10. Documentation of changes from version 1.2 to version 2.1 – Prevention of Skin Cancer

Version 2.1 · August 2021 · AWMF 032/052OL
Leitlinienprogramm Onkologie · Deutsche Krebsgesellschaft · Deutsche Krebshilfe · AWMF

Table 27: Dokumentation der Änderungen von Version 1.2 zu Version 2.1

Version 1.2

Version 2.1

Kommentare

3. Concepts of Prevention

3. Status quo of skin cancer

4. Status Quo Skin Cancer

3.1. The aetiology of skin cancer

4.1. The Etiology of Skin Cancer

3.1. Consensus-based statement

On the basis of current knowledge, ultraviolet (UV) radiation is considered to be the most significant risk factor in the aetiology of skin cancer, even if not all details of the induction, promotion and progression of skin cancer in humans have been elucidated.

4.1. Consensus-based statement

On the basis of current knowledge, ultraviolet (UV) radiation is considered to be the most significant risk factor in the etiology of skin cancer, even if not all details of the induction, promotion and progression of skin cancer in humans have been elucidated.

Checked 2020

3.2. Incidence and prevalence of skin cancer

4.2. Incidence, Prevalence, and Mortality of Skin Cancer

4.2. Consensus-based recommendation

In the clinical cancer registries, basal cell carcinomas (including multiple basal cell carcinomas occurring in one person) and squamous cell carcinomas should be included in the registration.

New 2020

3.4. Risk factors of skin cancer

4.3. Risk Factors of Skin Cancer

3.2. Consensus-based statement

Constitutional risk factors:

Non-melanocytic skin cancer (NMSC)

An important constitutional risk factor for NMSC (basal cell carcinoma and squamous cell carcinoma) is

skin type.

All other risk factors can be acquired during the course of life.

4.3. Consensus-based statement

Constitutional risk factors:

Non-melanocytic skin cancer (NMSC)

An important constitutional risk factor for non-melanocytic skin cancer (basal cell carcinoma and squamous cell carcinoma) is:

skin type.

Other risk factors (see 4.3.2, 4.3.4) can be acquired during the course of life.

Modified 2020

3.3. Consensus-based statement

Constitutional risk factors:

Malignant melanoma (MM)

The class of constitutional risk factors for MM includes

a) skin type and

b) (large) congenital naevus.

All other risk factors can be acquired during the course of life.

4.4. Consensus-based statement

Constitutional risk factors:

Malignant melanoma (MM)

The class of constitutional risk factors for MM includes

a) skin type and

b) large congenital naevus.

Other risk factors (see sections 4.3.2, 4.3.4, and 5.1) can be acquired during the course of life.

Checked 2020

3.4. Consensus-based statement

Acquired risk factors:

Non-melanocytic skin cancer (NMSC)

The main acquired risk factors for NMSC (basal cell carcinoma and squamous cell carcinoma) are:

a) actinic keratosis,

b) previous history of NMSC,

c) immunosuppression,

d) chronic radiation keratoses.

4.5. Consensus-based statement

Acquired risk factors:

Non-melanocytic skin cancer (NMSC)

The main acquired risk factors for non-melanocytic skin cancer (basal cell carcinoma and squamous cell carcinoma) are:

a) actinic keratosis,

b) previous history of NMSC,

c) immunosuppression,

d) chronic radiation keratoses.

Checked 2020

3.5. Consensus-based statement

Acquired risk factors:

Malignant melanoma (MM)

The main acquired risk factors for MM are:

a) previous history of melanoma,

b) family history of melanoma,

c) number of acquired naevi,

d) clinically atypical moles.

4.6. Consensus-based statement

Acquired risk factors:

Malignant melanoma (MM)

The main acquired risk factors for malignant melanoma are:

a) previous history of melanoma,

b) family history of melanoma,

c) number of acquired naevi,

d) clinically atypical naevi.

Checked 2020

3.6. Consensus-based statement

The probability of developing a squamous cell carcinoma is correlated with the UV dose to which a person is exposed during their life (cumulative dose).

For basal cell carcinoma, the cumulative UV exposure appears to be of secondary importance. Intermittent UV exposure and sunburn are important in the case of BCC.

For malignant melanoma, intermittent UV exposure and sunburn (at any age) are of major importance.

Deletion and inclusion in the background text

3.7. Consensus-based statement

Other risk factors that are described for non-melanocytic skin cancer are exposure to arsenic or tar, particularly in the work environment. HPV infections are discussed both as a risk factor for skin cancer in their own right and as a cofactor in combination with ultraviolet (UV) radiation.

4.7. Consensus-based statement

Other risk factors that are described for non-melanocytic skin cancer are exposure to arsenic or tar, particularly in the work environment. HPV infections are discussed both as a sole risk factor for skin cancer and as a cofactor in combination with ultraviolet (UV) radiation.

