ACTAS
Dermo-Sifiliográficas
113
(2022)
T781---T791
REVIEW
[Translated
article]
Current
State
of
Skin
Cancer
Prevention:
A
Systematic
Review
C.
Alonso-Belmonte
a
,
T.
Montero-Vilchez
a,b,∗
,
S.
Arias-Santiago
a,b
,
A.
Buendía-Eisman
a
a
Facultad
de
Medicina,
Universidad
de
Granada,
Granada,
Spain
b
Servicio
de
Dermatología,
Hospital
Universitario
Virgen
de
las
Nieves,
Granada,
Spain
Received
20
December
2021;
accepted
12
April
2022
Available
online
8
July
2022
KEYWORDS
Skin
cancer;
Melanoma;
Primary
prevention;
Secondary
prevention
Abstract
Skin
cancer
deaths
continue
to
rise
despite
the
implementation
of
numerous
pre-
ventive
campaigns
and
programs.
The
aim
of
this
systematic
review
was
to
evaluate
reviews
of
primary
and
secondary
skin
cancer
prevention
strategies
as
reported
over
the
past
10
years.
We
analyzed
63
systematic
reviews
and
meta-analyses:
30
(46.6%)
addressing
primary
inter-
ventions
and
35
(55.6%)
addressing
secondary
interventions.
Tw o
of
the
reviews
covered
both.
The
most
widely
reported
primary
prevention
approaches
were
education
programs
(63.3%),
followed
by
risk
modeling
to
identify
individuals
at
high
risk
for
melanoma
(17.6%),
and
the
promotion
of
sunscreen
use
(11.8%).
The
most
widely
reported
secondary
prevention
measures
concerned
imaging
systems
for
early
skin
cancer
detection
(40%),
smartphones
and
new
tech-
nologies
(22.9%),
and
visual
diagnosis
in
population-based
screening
(17.4%).
The
most
effective
measures
were
primary
prevention
education
programs
to
improve
sun
protection
habits.
©
2022
AEDV.
Published
by
Elsevier
Espa
˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALABRAS
CLAVE
Cáncer
cutáneo;
Melanoma;
Prevención
primaria;
Prevención
secundaria
Situación
actual
de
la
prevención
del
cáncer
de
piel:
una
revisión
sistemática
Resumen
La
mortalidad
por
cáncer
de
piel
continúa
aumentando
a
pesar
de
las
numerosas
intervenciones
dedicadas
a
su
prevención.
El
objetivo
de
esta
revisión
es
estudiar
la
situación
de
la
prevención
primaria
y
secundaria
del
cáncer
de
piel
en
los
últimos
10
a
˜
nos.
Se
incluye
un
total
de
63
revisiones,
30
(46,6%)
revisiones
incluyeron
estrategias
de
prevención
primaria
y
35
(55,6%)
de
prevención
secundaria,
incorporando
2
de
las
revisiones
información
sobre
DOI
of
original
article:
https://doi.org/10.1016/j.ad.2022.04.015
∗
Corresponding
author.
E-mail
address:
(T.
Montero-Vilchez).
https://doi.org/10.1016/j.ad.2022.04.018
0001-7310/©
2022
AEDV.
Published
by
Elsevier
Espa
˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://
creativecommons.org/licenses/by-nc-nd/4.0/
).
C.
Alonso-Belmonte,
T.
Montero-Vilchez,
S.
Arias-Santiago
et
al.
ambos
tipos
de
estrategias.
Para
la
prevención
primaria,
las
medidas
más
estudiadas
fueron
los
programas
educativos
(63,3%),
seguidos
de
la
creación
de
modelos
para
identificar
a
personas
con
alto
riesgo
de
desarrollar
un
melanoma
(17,6%)
y
la
promoción
del
uso
de
fotoprotectores
(11,8%).
Los
sistemas
de
toma
de
imagen
para
el
diagnóstico
precoz
del
cáncer
de
piel
(40%),
seguidos
por
el
empleo
de
smartphones
y
nuevas
tecnologías
(22,9%),
así
como
el
diagnóstico
visual
como
cribado
poblacional
(17,4%),
fueron
las
medidas
de
prevención
secundaria
más
evaluadas.
De
todas
las
medidas
revisadas,
las
estrategias
de
prevención
primaria
centradas
en
programas
educativos
para
mejorar
los
hábitos
de
fotoprotección
fueron
las
que
resultaron
más
efectivas.
©
2022
AEDV.
Publicado
por
Elsevier
Espa
˜
na,
S.L.U.
Este
es
un
art
´
ıculo
Open
Access
bajo
la
licencia
CC
BY-NC-ND
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Skin
cancer
is
the
most
frequent
type
of
cancer
in
the
world.
The
main
risk
factor
for
developing
skin
cancer
is
exposure
to
sunlight,
which
can
be
acted
upon.
1,2
Skin
cancer
can
be
classified
as
melanoma
skin
cancer
and
nonmelanoma
skin
cancer
(NMSC).
3
Melanoma
is
an
aggres-
sive,
highly
metastatic
cancer,
4
in
which
the
clinical
and
pathological
variety
is
affected
by
the
type
of
sun
expo-
sure.
Intermittent
exposure
and
sunburn
during
infancy
and
adolescence
predispose
individuals
to
superficial
spread-
ing
melanoma,
whereas
long-term
exposure
predisposes
to
lentigo
maligna
melanoma.
