. Naylor MF, Boyd A, Smith DW, et al.: High sun protection factor sunscreens in the suppression of actinic neoplasia. Arch Dermatol 131 (2): 170-5, 1995.
15. Thompson SC, Jolley D, Marks R: Reduction of solar keratoses by regular sunscreen use. N Engl J Med 329 (16): 1147-51, 1993.
16. Green A, Williams G, Neale R, 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 354 (9180): 723-9, 1999.
17. van der Pols JC, Williams GM, Pandeya N, et al.: Prolonged prevention of squamous cell carcinoma of the skin by regular sunscreen use. Cancer Epidemiol Biomarkers Prev 15 (12): 2546-8, 2006.
18. Frieling UM, Schaumberg DA, Kupper TS, et al.: A randomized, 12-year primary-prevention trial of beta carotene supplementation for nonmelanoma skin cancer in the physician's health study. Arch Dermatol 136 (2): 179-84, 2000.
19. Greenberg ER, Baron JA, Stukel TA, et al.: A clinical trial of beta carotene to prevent basal-cell and squamous-cell cancers of the skin. The Skin Cancer Prevention Study Group. N Engl J Med 323 (12): 789-95, 1990.
20. Kraemer KH, DiGiovanna JJ, Moshell AN, et al.: Prevention of skin cancer in xeroderma pigmentosum with the use of oral isotretinoin. N Engl J Med 318 (25): 1633-7, 1988.
21. Tangrea JA, Edwards BK, Taylor PR, et al.: Long-term therapy with low-dose isotretinoin for prevention of basal cell carcinoma: a multicenter clinical trial. Isotretinoin-Basal Cell Carcinoma Study Group. J Natl Cancer Inst 84 (5): 328-32, 1992.
22. Tangrea JA, Adrianza E, Helsel WE, et al.: Clinical and laboratory adverse effects associated with long-term, low-dose isotretinoin: incidence and risk factors. The Isotretinoin-Basal Cell Carcinomas Study Group. Cancer Epidemiol Biomarkers Prev 2 (4): 375-80, 1993 Jul-Aug.
23. Clark LC, Combs GF Jr, Turnbull BW, et al.: Effects of selenium supplementation for cancer prevention in patients with carcinoma of the skin. A randomized controlled trial. Nutritional Prevention of Cancer Study Group. JAMA 276 (24): 1957-63, 1996.
24. Duffield-Lillico AJ, Slate EH, Reid ME, et al.: Selenium supplementation and secondary prevention of nonmelanoma skin cancer in a randomized trial. J Natl Cancer Inst 95 (19): 1477-81, 2003.
25. Elmets CA, Viner JL, Pentland AP, et al.: Chemoprevention of nonmelanoma skin cancer with celecoxib: a randomized, double-blind, placebo-controlled trial. J Natl Cancer Inst 102 (24): 1835-44, 2010.
26. Bailey HH, Kim K, Verma AK, et al.: A randomized, double-blind, placebo-controlled phase 3 skin cancer prevention study of {alpha}-difluoromethylornithine in subjects with previous history of skin cancer. Cancer Prev Res (Phila) 3 (1): 35-47, 2010.
27. Autier P, Doré JF, Schifflers E, et al.: Melanoma and use of sunscreens: an Eortc case-control study in Germany, Belgium and France. The EORTC Melanoma Cooperative Group. Int J Cancer 61 (6): 749-55, 1995.
28. Wolf P, Donawho CK, Kripke ML: Effect of sunscreens on UV radiation-induced enhancement of melanoma growth in mice. J Natl Cancer Inst 86 (2): 99-105, 1994.
29. Green AC, Williams GM, Logan V, et al.: Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol 29 (3): 257-63, 2011.
30. Dennis LK, Beane Freeman LE, VanBeek MJ: Sunscreen use and the risk for melanoma: a quantitative review. Ann Intern Med 139 (12): 966-78, 2003.
31. Lin JS, Eder M, Weinmann S: Behavioral counseling to prevent skin cancer: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 154 (3): 190-201, 2011.
32. Glazebrook C, Garrud P, Avery A, et al.: Impact of a multimedia intervention "Skinsafe" on patients' knowledge and protective behaviors. Prev Med 42 (6): 449-54, 2006.
33. Glanz K, Schoenfeld ER, Steffen A: A randomized trial of tailored skin cancer prevention messages for adults: Project SCAPE. Am J Public Health 100 (4): 735-41, 2010.
34. Prochaska JO, Velicer WF, Redding C, et al.: Stage-based expert systems to guide a population of primary care patients to quit smoking, eat healthier, prevent skin cancer, and receive regular mammograms. Prev Med 41 (2): 406-16, 2005.