Checked 2020

3.8. Consensus-based statement

Values for relative risks (RR) or lifetime risks are given in the literature in various studies for the constitutional risk factors described. Examples of such values are listed below for non-melanocytic skin cancer:

Risk factor	RR (95 % CI)
Skin type I vs. IV (BCC)	5.1 (1.4-11.3)
Skin type II vs. IV (BCC)	5.3 (1.7-10.6)
Skin type I vs. IV (SCC)	1.4 (0.5-3.0)
Skin type II vs. IV (SCC)	2.2 (0.7-3.8)
Sources: [21, 213] The presence of multiple actinic keratoses over a 10‑year period is reported as being associated with a lifetime risk for the development of a squamous cell carcinoma (SCC) in the region of 6‑10%. With a personal history of SCC, the risk of developing another SCC within 5 years is 30% and of developing a basal cell carcinoma (BCC) about 40%. With a personal history of BCC, the risk of developing another BCC within 3 years is 44% and of developing an SCC about 6%. SCC occurs up to 65 times more frequently in immunosuppressed transplant patients than in controls. Immunosuppressed transplant patients develop more SCC than BCC (4:1).

Deletion and inclusion in the background text

3.9. Consensus-based statement

Risk factor	RR (95 % CI)
Number of acquired naevi (100-120 vs. < 15)	6.89 (4.63-10.25)
Skin type (I vs. IV)	2.09 (1.67-2.85)
Family history of melanoma (yes vs. no)	1.74 (1.41-2.14)
Number of atypical naevi (5 vs. 0)	6.36 (3.80-10.33)
Personal history of melanoma (yes vs. no)	8.5 (5.8-12.2)
Sources: [214, 247, 249] Congenital naevi with a diameter of > 10 to 20 cm are known as “large congenital naevi”. They are associated with a risk of approximately 2 10% of developing a melanoma during the course of life.

Deletion and inclusion in the background text

3.10. Consensus-based statement

The relative risks (RR) for the development of different skin cancer entities (basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and malignant melanoma (MM)) depend on the UV exposure pattern. BCC does not depend on the cumulative UV dose (RR = 0.98, 95% CI 0.68 1.41), whereas SCC is more strongly dependent on the cumulative dose (RR = 1.53, 95% CI 1.02 2.23). MM is intermediate between the two in relation to the cumulative dose (RR = 1.2, 95% CI 1.00 1.44). For MM, however, there is an increased risk from intermittent UV exposure (RR = 1.71, 95% CI 1.54 1.90) or from sunburn at any age (RR = 1.91, 95% CI 1.69 2.17) [20].

Deletion and inclusion in the background text

3.11. Consensus-based statement

The relative life risk (RR) for a malignant melanoma is RR = 1.75 (95% CI: 1.35 2.26) if solariums are used regularly (at least once a month) before the age of 35 [290].

Deletion and inclusion in the background text

4.4 Importance of Biomarkers for Primary and Secondary Prevention of Skin Cancer

4. Primary prevention

5. Primary Prevention

4.1. Individual behaviours

5.1. Individual Behaviours

4.1. Consensus-based recommendation

Protective measures against solar ultraviolet radiation must be applied in the following order:

avoidance of exposure to strong solar radiation,

wearing suitable clothing,

using sunscreens.

5.1. Consensus-based recommendation

Protective measures against solar ultraviolet radiation is particularly important for persons at increased risk and must be applied in the following order:

avoidance of exposure to strong solar radiation,

wearing suitable clothing,

using sunscreens.

Modified 2020

4.2. Consensus-based recommendation

The following measures must be taken to avoid exposure to strong solar radiation in the relevant weather conditions:

remain outside as little as possible,

avoid staying outside in the middle of the day,

the length of time in the sun should not exceed the individual intrinsic protection time of the skin,

seek shade,

undertake outdoor activities in the morning and evening hours,

accustom the skin slowly to the sun (e.g. in spring / on holiday),

avoid sunburn at all events.

5.2. Consensus-based recommendation

The following measures must be taken to avoid exposure to strong solar radiation (taking into account the type of skin):

At medium and high UV irradiance (UVI 3-7), seek shade during midday,

In the case of very high UV irradiance (UV index 8 and higher), avoid going outdoors during the midday period if possible. If this is not possible, seek shade,

If necessary, postpone outdoor activities to the morning and evening hours,

Avoid sunburn.

Modified 2020

4.3. Consensus-based recommendation

When staying outside in the sun, suitable clothing, headwear and sunglasses should be worn for protection.

5.3. Consensus-based recommendation

When staying outside in the sun, suitable clothing, headwear and sunglasses should be worn for protection.

Checked 2020

4.4. Consensus-based recommendation

Suitable sunglasses must be worn in strong sunlight.

Never look directly at the sun in the sky. This applies even when wearing sunglasses.

5.4. Consensus-based recommendation

Suitable sunglasses must be worn in strong sunlight.

Never look directly at the sun in the sky. This applies even when wearing sunglasses.

Checked 2020

4.5. Evidence-based recommendation

Where possible, physical measures (avoidance of exposure, textiles) must be used in the first place for protection from sunlight.