Nodular
melanoma
has
been
associated
with
both
intermittent
and
long-term
exposure
to
sunlight.
Acral
lentiginous
melanoma
is
not
associated
with
exposure
to
sunlight.
5
NMSC
includes
basal
cell
carcinoma
(BCC)
and
squamous
cell
carcinoma
(SCC),
together
with
other,
less
common
types
of
skin
cancer.
BCC
is
the
most
common
malignant
tumor
in
humans,
accounting
for
60%
of
all
skin
tumors,
and
is
associated
with
intermittent
exposure
to
sunlight
during
an
individual’s
lifetime.
6,7
SCC
is
associated
with
cumulative
exposure
over
time.
8
The
incidence
and
mortality
of
skin
cancer
have
risen
in
recent
years.
This
rise
has
been
associated
with
an
increase
in
exposure
to
sunlight,
an
increase
in
the
number
of
immunosuppressed
persons
(immunosuppression
is
also
a
risk
factor
for
skin
cancer),
and
increased
overall
survival
of
the
population.
9,10
In
Spain,
the
incidence
of
BCC
was
253.2
per
100
000
person-years,
that
of
SCC
was
38.2
per
100
000
person-years,
and
that
of
melanoma
8.8
per
100
000
person-
years.
11
Mortality
has
also
increased
in
recent
years
and
now
stands
at
2.2
per
100
000
person-years
12---14
compared
with
1.8
per
100
000
person-years
in
2001.
15
In
Australia,
the
mea-
sures
implemented
to
prevent
skin
cancer
some
decades
ago
have
clearly
proven
able
to
reduce
incidence.
2
However,
data
reported
for
the
Spanish
population
suggest
that
the
primary
preventive
strategies
implemented
are
insufficient
or
inappropriate.
16
The
World
Health
Organization
defines
primary
preven-
tion
as
the
set
of
measures
that
act
on
factors
that
cause
and
predispose
to
disease
in
order
to
reduce
their
incidence,
whereas
secondary
prevention
involves
early
diagnosis
of
incipient
(asymptomatic)
disease
in
order
to
enable
early
treatment,
thus
avoiding
severe
consequences
and
improv-
ing
survival.
17
The
objective
of
this
review
was
to
explore
primary
and
secondary
measures
for
prevention
of
skin
cancer
during
the
last
10
years.
Material
and
Methods
Design
and
Search
Criteria
We
designed
a
systematic
literature
review
to
answer
the
following
research
questions:
•
What
are
the
most
widely
studied
primary
and
secondary
prevention
methods
at
present?
•
What
interventions
for
preventing
skin
cancer
have
been
implemented
at
the
population
level
during
the
last
10
years?
•
Are
these
measures
really
effective
for
preventing
skin
cancer?
•
Are
the
strategies
currently
being
applied
in
the
popula-
tion
sufficient
for
preventing
skin
cancer?
On
March
15,
2021,
we
carried
out
a
bibliographic
search
of
the
Medline
databases
of
all
articles
published
from
Jan-
uary
1,
2011
to
March
14,
2021.
We
followed
the
Preferred
Reporting
Items
for
Systematic
Reviews
and
Meta-Analyses
(PRISMA)
guidelines
using
the
following
search
algorithm:
(‘‘skin
cancer’’
OR
‘‘melanoma’’)
AND
(‘‘prevention’’
OR
‘‘screening’’
OR
‘‘primary
prevention’’
OR
‘‘secondary
pre-
vention’’).
Inclusion
and
Exclusion
Criteria
The
search
was
limited
to
systematic
reviews
and
meta-
analyses
from
the
last
10
years
in
English,
Spanish,
Italian,
French,
and
German
that
included
information
associated
with
primary
and
secondary
prevention
(screening)
of
skin
cancer.
We
excluded
articles
with
other
types
of
design,
reviews
focusing
on
risk
and
etiologic
factors
or
treatments,
articles
on
prevention
for
high-risk
populations
(patients
with
a
previous
diagnosis
of
melanoma,
immunodepressed
patients,
and
other
special
situations),
and
articles
on
advanced
diagnostic
systems
focusing
on
the
individual
T782
ACTAS
Dermo-Sifiliográficas
113
(2022)
T781---T791
Figure
1
Flow
diagram
of
the
studies
included
in
the
review.
patient
and
not
applicable
at
the
population
level
(diag-
nosis
based
on
confocal
microscopy
and
optical
coherence
tomography).
Selection
of
Studies
Tw o
investigators
(CAB
and
ABE)
performed
the
first
screen
and
independently
reviewed
the
titles
and
abstracts
of
the
articles
found
in
the
first
search
to
identify
relevant
studies.
We
reviewed
the
full
text
of
all
those
articles
fulfilling
the
inclusion
criteria
and
checked
the
bibliographic
references
to
search
for
additional
sources.
Those
articles
considered
relevant
by
both
investigators
were
included
in
the
review.
Disagreements
on
the
exclusion
or
inclusion
of
articles
were
discussed
until
agreement
was
reached.
If
agreement
was
not
reached,
then
a
third
investigator
(SAS)
made
the
final
decision.
Variables
We
collected
information
on
the
type
of
prevention
strategy
(primary
or
secondary),
the
author,
type
of
tumor,
target
population,
intervention,
setting
for
application
(primary
care,
hospital
care,
or
other),
and
conclusions.