35. Prochaska JO, Velicer WF, Rossi JS, et al.: Multiple risk expert systems interventions: impact of simultaneous stage-matched expert system interventions for smoking, high-fat diet, and sun exposure in a population of parents. Health Psychol 23 (5): 503-16, 2004.
36. Geller AC, Emmons KM, Brooks DR, et al.: A randomized trial to improve early detection and prevention practices among siblings of melanoma patients. Cancer 107 (4): 806-14, 2006.
37. Hillhouse J, Turrisi R, Stapleton J, et al.: A randomized controlled trial of an appearance-focused intervention to prevent skin cancer. Cancer 113 (11): 3257-66, 2008.
38. Mahler HI, Kulik JA, Gerrard M, et al.: Long-term effects of appearance-based interventions on sun protection behaviors. Health Psychol 26 (3): 350-60, 2007.
39. Stapleton J, Turrisi R, Hillhouse J, et al.: A comparison of the efficacy of an appearance-focused skin cancer intervention within indoor tanner subgroups identified by latent profile analysis. J Behav Med 33 (3): 181-90, 2010.
40. Norman GJ, Adams MA, Calfas KJ, et al.: A randomized trial of a multicomponent intervention for adolescent sun protection behaviors. Arch Pediatr Adolesc Med 161 (2): 146-52, 2007.
41. Crane LA, Deas A, Mokrohisky ST, et al.: A randomized intervention study of sun protection promotion in well-child care. Prev Med 42 (3): 162-70, 2006.
42. Robinson JK: Compensation strategies in sun protection behaviors by a population with nonmelanoma skin cancer. Prev Med 21 (6): 754-65, 1992.
43. Berwick M, Fine JA, Bolognia JL: Sun exposure and sunscreen use following a community skin cancer screening. Prev Med 21 (3): 302-10, 1992.
44. Gruber SB, Roush GC, Barnhill RL: Sensitivity and specificity of self-examination for cutaneous malignant melanoma risk factors. Am J Prev Med 9 (1): 50-4, 1993 Jan-Feb.
45. Weinstock MA: Assessment of sun sensitivity by questionnaire: validity of items and formulation of a prediction rule. J Clin Epidemiol 45 (5): 547-52, 1992.

Changes to This Summary (02 / 15 / 2013)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Description of the Evidence

Updated statistics with estimated new cases and deaths for 2013 (cited American Cancer Society as reference 5).

This summary is written and maintained by the PDQ Screening and Prevention Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.

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About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about skin cancer prevention. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Screening and Prevention Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

  • be discussed at a meeting,
  • be cited with text, or
  • replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Screening and Prevention Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."

The preferred citation for this PDQ summary is:

National Cancer Institute: PDQ® Skin Cancer Prevention. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/prevention/skin/HealthProfessional. Accessed <MM/DD/YYYY>.

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.

Disclaimer

The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov Web site can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site's Contact Form.

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For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.

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The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.

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The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page. The results for a wide range of search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related to the search term entered.

There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.

Find Publications

The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).

Last Revised: 2013-02-15

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