Sunscreens must be used for areas of the skin that cannot otherwise be protected.

The use of sunscreens must not result in staying out longer in the sun.

5.5. Evidence-based recommendation

Appropriate sunscreen products should be used for skin areas that cannot be protected in any other way. The use of sunscreens must not result in a prolonged stay in the sun.

Modified 2020

4.6. Consensus-based recommendation

Sunscreens should be applied carefully to free areas of skin that are not covered by clothing (head, face, hands, arms, legs) and the following should be observed:

use an appropriate sun protection factor,

apply as thick a layer as possible (2 mg/cm²),

apply evenly to all uncovered areas of skin,

apply before exposure to the sun,

repeat the application after 2 hours and after bathing (the protective time is not prolonged as a result).

5.6. Consensus-based recommendation

Sunscreens should be applied carefully to free areas of skin that are not covered by clothing (head, face, hands, arms, legs) and the following should be observed:

use an adequate sun protection factor,

apply a sufficiently thick layer (2 mg/cm²),

apply evenly to all uncovered areas of skin,

apply before exposure to the sun,

repeat the application after 2 hours and after bathing (the protective time is not prolonged as a result).

Modified 2020

4.7. Evidence-based statement

There are contradictory data as to whether the risk of melanoma is reduced by using sunscreen.

5.7. Evidence-based statement

There is contradictory data on whether the risk of melanoma is reduced by sunscreen use.

Modified 2020

4.8. Consensus-based recommendation

In accordance with international and national recommendations (WHO, ICNIRP, EUROSKIN, SSK, DKH and ADP), the use of sun studios must be avoided to reduce the risk of development of skin cancer.

Deletion due to evidence-based chapters 5.8 to 5.10

5.8. Evidence-based statement

The risk of malignant melanoma (MM) is increased in sunbed users compared to non-sunbed users and increases with the frequency of sunbed visits. The younger the tanning bed user was at the first visit, the higher the risk.

New 2020

5.9. Evidence-based statement

Tanning bed users have an increased risk of basal cell carcinoma compared to non-tanning bed users.
The risk is even higher for people who use a tanning bed for the first time at the age of less than 20 years.

New 2020

5.10. Evidence-based recommendation

The use of sunbeds must be avoided in order to reduce the risk of developing skin cancer (especially melanoma).

New 2020

4.9. Evidence-based recommendation

Food supplementation with selenium, vitamin A and beta-carotene must not be recommended as a measure for skin cancer prevention.

5.11. Evidence-based recommendation

Food supplementation with selenium, vitamin A and beta-carotene must not be recommended as a measure for skin cancer prevention.

Checked 2020

4.10. Consensus-based recommendation

Intensive solar / ultraviolet (UV) radiation represents a risk for skin cancer to all certain groups and must be avoided.

Deletion and inclusion in the background text.

4.11. Consensus-based recommendation

Children must not be allowed to develop sunburn.

5.12. Consensus-based recommendation

Children must not get sunburned.

Checked 2020

4.12. Consensus-based recommendation

Babies must not be exposed to direct sunlight.

5.13. Consensus-based recommendation

Babies must not be exposed to direct sunlight.

Checked 2020

4.13. Consensus-based recommendation

Children must be required to wear skin-covering clothing in strong sunlight.

5.14. Consensus-based recommendation

Children must be required to wear skin-covering clothing in strong sunlight.

Checked 2020

4.14. Evidence-based recommendation

Children with a light skin colour in particular must use sunscreens as well as avoid strong ultraviolet (UV) radiation exposure and additionally wear sun-protective textiles.

5.15. Consensus-based recommendation

In the development of nevi, textile sunscreen is protective. The role of sunscreens is open.

Modified 2020

Conversion into Consensus-based recommendation, reformulation and further explanations in background text

4.15. Consensus-based recommendation

Children’s eyes must be protected by suitable children’s sunglasses that meet the previously mentioned requirements (see Recommendation 4.4.).

5.16. Consensus-based recommendation

Children's eyes must be protected by suitable sunglasses.

Modified 2020

4.16. Evidence-based recommendation

Immunosuppressed transplant recipients must use sunscreens to protect themselves from skin cancer as part of a consistent, comprehensive ultraviolet (UV) radiation protection strategy.

5.17. Evidence-based recommendation

Immunosuppressed transplant recipients must use sunscreens to protect themselves from skin cancer as part of a consistent, comprehensive ultraviolet (UV) radiation protection strategy.

Checked 2020

4.17. Consensus-based recommendation

Immunosuppressed people must ensure they have a consistent, comprehensive untraviolet (UV) radiation protection strategy.

5.18. Consensus-based recommendation

Immunosuppressed people must ensure they have a consistent, comprehensive untraviolet (UV) radiation protection strategy.

Checked 2020

4.18. Consensus-based recommendation

In people at high risk for skin cancer (e.g.: transplant recipients, immunosuppressed patients) who practice consistent, extensive sun protection, vitamin D levels should be checked and vitamin D supplements given where necessary.