Results
The
search
yielded
a
total
of
728
articles,
of
which
63
were
eventually
included
(Fig.
1).
Thirty
reviews
(46.6%)
included
primary
prevention
strategies
and
35
(55.6%)
included
sec-
ondary
prevention
strategies.
Tw o
of
the
reviews
included
information
on
both
types
of
strategy.
The
prevention
strate-
gies
focused
mainly
on
preventing
melanoma
or
skin
cancer
in
general.
Primary
Prevention
We
included
30
reviews
on
primary
prevention.
The
useful-
ness
of
educational
programs
was
the
most
widely
studied
measure
(n
=
19,
63.3%)
(Table
1).
Six
reviews
(20%)
eval-
uated
models
for
identifying
people
with
a
high
risk
for
melanoma,
4
(13.3%)
contained
information
on
the
use
of
sunscreen,
and
1
(3.3%)
included
information
on
the
legisla-
tion
applying
to
the
use
of
sunbeds.
Education
Programs
Educational
programs
were
the
most
widely
studied
primary
prevention
strategy
(n
=
19,
63.3%).
Measures
to
prevent
skin
cancer
are
cost-effective.
18
Informative
images
are
an
effective
way
to
improve
attitudes,
knowledge,
and
behav-
ior
with
respect
to
sun
protection
and
the
effectiveness
of
T783
C.
Alonso-Belmonte,
T.
Montero-Vilchez,
S.
Arias-Santiago
et
al.
Table
1
Articles
Included
in
the
Review
on
Primary
Prevention.
Primary
prevention
Method
No.
of
reviews
Additional
information
Conclusions
Educational
measures
19
-
Reminders
-
Educational
images
-
Physical
appearance
-
UV
index
-
Educational
programs
Improve
behaviors
through
self-information
Improve
behaviors,
especially
if
the
images
focus
on
appearance.
All
images
are
of
White
persons
Improve
behaviors
more
than
interventions
focusing
on
health
Not
useful,
as
not
understood
by
general
population
Useful
in
the
various
settings
where
they
are
applied
and
improve
behaviors,
although
they
are
insufficient
and
policies
to
support
them
are
lacking
Risk
assessment
models
6
Melanoma
Report
the
usefulness
of
risk
protection
models
for
identification
of
persons
with
a
high
suspicion
of
melanoma
and
who
are
candidates
for
exhaustive
prevention
measures.
Validated
models
are
necessary
before
systematic
use
in
clinical
practice
Use
of
sunscreen
4
Melanoma
and
nonmelanoma
skin
cancer
The
association
between
reduced
incidence
of
melanoma
and
use
of
sunscreen
is
weak,
probably
because
use
of
sunscreen
is
linked
to
increased
exposure.
With
respect
to
nonmelanoma
skin
cancer,
sunscreen
has
proven
effective
for
prevention
of
actinic
keratosis
and
squamous
cell
cancer,
whereas
this
efficacy
is
less
clear
for
basal
cell
cancer
Tanning
booths
1
Melanoma
in
young
people
Legislation
regulating
the
use
of
sunbeds
is
associated
with
a
reduction
in
their
use
self-examination.
19---21
Images
can
also
affect
the
way
people
perceive
the
attractiveness
of
tanned
skin.
21
Tw o
reviews
analyzed
the
impact
of
reminders
via
text
messages
and
email
on
the
prevention
of
skin
cancer.
22,23
The
authors
found
that
reminders
reduce
the
number
of
cases
of
sunburn;
however,
since
the
information
was
self-reported,
they
were
unable
to
conclude
that
this
measure
had
a
real
impact
on
the
prevention
of
skin
cancer.
23
A
review
of
5
trials
reported
that
reminders
via
text
messages
had
no
beneficial
effects
on
sun
protection
habits.
22
Prevention
strategies
focusing
on
physical
appearance
and
skin
aging
have
also
been
evaluated,
revealing
that
in
terms
of
sun
protection,
strategies
focusing
on
physi-
cal
appearance
were
more
effective
than
those
focusing
on
health,
since
tanned
skin
is
usually
associated
with
concerns
over
cosmetic
appearance.
24,25
Educational
interventions
focusing
on
physical
appearance
reduce
exposure
to
the
sun’s
rays
and
improve
people’s
intentions
and
habits
with
respect
to
sun
protection
immediately
after
application
and
up
to
1
year
later.
24
General
knowledge
of
the
Global
Solar
UV
Index
is
poor,
26
and
it
is
not
clear
whether
an
under-
standing
of
the
index
affects
attitudes
to
sun
protection,
since
this
has
been
associated
with
higher-risk
behavior
and
more
frequent
deliberate
exposure
to
sunlight,
as
well
as
with
lower-risk
behavior,
in
the
form
of
a
fewer
cases
of
sunburn.
27
As
for
implementation
of
education
strategies
for
prevention
in
specific
settings,
3
reviews
focused
on
the
occupational
setting.
28---30
Knowledge
of
and
attitudes
toward
sunlight
differ
between
workers,
and
there
are
even
some
people
who
have
never
heard
of
skin
cancer.
28
Edu-
cational
interventions
in
the
workplace
are
effective
for
improving
sun
protection
habits
among
people
who
work
outdoors
and
for
reducing
the
frequency
of
sunburn.
