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Table 2. Summary of evidence for screening for skin cancer

Linkage in analytic framework Evidence code a Quality of evidence
1a. Accuracy of total-body skin examination: evidence that total-body skin examination can detect skin cancer. II-2 Fair: The accuracy of a total-body skin examination by primary care physicians in unselected patients may be low. Reliability of pathologic diagnosis in community practice in the United States is not known.
1b. Accuracy of risk assessment: evidence that a questionnaire or interview, followed by examination in selected patients, can detect skin cancer. II-2 Fair: Mole counts and other factors predict elevated risk over time, but no study has determined the accuracy of risk stratification followed by total-body skin examination in selected patients as a screening method.
1c. Effect of screening on patients' skin knowledge and self-care behavior (use of sun protection, sun avoidance, and self-examination). II-2 Poor: Patients with skin lesions who attended skin cancer screenings increased their rate of performing skin self-examination. However, there is no evidence about the effect of screening or skin knowledge on sun protection behaviors.
2. Adverse effects of screening: evidence that screening causes significant harms. III Poor: Most postulated adverse effects have not been evaluated in studies.
3. Effectiveness of early detection: evidence that persons detected through screening have better outcome than those who are not screened. II-3 Poor: there are no studies that directly link screening to lower mortality and morbidity. Most well-done, population-based studies concern promotion of self-care behaviors such as self-examination rather than universal screening.
4a. Effectiveness of treatment of nonmelanoma skin cancer found by screening. III Poor: The hypothesis that early detection by screening could reduce mortality and morbidity is plausible but has not been examined in studies.
4b. Effectiveness of treatment of melanoma found by screening. II-1, III

Fair: There are no controlled studies of treatment in patients found by screening to have thin melanomas, but epidemiologic studies, studies of skin health behaviors, and studies of factors associated with advanced melanoma suggest that elderly men are at high risk and are unlikely to benefit from health promotion efforts.

Studies of delay in diagnosis have conflicting results, and the ability of screening to reach individuals at high risk and to find aggressive tumors while they are still curable have not been established.

[a] I: Randomized controlled trial; II-1: Controlled trial without randomization; II-2: Cohort or case-control analytic studies; II-3: Multiple time-series, dramatic uncontrolled experiments; III: Opinions of respected authorities, descriptive epidemiology.

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