5.19. Consensus-based recommendation

Checked 2020

4.19. Evidence-based statement

Moderate exposure to ultraviolet (UV) radiation and high vitamin D levels possibly have a protective effect against the occurrence and development of various types of cancer, including malignant melanoma. However, the existing evidence for a relationship between the risk of cancer and vitamin D intake is insufficient.

Deletion, inclusion in the background text including further explanations

4.20. Consensus-based statement

The Guideline Group is currently unable to answer the question as to the optimal (reasonable) ultraviolet (UV) radiation exposure to ensure sufficient endogenous vitamin D production without incurring an increased risk of skin cancer.

5.20. Consensus-based statement

For sufficient vitamin D synthesis, it is sufficient to expose the face, hands, and arms uncovered and without sunscreen two to three times a week to half of the minimum sunburn-effective UV dose (0.5 MED), i.e., half of the time in which one would otherwise get a sunburn without protection.

Modified2020

4.21. Dessenting opinion of DEGAM on section 4.1.

The German Society of General Practice and Family Medicine (DEGAM) generally does not pass on recommendations with the strength of recommendation “must” to the general population. On the one hand, the data relating to a possible vitamin D deficiency and the need to spend time outdoorsdoes not suffice to issue a general recommendation to avoid sunlight. Secondly, it is not DEGAM’s policy to give- well-intentioned-generalised recommendations for behaviour in terms of cancer prevention to the population, which fail to take into account the particular aspects and preferences of the individual subjects.

Deletion

5.2. Status Quo: Sun Protection and Exposure Behaviour

5.3 Status Quo: Skin Cancer-Related Knowledge, Perceptions and Attitudes

4.2. Primary prevention measures for the population

5.4. Primary Prevention Measures for the Population

5.21. Consensus-based statement

Measures of primary prevention of skin cancer start well before the development of a disease and aim to reduce risk factors for the occurrence of skin cancer. Therefore, the following risk factors and indicators are considered relevant as intermediate endpoints for the evaluation of primary prevention measures:

Sun protection and tanning behaviour, use of sunbeds, etc.

Knowledge, attitudes towards skin cancer, sun protection, and exposure

Number of nevi

Number of sunburns

Most studies in primary prevention were only able to influence these intermediate endpoints. Because of the long time lag before skin cancer develops and multiple other influencing factors (confounders), it is extremely difficult, if not impossible, to assess the effect of preventive interventions to reduce skin cancer incidence.

When evidence-based recommendations are made in the following, the corresponding evidence refers exclusively to the above-mentioned intermediate endpoints, not to the skin cancer risk itself. Because the risk markers described increase the risk of skin cancer, the guideline group assumes a benefit.

New 2020

4.22. Evidence-based recommendation

Knowledge about the effects of ultraviolet (UV) radiation and sun protection measures must be passed on constantly.

5.22. Evidence-based statement

Educational measures on UV radiation and protective measures in kindergartens or schools can improve knowledge on UV protection.

Modified 2020

4.23. Evidence-based recommendation

To improve sun protection behaviour, interventions about ultraviolet (UV) radiation protection should be conducted in schools and playschools or day care centres, with particular regard to the target group of younger children.

Deletion due to detailled assessment in the following recommendations

5.23. Consensus-based recommendation

UV risk communication should address aspects relevant to everyday life, the subjective perception of the benefits of UV exposure, and the beauty ideal of tanned skin. An important starting point for communication should be social ideals and behavioural routines with regard to tanned skin and sunbathing.

New 2020

5.24. Consensus-based recommendation

The media information on skin cancer prevention must be qualitatively and quantitatively expanded, since the media are the most important source of information for adults.

New 2020

5.25. Consensus-based recommendation

Digital media literacy as part of the health literacy of the population should be promoted in order to be able to find, understand, and assess the quality of targeted information on skin cancer and skin cancer prevention.

New 2020

5.26. Consensus-based recommendation

Parents with children of kindergarten age as well as educators, teachers, and directors of day-care centres must be informed about UV radiation as a risk factor for skin cancer and about the insufficient protective function of clouds against UV radiation.

New 2020

4.24. Evidence-based recommendation

Interventions that target a sustained effect on behaviour should involve several components and should be implemented intensively and repeatedly.

5.27. Evidence-based recommendation

Interventions that target a sustained effect on behaviour must involve several components and must be implemented intensively and repeatedly.

Modified 2020

5.28. Evidence-based recommendation

Behaviour change interventions should be based on behavioural theories and take into account the available evidence.

New 2020

5.29. Evidence-based recommendation

Measures to communicate primary prevention of skin cancer should be multimedia, interactive, and integrate multiple communication channels.

New 2020

5.30. Evidence-based statement

Personalised messages have a greater impact on sun protection behaviour than generalised messages.

New 2020

5.31. Evidence-based recommendation

Education and training programmes for the primary prevention of skin cancer should address the target persons individually ("individual-level-interventions") and include individualised information and feedback elements.