29
Edu-
cational
and
multicomponent
interventions
increase
the
use
of
personal
protection
material,
such
as
sunscreen;
however,
there
is
less
evidence
on
the
effectiveness
of
policies
or
the
specific
components
of
the
intervention.
30
Interventions
targeting
school
children
have
shown
promising
results.
31---33
Education
programs
on
prevention
are
more
useful
when
applied
to
younger
school
children
than
to
adolescents.
33
Education
programs
in
primary
and
sec-
ondary
schools
led
to
improved
sun
protection
knowledge
and
habits,
although
few
studies
led
to
reduced
sun
exposure
time.
31
The
results
reported
were
considerably
heteroge-
neous,
except
for
the
improvement
in
attitudes
toward
the
appropriateness
of
tanned
skin.
Sunburn
and
nevus
counts
were
evaluated
less
frequently,
although
around
half
of
the
studies
reported
a
reduction
in
the
number
of
burns
and
nevi
after
application
of
prevention
strategies.
31
In
outdoor
settings,
providing
free
sunscreen
attracted
considerable
interest
among
the
public,
although
no
clear
T784
ACTAS
Dermo-Sifiliográficas
113
(2022)
T781---T791
results
were
established
on
its
effectiveness.
32
Interventions
implemented
among
tourists
were
ineffective,
with
strate-
gies
based
on
images
of
photoaging
the
only
ones
that
proved
to
be
of
notable
use.
34
Multicomponent
community
interventions
increased
the
use
of
sunscreen
and
reduced
sun
exposure.
35
Interventions
implemented
through
the
media
alone
were
not
effective,
although
they
did
slightly
improve
sun
protection
habits.
35
Behavioral
interventions
implemented
through
primary
care
served
to
improve
sun
protection
habits
and
skin
self-
examination.
However,
they
did
entail
an
increase
in
the
number
of
unnecessary
diagnostic
and
therapeutic
proce-
dures,
with
no
reduction
in
the
number
of
cases
of
sunburn
or
in
the
incidence
of
skin
cancer.
36
Risk
Assessment
Systems
Six
reviews
(20%)
analyze
the
usefulness
of
identifying
peo-
ple
at
high
risk
of
melanoma
and
who
would
be
candidates
for
preventive
measures,
follow-up,
and
early
and
exhaus-
tive
screening.
37---42
Many
risk
prediction
models
are
available,
although
they
differ
in
terms
of
the
risk
factors
included.
The
most
com-
monly
included
risk
factor
is
the
nevus
count.
37,38
Other
factors
included
in
the
models
are
degree
of
sun
exposure,
the
presence
and
density
of
freckles,
history
of
sunburn,
hair
color,
skin
color,
and
age.
37---39
Internal
and
external
validation
of
these
models
is
uncommon,
and
other
perfor-
mance
measures
and
their
application
in
clinical
practice
are
rarely
reported.
37,39
Tw o
reviews
showed
the
discriminatory
capacity
of
the
models
to
be
low
owing
to
heterogene-
ity
in
the
selection
and
evaluation
of
risk
factors.
The
authors
state
that
it
is
difficult
to
draw
comparisons
between
the
models
owing
to
differences
in
methodology
during
development.
37,39
Nevertheless,
another
review
showed
that
despite
the
disparity
between
the
factors
included
and
the
different
sensitivity
and
specificity
cut-offs,
almost
all
the
models
had
a
similar
discriminatory
power,
with
sensitiv-
ity
and
specificity
values
that
fit
along
a
receiver
operating
characteristic
curve
and
an
area
under
the
curve
of
0.755.
38
A
systematic
review
of
international
clinical
practice
guidelines
also
reported
differences
concerning
which
indi-
viduals
are
at
high
risk
of
melanoma.
The
most
consistently
included
high-risk
characteristics
were
the
presence
of
mul-
tiple
melanocytic
nevi,
dysplastic
nevi,
family
history
of
melanoma,
giant
congenital
nevi,
and
Fitzpatrick
skin
types
I
and
II.
40
Identification
of
persons
at
risk
of
melanoma
and
appli-
cation
of
preventive
behaviors
improved
sun
protection
habits
and
increased
the
frequency/thoroughness
of
skin
self-examination.
41
Moreover,
detection
of
gene
mutations
that
predispose
to
melanoma
in
persons
with
a
family
his-
tory
of
risk
impacted
behaviors
for
prevention
of
skin
cancer,
although
there
is
no
evidence
on
measures
to
be
taken,
recommendations,
or
follow-up
of
affected
patients.
42
Use
of
Sunscreen
The
effect
of
sunscreen
as
a
preventive
measure
was
eval-
uated
in
4
reviews
(13.3%).
3,43---45
The
association
between
the
use
of
sunscreen
and
reduced
risk
of
melanoma
is
weak
and
heterogeneous,
since
the
use
of
sunscreen
may
be
associated
with
increased
sun
exposure
owing
to
the
false
sense
of
security
it
provides
and,
on
occasion,
inappropriate
application.
43,44
One
review
showed
that
the
use
of
sun-
screen
did
not
increase
the
risk
of
melanoma,
BCC,
or
SCC.
3
Sunscreen
was
also
effective
for
reducing
the
frequency
of
actinic
keratosis
and
SCC,
45
as
well
as
that
of
BCC,
although
this
association
is
less
clear.
