An expert panel has cited "insufficient evidence" to recommend visual screenings for melanoma. Here's what that really means.
A panel of government experts announced today that there’s not enough evidence to recommend that doctors perform visual screenings (a.k.a. full-body skin checks) for melanoma for patients with no known special risk for skin cancer.
That may sound like a change, especially if you’ve been getting annual exams from a dermatologist or have been encouraged to do screenings on yourself at home. But actually, it’s not a change at all: The panel’s decision was the same as it was the last time they reviewed this topic in 2009.
That doesn’t mean all skin-cancer experts are satisfied with the recent decision, though—or that you should stop any screenings you’re already doing. To get the full story, we spoke with Martin Weinstock, MD, PhD, professor of dermatology in the Warren Alpert Medical School of Brown University and co-author of an editorial published today in JAMA along with the official recommendation statement from the U.S. Preventive Services Task Force. Here’s Dr. Weinstock's take on the decision, and his advice for real life.
What does “insufficient evidence” mean?
First, some background: The Task Force is a panel of experts that makes recommendations for all types of medical procedures and screenings. Doctors and insurance companies are encouraged (and often required) to follow their lead, so their decisions can have big impacts on how medical care is delivered and paid for.
To make these recommendations, the Task Force looks at research—ideally, large-scale clinical trials—and weighs a procedure’s potential costs versus benefits.
For something like visual screenings for skin cancer, though, there aren’t a lot of large studies for the Task Force to look at. “It’s difficult to definitively know whether a screening in a doctor’s office is the thing that ultimately saves a person’s life,” says Dr. Weinstock. “To do a randomized clinical trial would cost millions of dollars, and it just doesn’t look like that’s going to happen anytime soon.”
Because of that, the Task Force says it is unable to make a blanket statement about screenings for all Americans. But, says Dr. Weinstock, it’s important to note: “Not making a recommendation is different from saying it’s not recommended, or that you shouldn’t do it.”
Are screenings still a good idea?
Even though the evidence wasn’t overwhelming enough to change the Task Force’s recommendation, some studies have shown that skin exams by doctors can reduce deaths from melanoma, the most dangerous type of skin cancer.
Melanoma is highly treatable if caught early, says Dr. Weinstock, and dermatologists believe that looking at the skin is the best way to do that. In fact, the American Academy of Dermatology (AAD) says that its own skin cancer screening program has resulted in the detection of more than 28,500 melanomas in the last 30 years.
“It is clear that approximately 10,000 Americans die of melanoma every year, and we would like to drastically reduce that number,” Dr. Weinstock says. “We do that through early detection—and that means visually identifying a cancer and surgically removing it once it’s diagnosed.”
What about risks versus benefits?
The benefits of skin cancer screenings are pretty clear: In some cases, they can save lives. But Dr. Weinstock agrees that the risks should be considered, as well.
“One concern is that everyone starts paying attention to their skin and seeing spots they didn’t see before, and then millions of people are getting surgery that turns out not to be necessary because most of these spots would never become cancerous,” he says.
But, he points out, he and his colleagues have developed a free online program to train primary care doctors to recognize skin cancers as well as benign (non-cancerous) moles and skin growths. A recent study in the journal Cancer found that when doctors were trained with this program and performed regular screenings, there was no spike in surgeries or referrals to dermatologists.
So it’s important that doctors know what to look for, especially if screenings were to be recommended in a primary care setting. On the other hand, the screening itself—a doctor looking over someone’s entire body—isn’t nearly invasive as, say, a colonoscopy.
“When you’re deciding whether we should recommend screenings for colon cancer, you consider the fact that a colonoscopy is a very unpleasant procedure; no one would do it voluntarily except that we know it saves lives,” Dr. Weinstock says. “For a skin cancer screening, we shouldn’t need the same type of evidence. Detection is simply looking at the skin.”
In other words, says Dr. Weinstock, the Task Force’s standards may be too high for a situation in which the risks are so minor. “My view is that the standard of evidence should be lower for demonstrating benefit,” he says.
So what should we do?
Dr. Weinstock’s advice for everyone (and the advice of the AAD) is to be aware of the warning signs of skin cancer: “anything new or changing in size, shape, or color,” he says.
Perform a monthly total-body self-exam at home, with the help of a friend or partner who can check hard-to-see areas for you. (Check out our guide to performing a self-exam.)You may even want to take photographs of any moles you do have, to track their size and shape over time.
People who are at increased risk of skin cancer—who are fair skinned or have a family history, for example—should also consider getting regular checks from a dermatologist, says Dr. Weinstock.
And most importantly, Dr. Weinstock points out that the Task Force’s report was directed at people without skin cancer symptoms. “Anything new or changing should still be brought to your doctor’s attention right away,” he says.