New 2020

5.32. Consensus-based recommendation

Information can be provided via parents, teachers, educators, peers, and other multipliers.

New 2020

5.33. Consensus-based recommendation

Skin cancer prevention interventions can also use new media (websites, social media, SMS, apps) as a communication strategy.

New 2020

5.34. Consensus-based statement

Skin cancer prevention interventions that also address external appearance are one strategy to change sun protection behaviour.

New 2020

5.35. Evidence-based statement

The use of personalised digital methods to depict potential UV radiation-related attractiveness losses can have positive effects on sun protection and exposure behaviour in certain target groups.

New 2020

5.36. Consensus-based recommendation

Measures of primary prevention of skin cancer should be designed in a target group-oriented way and take into account the target group-specific needs.

New 2020

5.37. Consensus-based recommendation

Measures of primary prevention of skin cancer should start in the living environment (i.e., be setting-related) in order to reach people where they live their daily lives.

New 2020

5.39. Consensus-based recommendation

To improve sun protection behaviour, UV protection interventions should be implemented in schools and preschools or day care centres.

New 2020

5.40. Consensus-based recommendation

Measures of primary prevention of skin cancer must specifically address the target group of sunbed users, inform them about the risks of use, and aim to change their behaviour. The interventions must take into account the heterogeneity of the target group (e.g. migration background, level of education) and address this in their approach. Special attention must be paid to underage sunbed users.

New 2020

5.41. Consensus-based recommendation

The knowledge about an increased risk of skin cancer and the implementation of protective behaviours among organ transplant patients and skin cancer patients should be further improved.

New 2020

4.25. Evidence-based recommendation

Doctor-patient communication (e.g. in connection also with skin cancer screening) should be used for primary preventive measures.

(see also section 5.4 Doctor-patient communication)

5.42. Evidence-based recommendation

The medical consultation (e.g. in connection also with skin cancer screening) must be used for indications of primary prevention measures on an ad hoc basis.

Modified 2020

4.26. Consensus-based recommendation

The following recommendations must be given in the doctor-patient discussion on cancer prevention:

Content	Done?
Information about the risks of ultraviolet (UV) radiation
Motivation to change behaviour
Avoid exposure to strong solar radiation
Avoid the midday sun
Stay out in the sun for as little as possible
Seek shade
Avoid sunburn
Be aware of the ultraviolet (UV) radiation index
Accustom the skin slowly to the sun
Wear protective clothing
Use sunscreens without prolonging exposure time
Be aware of individual skin sensitivity
Give information about the different skin types
Advice on individual protective measures according to the patient’s skin type
Pay attention to possible side effects of medicines in the sun
Protect children in particular
Avoid sun studios (refer to NiSG)
Wear sunglasses

5.43. Consensus-based recommendation

The following recommendations must be given in the doctor-patient discussion on cancer prevention:

Content

Information about the risks of excessive ultraviolet (UV) radiation

Motivation to change behaviour

Avoid exposure to strong solar radiation

In the case of medium and high UV exposure (UVI 3-7), seek shade during the midday periode

In the case of very high UV exposure (UV index 8 and higher), avoid being outdoors during the midday period if possible. If this is not possible, seek shade

If necessary, postpone outdoor activities to the morning and evening hours

Avoid sunburn at all costs

Wear protective clothing

Use sunscreens without prolonging exposure time

Be aware of individual skin sensitivity

Give information about the different skin types

Advice on individual protective measures according to the patient’s skin type

Pay attention to possible side effects of medicines in the sun

Protect children and infants in particular

Avoid sun studios (refer to NiSG)

Wear sunglasses

Modified 2020

5.44. Consensus-based recommendation

The knowledge about and the importance of the UV index for the sun protection behaviour of the population is currently low and dependent on age and socio-economic status.

New 2020

4.27. Consensus-based recommendation

The ultraviolet (UV) radiation index should be more intensively publicised, firmly anchored in the media and used as an aid in UV protection campaigns. At the same time, the limits of its value should be observed.

abei sollten die Grenzen seiner Aussagekraft beachtet werden.

5.45. Consensus-based recommendation

The ultraviolet (UV) radiation index should be more intensively publicised as part of sun protection recommendations, firmly anchored in the media and used as an aid in UV protection campaigns. Attention must be paid to a comprehensible explanation of the UVI so that it is correctly understood and used in the sense of UV protection.

Modified 2020

4.28. Evidence-based recommendation

Parents of babies and young children must be informed about appropriate sun protection for their children.

(see also Recommendation 4.7.)

5.38. Evidence-based recommendation

Parents of babies and young children must be informed about appropriate sun protection for their children. Regular early detection examinations must also be used for this purpose.

Modified 2020

5.46. Consensus-based recommendation

Proportional prevention measures for skin cancer prevention must be guided by the policy paper "Preventing Health Damage from the Sun – Proportional Prevention in Urban and Rural Areas" (2017) of the UV Protection Alliance.