45
Other
Primary
Prevention
Measures
One
review
found
that
legislation
regulating
the
use
of
tan-
ning
beds
was
associated
with
a
decreased
frequency
of
use.
46
Secondary
Prevention
A
total
of
35
reviews
provided
information
on
secondary
pre-
vention
strategies
(55.5%)
(Table
2).
The
most
widely
studied
strategy
was
digital
imaging
systems
for
early
diagnosis
with
dermoscopy
or
artificial
intelligence
systems
(n
=
14,
40%).
Eight
reviews
(22.9%)
included
information
about
strategies
based
on
the
use
of
a
smartphone
as
a
diagnostic
system
or
as
a
teledermatology
tool,
6
(17.4%)
on
visual
diagnosis
and
its
role
in
population
screening,
and
others
on
various
topics.
Early
Diagnosis
Based
on
Imaging
Systems
Fourteen
reviews
(40%)
evaluated
the
effect
of
imag-
ing
techniques
on
secondary
prevention
of
skin
cancer.
Eight
evaluated
dermoscopy
(57.1%),
4
artificial
intelligence
(28.6%),
and
2
total
body
photography
(14.3%).
Combined
with
an
exhaustive
clinical
history
and
visual
inspection,
dermoscopy
favored
early
diagnosis
of
melanoma
and
NMSC
when
used
by
dermatologists.
47---54
Fur-
thermore,
follow-up
of
persons
at
high
risk
of
melanoma
with
digital
dermoscopy
increased
the
number
of
melanomas
treated
in
early
stages.
47
Its
usefulness
in
primary
preven-
tion
is
more
controversial.
48---51
Dermoscopy
proved
to
be
a
useful
technique
for
urgent
referral
of
patients
at
high
risk
of
skin
cancer
49
and
for
differentiating
between
benign
and
malignant
lesions.
48,50
Nevertheless,
there
are
no
struc-
tured
algorithms
showing
the
accuracy
of
dermoscopy
for
detection
of
SCC.
52
Artificial
intelligence
consists
of
the
development
of
neu-
ronal
networks
that
can
analyze
images
of
skin
lesions
in
order
to
provide
a
diagnosis.
Together
with
a
physical
exam-
ination
and
dermoscopy,
artificial
intelligence
has
proven
to
be
a
useful
method
for
early
diagnosis
of
skin
cancer,
espe-
cially
melanoma,
even
in
primary
care.
55---58
Nevertheless,
this
approach
is
still
under
development
and
requires
the
participation
of
dermatologists
to
improve
the
technology
so
that
it
can
be
applied
in
future
clinical
practice.
58
Total
body
photography
has
proven
useful
for
the
diagno-
sis
of
early-stage
melanoma
in
high-risk
patients.
However,
further
studies
are
necessary
to
determine
the
factors
that
make
it
possible
to
identify
this
high-risk
population
and
enable
appropriate
implementation
of
programs
in
clinical
practice.
59,60
T785
C.
Alonso-Belmonte,
T.
Montero-Vilchez,
S.
Arias-Santiago
et
al.
Table
2
Articles
Included
in
the
Review
on
Secondary
Prevention.
Secondary
prevention
Method
No.
of
reviews
Additional
information
Conclusions
Early
diagnosis
with
imaging
systems
14
-
Dermoscopy
-
AI
-
TBP
Useful
in
early
diagnosis,
and
more
so
if
used
in
high-risk
patients.
Favors
diagnosis
during
early
stages
of
melanoma
and
BCC,
especially
if
combined
with
visual
inspection
and
used
by
dermatologists.
Could
prove
useful
in
primary
care
Not
yet
shown
to
be
effective.
Under
development
Useful
for
the
diagnosis
of
early-stage
melanoma
in
high-risk
patients.
Criteria
for
implementation
must
be
set
Smartphones
and
new
technologies
8
-
Apps
for
early
diagnosis
-
As
an
aid
in
teledermatology
Apps
cannot
yet
be
considered
reliable.
Only
developed
for
melanoma
Useful
tool
for
facilitating
consultations
with
the
primary
care
dermatologist
by
making
best
use
of
the
patient’s
time
and
reducing
the
number
of
referrals.
Implies
greater
workload,
lack
of
clinical
information
for
diagnosis,
and
more
consultations.
Standardized
clinical
guidelines
are
necessary
to
regulate
their
use
Visual
examination
6
-
As
a
diagnostic
method
-
As
population
screening
-
Self-examination
This
approach
is
insufficient
and
depends
on
the
professional
performing
the
examination.
Should
be
combined
with
dermoscopy
Cost-effective
in
high-risk
patients.
No
benefit
when
applied
to
healthy
persons,
since
it
leads
to
overdiagnosis
and
unnecessary
treatment
No
benefits
Abbreviations:
AI,
artificial
intelligence;
BCC,
basal
cell
cancer;
TBP,
total
body
photography.
Smartphones
and
New
Technologies
Eight
reviews
(22.9%)
studied
the
effect
of
smartphones
and
new
technologies
on
secondary
prevention
of
skin
cancer.
61---68
Smartphone
applications
for
the
diagnosis
of
skin
cancer
are
not
reliable
because
they
are
only
designed
to
distinguish
between
melanoma
and
other
lesions.
