Good advice?

By Allison Evans, assistant managing editor

In March 2018, the United States Preventive Services Task Force (USPSTF) issued recommendations on behavioral counseling to prevent skin cancer, recommending behavioral counseling for only young and vulnerable patients. In its draft, the USPSTF concluded that “the current evidence is insufficient to assess the balance of benefits and harms of counseling adults about skin self-examination to prevent skin cancer.”

These recommendations garnered strong reactions from the specialty (see sidebar for more details). However, it also made many dermatologists wonder: What is the USPSTF, how does it come up with its recommendations, and what authority does it have to enforce them? Dermatology World reviews the scope and purpose of the USPSTF and how its recommendations affect dermatologists and their patients.

What is the USPSTF and what does it do?

Created in 1984, the USPSTF is an independent, volunteer panel of 16 national experts in disease prevention and evidence-based medicine, including representatives from primary care and preventive medicine, such as family medicine, pediatrics, behavioral health, gynecology, and nursing.

The mission of the task force is to improve the health of all Americans by making evidence-based recommendations about clinical preventive services, including screening tests, counseling, and preventive medications. “We make recommendations for clinical preventive services based on a selection of topics that are likely to have impact on the health of the population and based on very rigorous and prescribed reviews of the existing research,” said Susan Curry, PhD, chair of the USPSTF and professor of health management and policy at the University of Iowa’s College of Public Health.

While the task force makes recommendations for physician services, its intended audience is primary care physicians or those who provide services referred by a primary care physician. “We make recommendations for preventive clinical services for individuals who do not have signs of symptoms of disease,” said Dr. Curry.

“The organization [USPSTF] functions in a very thoughtful and precisely controlled manner of reviewing evidence-based publications, and making recommendations for primary care physicians. They aren’t making recommendations for dermatologists,” said June Robinson, MD, research professor of dermatology at Northwestern’s Feinberg School of Medicine.

The USPSTF was authorized by Congress, requiring the U.S. Department of Health and Human Services (HHS) to support the task force’s work. The Agency for Healthcare Research and Quality (AHRQ) supports the task force by helping with day-to-day operations, coordinating production of evidence reports, ensuring consistency of task force methods, and disseminating task force materials and recommendations. Despite this support, the USPSTF remains an independent body whose work does not require AHRQ or HHS approval.

“The task force does not do research of preventive services. We work with Evidence-based Practice Centers (EPC) that are under contract with AHRQ,” said Dr. Curry. “We work with these centers to scope reviews of topics that are selected.” The EPCs, which often consult with specialist physicians, will do the evidence reviews, and then the task force synthesizes the findings, deliberates the evidence, and makes recommendations.

How does the recommendation process work?

For each recommendation submitted to the task force, there is a rigorous four-stage development process that occurs over the course of two or more years.

The process includes the following:

1. Topic nomination

Anyone can submit a topic recommendation for review via the USPSTF website. The public can suggest a new preventive service topic or recommend reconsideration of an existing topic based on new evidence or changes in the public health burden of the condition. Topic nominations are accepted throughout the year.

2. Draft and final research plans

The task force, along with the researchers from an EPC, develops a draft research plan for the nominated topic. The plan includes key questions to be answered and target populations to be considered. The draft research plan is available on the USPSTF website for four weeks for public comment. The task force and researchers review and consider all comments while making any necessary revisions to the plan. The finalized research plan is posted on its website.

3. Draft evidence review and recommendation statement

Using the final research plan as a guide, EPC researchers gather, review, and analyze evidence on the topic from studies published in peer-reviewed scientific journals.

4. Final evidence review and recommendation statement

The task force and EPC consider all comments on draft evidence reviews and the draft recommendation statements. The EPC revises and finalizes the evidence reviews, and the task force finalizes the recommendation statements based on the final evidence review and public comments. The final recommendation statements and evidence reviews are posted on the USPSTF website and published in a peer-reviewed scientific journal.

Once the recommendation statements are finalized, various partners help disseminate and implement the recommendations.

USPSTF AND DERMATOLOGY

In total, the task force has published three recommendations on skin cancer screenings. In March 2018, the USPSTF published its recommendation, “Behavioral Counseling to Prevent Skin Cancer” in the Journal of the American Medical Association (2018;319(11):1134-1142), as an update to the 2009 recommendation on skin cancer screening with skin self-examination (SSE), and the 2012 recommendation on behavioral counseling for the primary prevention of skin cancer.

The USPSTF reviewed the evidence on whether counseling patients about sun protection reduces intermediate outcomes (e.g., sunburn or precursor skin lesions) or skin cancer. The task force also explored the links between counseling and behavior change; behavior change and skin cancer incidence; and counseling patients to SSE and skin cancer outcomes, as well as the harms of skin SSE.