New 2020

5.47. Consensus-based recommendation

In order to ensure compliance with the NiSG and the UVSV, in particular with regard to the prohibition of the use of sunbeds by minors and the presence of qualified personnel in sunbed establishments, controls and enforcement of the law and the ordinance must be improved.

New 2020

4.29. Evidence-based recommendation

Schoolchildren and adolescents must be intensively informed about skin cancer risks, instructed in the practical use of protective measures and receive appropriate support from teachers.

Deletion due to inclusion in other recommendations

4.30. Evidence-based recommendation

The tendency to acquire risk factors for skin cancer (e.g. naevi) must be reduced by interventions at school age with a long-term and repetitive approach.

Deletion due to inclusion in other recommendations

4.31. Evidence-based recommendation

Sufficient shaded areas must be established in day-care centres, kindergartens and schools.

5.48. Evidence-based recommendation

Sufficient shaded areas must be established in day-care centres, kindergartens and schools.

Checked 2020

4.32. Evidence-based recommendation

Technical and organisational measures to minimise ultraviolet (UV) radiation exposure, particularly during the midday hours (e.g. provision of shaded areas, structuring of the timetable, consideration of UV radiation protection in the timetabling of sports events), should be an essential part of primary prevention.

5.49. Evidence-based recommendation

Technical and organisational measures to avoid excessive UV exposure, particularly during the midday hours (e.g. provision of shaded areas, structuring of the timetable, consideration of UV radiation protection in the timetabling of sports events), must be an essential part of primary prevention.

Modified 2020

5.50. Consensus-based recommendation

Intervention projects and programmes in the context of primary skin cancer prevention should be evaluated formatively and summatively.

The evaluation parameters used should be derived from a theoretically proven model.

New 2020

5.51. Consensus-based recommendation

Evaluations of interventions in the context of primary skin cancer prevention must use empirically proven measurement methods that are specific to the endpoints in question.

New 2020

5.52. Evidence-based recommendation

To evaluate the effectiveness of interventions for the primary prevention of skin cancer, skin cancer prevention-specific attitudinal and behavioural parameters as well as indicators on contact frequency/intensity, assessment of communication tools and their mediation quality, and performance should be used.

New 2020

4.33. Consensus-based recommendation

For outdoor workers, suitable technical and organisational ultraviolet (UV) radiation protection measures (shaded areas, work organisation, rules governing breaks) should be promoted and take precedence over personal protective measures.

Deletion due to specific new chapter 7. Occupational Skin Cancer

4.34. Evidence-based recommendation

Outdoor workers must be informed of the ultraviolet (UV) radiation risks and UV radiation protection measures by means of training measures.

Deletion due to specific new chapter 7. Occupational Skin Cancer

4.35. Consensus-based recommendation

Outdoor workers must be protected by detailed legal regulations as they are at particular risk from intensive ultraviolet (UV) radiation.

Deletion due to specific new chapter 7. Occupational Skin Cancer

6. Climate Change and UV Radiation

6.1. Climate Change and UV Radiation

6.1. Consensus-based statement

Climate change has an influence on global and regional air temperature. Climate change has an indirect influence on UV radiation exposure. So far, however, no quantitative statements can be made on the associated region-specific impacts.

New 2020

6.2. Consensus-based recommendation

Rising air temperatures and changes in UV radiation exposure due to climate change have an influence on the morbidity of society. An influence on mortality can currently only be seen in relation to rising air temperatures. The extent to which climate change, in interaction with processes in the stratospheric ozone layer, has or will have an impact on the incidence and prevalence of skin cancer, can currently only be quantified under simplified assumptions. Adaptation strategies to the health consequences of climate change must accordingly focus on preventive measures for the prevention of UV- and heat-related diseases, especially skin cancer.

New 2020

6.3. Consensus-based recommendation

There is an influence of climate change (global warming) on the processes in the stratospheric ozone layer with the consequence of temporarily and locally increased UV radiation exposure in the northern hemisphere with great significance for the health of the population. Efforts should therefore be made to identify these short-term and temporary events at an early stage and to communicate them effectively so that protective measures can be taken to prevent skin cancer at the moment of the event.

New 2020

6.2. Status Quo: Perception of Heat and UV Radiation

6.4. Consensus-based recommendation

Findings on temperature-dependent behaviour are not yet available independent of the season, and thus daylight duration. The frequency and duration of outdoor activities increase with longer daylight hours and higher temperatures in the range of thermal comfort to mild heat stress. With free choice, temperature-dependent behaviour depends on thermal sensation and internal attitudes toward the prevailing temperature. In hot conditions (severe or extreme thermal discomfort), outdoor activities tend to be avoided. The temperature-dependent behaviour can be influenced by and dependent on specifications and organisational boundary conditions in the various living environments.

Temperature-dependent behaviour should therefore be taken into account when designing prevention measures.