61---63
Vari-
ations
in
skin
lesions
in
the
general
population
and
in
image
quality
made
it
difficult
to
diagnose
skin
cancer
using
these
applications.
64
In
the
case
of
teledermatology,
smartphones
and
other
technological
devices
did
in
fact
prove
useful
for
enabling
referrals
to
dermatology
from
primary
care,
thus
optimizing
waiting
time
and
reducing
the
number
of
in-person
referrals.
This
approach
proved
especially
useful
in
rural
areas,
where
attending
a
hospital
is
difficult.
65---67
The
main
obstacles
to
implementation
were
increased
work-
load
and
lack
of
clinical
information
on
which
to
base
a
diagnosis.
63
Guidelines
are
necessary
for
standardization
of
the
techniques
used
to
obtain,
store,
and
review
images,
65
as
are
studies
for
prospective
and
practical
evaluation
of
the
ability
of
this
channel
to
provide
an
accurate
diagnosis
and
classify
lesions.
66
Visual
Inspection
and
Population
Screening
Six
reviews
(17.4%)
that
analyzed
the
impact
of
skin
can-
cer
screening
in
the
general
population
were
unable
to
find
benefits.
18,33,69---72
Skin
cancer
screening
did
prove
beneficial
in
high-risk
patients
69
and
was
cost-effective.
18
However,
screening
of
the
general
public
for
melanoma
and
NMSC
based
on
whole
body
examination
is
not
supported
by
evidence,
33
since
it
is
associated
with
overdiagnosis
and
inappropriate
treatment,
with
psychosocial
consequences
for
the
public.
70,71
Furthermore,
used
as
the
only
diagnos-
tic
tool,
visual
inspection
proved
insufficient
and
depended
on
the
professional
who
performed
the
examination.
70
The
effectiveness
of
skin
self-examination
for
prevention
of
skin
cancer
is
controversial.
72
Other
Secondary
Prevention
Strategies
Early
detection
of
skin
cancer
increased
incidence,
albeit
with
a
specific
increase
in
the
rates
of
diagnosis
of
early-stage
melanoma,
and
while
this
was
associated
with
decreased
mortality,
the
level
of
evidence
remains
low.
73
The
diagnostic
delay
observed
in
BCC
entails
increased
costs
and
more
complex
surgical
procedures.
74
Nursing
staff
could
play
an
important
role
in
skin
cancer
screening,
although
their
current
level
of
training
is
insufficient
to
perform
a
whole
body
skin
examination.
75---77
Many
educational
inter-
ventions
for
prevention
of
skin
cancer
have
focused
on
primary
care
physicians,
although
the
effectiveness
of
this
approach
has
not
been
evaluated.
78
Similarly,
the
growing
concern
and
awareness
of
skin
cancer
are
leading
to
an
increase
in
the
number
of
unnecessary
surgical
procedures
as
a
prophylactic
approach
for
melanocytic
lesions.
79
T786
ACTAS
Dermo-Sifiliográficas
113
(2022)
T781---T791
Discussion
Multiple
measures
have
been
applied
for
the
primary
and
secondary
prevention
of
skin
cancer.
The
most
effective
have
been
primary
prevention
strategies
focusing
on
edu-
cation
programs
aimed
at
improving
sun
protection
habits.
However,
evidence
is
lacking
for
the
direct
impact
of
this
approach
on
the
morbidity
and
mortality
of
cancer.
Screen-
ing
of
the
general
population
is
not
effective,
and
it
is
necessary
to
develop
models
for
evaluation
and
prediction
of
skin
cancer
in
order
to
select
those
patients
who
are
at
greater
risk
of
skin
cancer
and
candidates
for
targeted
interventions.
What
are
the
Most
Widely
Studied
Primary
and
Secondary
Prevention
Measures
at
Present?
In
primary
prevention,
most
strategies
focus
on
education
programs
aimed
at
increasing
knowledge
of
risk
factors
in
skin
cancer
and
on
the
measures
necessary
to
prevent
it,
with
the
greatest
emphasis
on
sunscreen.
19---21
The
second
most
studied
strategy
was
the
implementation
of
risk
assess-
ment
systems
to
identify
persons
at
greater
risk
of
skin
cancer
who
are
potential
candidates
for
targeted
prevention
programs.
37,38
The
use
of
sunscreen
was
also
evaluated,
45
as
was
the
existence
of
legislation
on
indoor
tanning
devices.
80
The
most
widely
evaluated
secondary
prevention
strate-
gies
were
as
follows:
early
diagnosis
based
on
imaging
systems
(including
dermoscopy),
47
artificial
intelligence,
58
and
total
body
photography
60
;
the
use
of
smartphones
as
tools
for
diagnosing
skin
cancer
64
and
as
an
aid
in
teledermatology
65
;
and
visual
inspection
as
a
population
screening
technique.
69
Smartphones
and
new
technologies
are
increasingly
used
in
many
areas
of
medicine,
81---83
with
dermatology
being
one
of
the
specialties
where
this
approach
is
has
most
fre-
quently
been
implemented.
84
However,
most
of
these
tools
require
additional
assessments
to
clearly
demonstrate
their
effectiveness.
63,66
The
use
of
new
technologies,
such
as
smartphones
and
instant
messaging,
could
increase
work-
ers’
knowledge
of
sun
exposure
and
reduce
the
incidence
of
skin
cancer.