The USPSTF determined that behavioral counseling interventions are of “moderate benefit in increasing sun protection behaviors in children, adolescents, and young adults with fair skin types.” It found adequate evidence that “behavioral counseling interventions result in a small increase in sun protection behaviors in adults older than 24 years with fair skin types.” Finally, the task force found insufficient evidence on the benefits of counseling adults about SSE to prevent skin cancer.

The USPSTF recommended “counseling young adults, adolescents, children, and parents of young children about minimizing exposure to UV radiation for persons aged six months to 24 years with fair skin types to reduce their risk of skin cancer.” This recommendation received a B grade. The task force recommended that “clinicians selectively offer counseling to adults older than 24 years old with fair skin types about minimizing their exposure to UV radiation to reduce the risk of skin cancer. Existing evidence indicates that the net benefit of counseling all adults older than 24 years is small.”

The recommendation also states that “clinicians should consider the presence of risk factors for skin cancer when determining whether this service is appropriate.” This recommendation received a C grade. Finally, the USPSTF gave the recommendation to counsel adults about SSE an I grade due to insufficient evidence to assess the balance of benefits and harms. (Read about the Academy’s response to the recommendations in the sidebar.)

“Benefits” vs. “harms”

According to the USPSTF recommendations, overutilizing skin cancer screenings could result in excessive biopsies, scarring that may occur after the procedure, patient anxiety, and superfluous doctor visits.

“The USPSTF’s recommendations for melanoma counseling are a reflection that our science has not been as strong as it should be,” said Martin Weinstock, MD, PhD, professor of dermatology and epidemiology at Brown University, and director of the Cutaneous Oncology Program and Pigmented Lesions Unit. Dr. Robinson adds, “Dermatologists need to produce the evidence to show we don’t cause undue anxiety or do excess biopsies, and that we don’t overload the system with too many doctor visits.”

Dr. Weinstock recently published a study that explored the psychosocial impact of skin biopsies in the setting of melanoma screenings. His research found no evidence of increased anxiety and distress for patients (Br J Dermatol. 2018 Sep 5. doi: 10.1111/bjd.17134. [Epub ahead of print] and Prev Med Rep. 2018; 10:310-6). Additionally, “we looked for evidence that people who were screened were more likely to have surgeries on their skin, and we did not find that. We also looked for evidence of excess visits and increased health care costs, but we found no evidence of that either. These were not randomized trials, so they have their limitation, but it is real evidence.” Dr. Weinstock and his colleagues’ findings were published too late, however, to be considered for the USPSTF’s final recommendations.

Even with this evidence, the USPSTF requires too high a level of proof compared to other preventive services, said Dr. Weinstock. Skin examinations aren’t as invasive as a colonoscopy, for example. “For someone to undergo a procedure like that, we want really really strong evidence,” he maintained. “The standard of proof should be correspondingly lowered for skin examinations.”

What does it mean for dermatologists?

While the USPSTF’s recommendations may give dermatologists pause, it is important to note that “since highly selected at-risk populations, such as patients with a personal history or family history, are not the focus of the USPSTF counseling recommendation, randomized clinical trials among individuals at risk did not weigh in the decision,” Dr. Robinson wrote in an editorial published in JAMA (2018;319(11):1101-1102.doi:10.1001/jama.2018.0163).

“Every study that they are going to review and place weight upon must have been performed in the population cared for by primary care physicians. The work that we as dermatologists are doing, which is key to people who are at elevated risk for skin cancer, carries limited weight to this group,” Dr. Robinson said. Essentially, much of the research offered up by dermatologists didn’t make the cut for the USPSTF evidence review because that work was done in high-risk populations of melanoma survivors. “That doesn’t mean the work is any less important. It just means it’s not important to primary care physicians. They’re not following melanoma patients like we are,” she said.

In her editorial, Dr. Robinson also highlights the problems of using the term “fair skin types,” and advocates that the definition of risk must be refined to incorporate population diversities. She worries that using that term may lead to misinterpretation of the at-risk population, such as people who sunburn but are not considered as having a fair skin type. “The terminology used by investigators needs to evolve to include all persons at risk, without disenfranchising portions of the diverse U.S. population.” She recommends using a more nuanced term like “sun-sensitive skin.”

Dr. Weinstock has spent much of his career focused on early detection of, and screening for, melanoma. Melanoma is a leading cause of death among skin conditions with close to 10,000 deaths per year for many years now, he said. “We really need to cut that number in half — or more — but at least make a substantial reduction. It seems to me that early detection is key to doing that. Primary prevention for the general population doesn’t work that well because we haven’t figured out how to do it very effectively,” he said.

Every five years, the USPSTF revisits its recommendations, which means in a few short years new research can be submitted for consideration. While the USPSTF’s recommendation may not impact how dermatologists practice, it highlights research gaps and can help guide researchers to conduct studies that address the task force’s evidentiary concerns.

What is the USPSTF and what do its skin cancer counseling recommendations mean for the specialty and its patients?