New 2020

6.3. Status Quo: Climate Change and Urban Development

6.5. Consensus-based recommendation

The primary objective of urban development and planning measures relating to protection from excessive UV radiation and heat must be to protect people in their living environments from unhealthy and unwanted exposure. This requires that the protection offered must be increased.

New 2020

6.6. Consensus-based recommendation

Development, structural engineering measures, and, above all, planting (trees, greening of buildings and lawns), which individually and in combination enable an effective reduction of high solar radiation loads, must be increasingly integrated into climate adaptation strategies of the federal government and local authorities.

Particularly for areas with high solar radiation, development must ensure good shading and, where appropriate, canopies with shading elements.

Sunlight loads must be reduced through informed planning of daily routines in kindergartens and schools as well as work scheduling.

New 2020

6.7. Consensus-based recommendation

In view of the advancing climate change, surfaces with the lowest possible albedo should be used when creating or redesigning squares (including schoolyards and kindergartens) or streets. In order to reduce the albedo and for the purpose of shading, the majority of all surfaces in residential areas that are not built over must be planted with vegetation.

New 2020

6.8. Consensus-based recommendation

UV protection must be consistently introduced in cities and municipalities as a further line of argument and guiding objective for the implementation of climate protection and adaptation measures. Laws and regulations to implement measures as comprehensively as possible must be enacted or expanded, and funding programmes to optimise UV protection must be launched by municipalities.

New 2020

7. Occupational Skin Cancer

7.1. Status Quo Outdoor Worker

7.1. Consensus-based recommendation

If employees are exposed to intensive UV radiation outdoors due to their work, targeted technical, organisational, and personal protection and prevention measures must be integrated into everyday working life.

New 2020

7.2. Measures of Behavioural and Situational Prevention for Outdoor Workers

7.2. Evidence-based recommendation

Technical measure:
Workplaces and break areas must offer shading.

New 2020

7.3. Evidence-based recommendation

Organisational measure:
Employees working outdoors must be informed about UV radiation and the associated health risks as well as the protective measures to be taken.

New 2020

7.4. Consensus-based recommendation

Organisational measure:
Necessary means (e.g. sun hat with brim and neck protection, sunglasses, covering clothing, sunscreen) to protect against UV radiation must be provided at the workplace.

New 2020

7.5. Consensus-based recommendation

Organisational measure:
In order to reduce UV exposure, working hours including breaks (e.g. avoiding outdoor work at lunchtime) must be organised.

New 2020

7.6. Evidence-based recommendation

Personal measure:

The skin and eyes of outdoor workers must be protected from solar radiation. The body must be covered to the maximum with suitable clothing, i.e., in the form of long-sleeved clothing and headgear with neck protection.

New 2020

7.7. Evidence-based recommendation

Personal measure:
Body parts that cannot be covered or shaded by textiles must be covered with suitable sunscreens.

New 2020

7.3. Providing Information and Motivating Employees to Take Protective Measures

7.8. Evidence-based recommendation

Protection and prevention measures must be taught in person.

Visual support or reminders of the desired target behaviour can be provided, e.g. in the form of posters, pictures, or videos.

New 2020

7.4. Occupational Health Screening for Outdoor Workers

7.9. Evidence-based recommendation

The fact that UV radiation exposure represents the highest occupational cancer risk for outdoor workers in Germany must be the reason for the legislator to prescribe mandatory screening for all highly exposed persons.

New 2020

5. Secondary prevention

8. Secondary Prevention

5.1. Early detection of skin cancer

8.1. General Information on the Early Detection of Skin Cancer

5.1. Evidence-based statement

Population-based screening with the target diseases of malignant melanoma, basal cell carcinoma and squamous cell carcinoma, in which a standardised examination of the skin over the whole body is performed by trained physicians, has been shown to result in an increase in the detection rate of tumours at an early stage.

Deletion

5.2. Evidence-based statement

Skin cancer screening of the general adult population results in an initial increase in the incidence of skin cancer (prevalence phase of screening) and an increase in the detection rate of skin cancer at an early stage. This result could impact on the morbidity of malignant melanoma, basal cell carcinoma and squamous cell carcinoma.

Deletion

5.3. Evidence-based statement

A single study indicates that population-based skin cancer screening could reduce mortality from melanoma.

Deletion

5.4. Evidence-based recommendation

Skin cancer screening should be offered as part of the prevention of skin cancer.

8.20. Evidenzbasierte Empfehlung

Skin cancer screening should be offered as part of the prevention of skin cancer.

Checked 2020

5.5. Dessenting opinion of DEGAM

The German Society of General Practice and Family Medicine (DEGAM) regards the evidence for the benefit of a general skin cancer screening programme as insufficient. In individual cases, early detection of skin cancer can be performed following balanced information about the pros and cons.

8.21. Dessenting opinion of DEGAM

The German Society of General Practice and Family Medicine (DEGAM) and the German Society of HNO (DGHNO), Head and Neck Surgery e.V. regard the evidence for the benefit of a general skin cancer screening programme as insufficient compared to opportunistic screening, in agreement with international institutions.