28
Smartphones
could
be
more
widely
applied
in
teledermatology,
although
validated
clinical
guidelines
are
necessary
to
improve
implementation.
61,67
Artificial
intelligence
could
play
a
major
role
in
the
link
between
dermatology
and
primary
care.
56,58,84,85
What
Interventions
for
Preventing
Skin
Cancer
Have
Been
Implemented
at
the
Population
Level
in
the
Last
10
Years?
Education
strategies
19---21
and
skin
cancer
screening
aimed
at
high-risk
persons
69
are
the
main
skin
cancer
strategies
at
population
level.
Education
strategies
have
the
greatest
effect
on
preven-
tion
of
skin
cancer,
since
they
improve
sun
protection
habits
among
the
population,
29
although
studies
should
be
per-
formed
to
establish
a
correlation
with
reduced
morbidity
and
mortality
of
skin
cancer.
28
The
yield
of
education
pro-
grams
is
particularly
good
in
children.
18
This
observation
is
highly
relevant,
since
75%
of
cases
of
skin
cancer
could
be
prevented
with
appropriate
protection
during
childhood.
15
The
information
in
these
programs
should
focus
on
the
bene-
fits
of
sun
protection
in
terms
of
physical
appearance,
rather
than
on
health
and
disease,
24,25
and
should
be
provided
via
visual
images
of
sun
damage.
20,21
Given
that
tanned
skin
is
a
cosmetic
issue,
showing
images
of
the
damage
caused
by
exposure
to
sunlight
could
have
a
considerable
impact
on
the
population.
One
example
is
the
national
campaign
of
the
Healthy
Skin
Foundation
(Fundación
Piel
Sana)
of
the
Span-
ish
Academy
of
Dermatology
and
Venereology
(Academia
Espa
˜
nola
de
Dermatología
y
Venereología),
which
uses
the
slogan
‘‘A
suntan
is
not
synonymous
with
health
and
should
not
be
synonymous
with
beauty’’
(El
bronceado
no
es
sinón-
imo
de
salud
y
no
debería
serlo
de
belleza).
86
Education
strategies
improve
people’s
behavior,
although
we
should
assess
their
impact
in
terms
of
incidence
and
mortality.
36
These
programs
should
also
be
supported
by
consistent
policies
that
favor
their
application.
28
The
Aus-
tralian
campaign
SunSmart,
which
was
implemented
more
than
3
decades
ago,
has
shown
the
importance
of
cam-
paigns
aimed
at
schoolchildren
for
improving
sun
protection
habits.
87
In
Europe,
we
have
the
Euromelanoma
project,
a
campaign
that
offers
free
skin
examinations
to
the
public.
The
campaign
is
implemented
in
Spain
through
the
Healthy
Skin
Foundation,
focusing
on
both
primary
and
secondary
prevention
of
skin
cancer
and
offering
free
skin
examina-
tions,
talks,
and
interventions
at
universities
and
schools
and
via
social
networks.
86
Furthermore,
the
year
2020
saw
the
implementation
of
the
campaign
‘‘Cuentos
lunares,
poemas
y
microrrelatos
que
salvan
vidas’’
(Cuentos
lunares:
poems
and
flash-fiction
that
save
lives)
1
during
the
COVID-19
pan-
demic
to
disseminate
the
harmful
effects
of
sun
for
the
skin
and
possible
prevention
strategies
through
flash
fiction
and
poems.
88
In
addition,
through
microinfluencers
and
social
networks
(Instagram,
Facebook,
and
Twitter),
members
of
the
public,
dermatologists,
and
other
collaborators
used
a
photograph
as
inspiration
to
write
a
poem
or
flash
fiction
on
a
common
subject,
namely,
the
observation
of
moles
or
beauty
spots.
88
This
year,
the
campaign
entitled
‘‘Misión
Amarte’’
(literally
‘‘The
love
your
skin
mission’’)
is
using
social
media
to
disseminate
a
message
in
favor
of
self-protection
and
care.
89
Screening
of
the
asymptomatic
general
public
is
not
effective,
leading
to
overdiagnosis
and
unnecessary
treat-
ment
that
increases
the
cost
of
health
care
and
may
have
a
negative
impact
on
patients’
psychosocial
health.
70,71
Also
potentially
effective
is
screening
of
the
high-risk
population
by
dermatologists
using
a
combination
of
visual
inspec-
tion
and
dermoscopsy.
69
When
they
are
aware
of
this
risk,
more
vulnerable
persons
improve
their
behavior.
47
However,
exactly
which
persons
are
considered
high-risk
and
how
to
identify
them
remain
unclear.
We
still
require
validated
models
to
predict
the
risk
of
melanoma
when
selecting
these
patients
37---39
and
clinical
practice
guidelines
to
regulate
the
process
of
identification
and
subsequent
follow-up.
74
1
Translator’s
note:
‘‘Cuentos
lunares’’
is
a
play
on
words.
‘‘Cuentos’’
means
‘‘tales’’
or
‘‘stories’’,
and
the
word
‘‘lunar’’
in
Spanish
is
a
noun
meaning
‘‘mole’’
or
‘‘beauty
spot’’
and
also
an
adjective
relating
to
the
moon,
as
in
English.
T787
C.
Alonso-Belmonte,
T.
Montero-Vilchez,
S.
Arias-Santiago
et
al.
Ensuring
that
people
can
recognize
clinical
alarm
signals
with
respect
to
pigmented
and
nonpigmented
lesions
could
also
favor
early
diagnosis
of
skin
cancer.
Are
These
Measures
Really
Effective
for
Preventing
Skin
Cancer?
After
implementation,
education
programs
show
an
improvement
in
sun
protection
habits,
although
it
is
diffi-
cult
to
evaluate
the
real
impact
in
terms
of
the
incidence
of
cancer-related
mortality.
29
Educational
strategies
seem
to
have
had
the
greatest
impact,
especially
those
associated
with
physical
appearance
based
on
images.
24,25
The
imple-
mentation
of
legislation
regulating
the
use
of
tanning
beds
has
been
associated
with
less
frequent
use,
which
could
decrease
the
risk
of
melanoma.
46
Risk
prediction
models
for
identifying
persons
who
are
more
susceptible
to
melanomas
are
effective,
although
they
have
yet
to
be
validated.
40
Dermoscopy
and
total
body
photography,
together
with
visual
inspection
and
history-taking,
favor
early
diagnosis
of
persons
at
high
risk
of
skin
cancer.
47
Similarly,
no
association
has
been
established
between
the
isolated
use
of
sunscreen
with
no
additional
measures
or
the
UV
score
and
reduced
incidence
of
skin
cancer.
43,44
Screening
for
skin
cancer
among
the
general
population
was
not
effective
and
could
lead
to
overdiagnosis
and
overtreatment.
70,71
Apps
for
early
diagnosis
of
skin
cancer
and
artificial
intelligence
are
both
fields
that
are
still
under
study.
58
Clinical
trials
have
shown
that
sunscreens
reduce
the
risk
of
melanoma.
90
However,
the
present
review
high-
lighted
their
lack
of
effectiveness
as
a
preventive
strategy,
probably
because
of
the
association
with
risk
behaviors,
such
as
increased
exposure
to
sunlight
and
inappropriate
application.
43,44
Educating
the
public
about
sun
protection
is
a
public
health
objective.
Once
implemented,
edu-
cation
campaigns
show
that
people
who
work
outdoors
improve
their
sun
protection
habits,
although
this
strategy
is
insufficient
without
concomitant
structural
and
politi-
cal
measures.
It
is
necessary
to
draw
up
policies,
such
as
the
recommendations
made
in
Germany,
whose
focus
is
multifaceted,
including
both
behavioral
(individual)
and
structural
(social)
approaches
and
favoring
both
general
protective
behaviors
and
personalized
measures,
such
as
modifying
one’s
work
timetable.
91
Are
the
Strategies
Currently
Being
Applied
in
the
Population
Sufficient
for
Preventing
Skin
Cancer?
The
incidence
and
mortality
of
skin
cancer
are
increas-
ing,
despite
the
wide
variety
of
preventive
strategies
available
9,10
;
therefore,
we
can
conclude
that
these
mea-
sures
are
not
completely
effective.
This
may
be
because
incorrect
or
inappropriate
application
prevents
them
from
having
a
real
impact
on
health.
New
technologies
for
recording
images
could
prove
useful
for
the
diagnosis
of
skin
cancer
and
for
facilitating
prefer-
ential
access
to
a
dermatologist
in
cases
of
a
high
suspicion
of
skin
cancer.
52
Given
that
primary
care
is
an
individual’s
first
contact
with
the
health
system,
it
would
be
necessary
to
train
health
professionals
who
are
not
dermatologists
to
differentiate
between
benign
and
malignant
lesions.
These
professionals
are
an
important
part
of
the
prevention
pro-
cess,
although
their
current
knowledge
is
suboptimal.
52,75
Limitations
(1)
We
only
included
systematic
reviews
and
meta-analyses.
Therefore,
some
preventive
approaches
have
not
been
included
(no
reviews
were
available).
(2)
We
only
analyzed
strategies
for
early
diagnosis
that
are
currently
applied
to
reduce
mortality.
(3)
The
search
was
limited
to
the
last
10
years.
Future
Lines
of
Research
Studies
demonstrating
the
association
between
preventive
strategies
and
the
reduction
in
morbidity
and
mortality
of
skin
cancer
are
warranted.
Such
measures
improve
sun
pro-
tection
habits
and
self-examination
of
skin
lesions,
although
the
direct
impact
on
incidence
and
mortality
remains
unclear.
It
is
necessary
to
establish
clinical
practice
guidelines
and
legislation
that
favor
prevention
of
skin
cancer,
since
an
approach
of
this
type
can
prove
beneficial
for
public
health
and
reduce
costs
for
the
health
system.
Conclusion
Primary
and
secondary
prevention
of
skin
cancer
is
a
very
relevant
issue.
Population-based
screening
strategies
are
not
justified.
Early
detection
systems
should
be
optimized
in
the
case
of
high-risk
patients.
Educational
programs
are
the
most
effective
strategies.
The
fact
that
deaths
from
skin
cancer
are
not
decreasing
shows
that
current
preven-
tion
strategies
are
insufficient.
Therefore,
these
should
be
improved,
standardized,
and
regulated
based
on
proven
effective
approaches
in
order
reduce
the
impact
of
skin
cancer
on
the
population.
Conflicts
of
Interest
The
authors
declare
that
they
have
no
conflicts
of
interest.
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