Since the introduction of skin cancer screening, the mortality from skin cancer in Germany has not decreased. Therefore, no opportunistic skin cancer screening must be offered. In individual cases, early detection of skin cancer can be performed following balanced information about the pros and cons, especially in people at increased risk.

Modified 2020

5.6. Evidence-based recommendation

The standardised whole-body skin examination to screen for malignant skin tumours must be performed by physicians.

The precondition for this is participation in special advanced education courses on the early detection of skin cancer.

8.10 Consensus-based recommendation

For skin cancer screening, a standardized whole-body skin examination of the skin must be performed by physicians who have participated in a special training course on the early detection of skin cancer as defined in the guideline for early detection of cancer.

Modified 2020

5.7. Consensus-based recommendation

On the basis of the current evidence, it is not possible to make any statement about examination intervals for people not at increased risk.

8.13. Consensus-based statement

On the basis of the current evidence, it is not possible to make any statement about the intervals between screening examinations for skin cancer for people not at increased risk.

Modified 2020

5.8. Consensus-based recommendation

In the context of skin cancer screening, the time to presentation for further confirmation of the findings following the suspicion of a malignant melanoma, basal cell carcinoma or squamous cell carcinoma should not exceed ten working days.

8.11. Consensus-based recommendation

In the context of skin cancer screening, the period of time until the next appointment for further confirmation of findings following the suspicion of a malignant melanoma or squamous cell carcinoma should not exceed ten days.

Modified 2020

8.12. Consensus-based recommendation

Within the scope of a skin cancer screening, the period of time until the next appointment for further confirmation of findings after a suspected basal cell carcinoma can be individually adjusted.

New 2020

5.9. Dessenting opinion of DEGAM

In the context of skin cancer screening, people with a suspected malignant melanoma must be given the opportunity to attend for further, where necessary surgical, investigations within ten working days.

Deletion

5.10. Consensus-based recommendation

At-risk persons (see section 3.4) must be taught to carry out skin self-examination so as to be able to identify abnormal skin lesions.

At-risk persons must be informed about their individual risk and be regularly examined (at intervals to be defined individually) by a trained physician by means of a whole-body skin examination.

8.7. Consensus-based recommendation

At-risk persons must be taught to carry out skin self-examination so as to be able to identify abnormal skin lesions.

At-risk persons must be informed about their individual risk and be regularly examined (at intervals to be defined individually) by a trained physician by means of a whole-body skin examination.

Checked 2020

5.11. Consensus-based recommendation

For people at increased risk for skin cancer, the physician, together with the person to be screened, should define an appropriate interval, based on an assessment of the individual risk profile.

8.14. Consensus-based recommendation

For people at increased risk for skin cancer, the physician, together with the person to be screened, should define an appropriate interval until the next presentation, based on an assessment of the individual risk profile.

Modified 2020

5.12. Evidence-based statement

Negative consequences of skin cancer screening involve excisions with a benign histology (false-positive tests).

The number-needed-to-excise described in studies ranges from 3.25 to 179, i.e. between 3.25 and 179 excisions are needed to confirm one malignant skin tumour histologically.

8.1. Evidence-based statement

Negative consequences of skin cancer screening involve excisions with a benign histology (false-positive tests).

The number-needed-to-excise described in studies ranges from 3.25 to 179, i.e. between 3.25 and 179 excisions are needed to confirm one malignant skin tumour histologically.

Checked 2020

5.13. Consensus-based recommendation

With the exception of false-positive tests, there is little evidence to date about potential risks and negative consequences of skin cancer screening. Possible negative consequences are overdiagnosis, overtreatment, negative psychological consequences and possible delays in diagnosis as a result of false-negative tests.

These potential risks and negative consequences of skin cancer screening should be reduced as far as possible by appropriate physician training and teaching measures. Physicians should discuss potential risks and negative consequences with their patients before the screening.

8.2. Consensus-based recommendation

Checked 2020

8.3. Consensus-based recommendation

Skin self-examination must be recommended.

New 2020

5.2. Screening test / presumptive diagnostic procedures

5.14. Evidence-based recommendation

A whole-body examination must be performed for skin cancer screening.

8.4. Evidence-based recommendation

To screen for skin cancer, a whole-body examination must be performed.

Modified 2020

5.15. Consensus-based recommendation

For a whole-body examiantion, the examination room must be well-lit and the examiner must approach the person to be screened close enough to be able to detect skin changes with the naked eye.

8.5. Consensus-based recommendation

For a whole-body examiantion, the examination room must be sufficiently bright and the examiner must approach the person to be screened close enough to be able to detect skin changes with the naked eye.

Modified 2020

5.16. Evidence-based statement

The diagnosis of non-melanocytic skin cancer by whole-body examination has a sensitivity of 56 90% and a specificity of 75 90%.

Deletion and inclusion in the background text

5.17. Evidence-based statement

In a cross-sectional study with Australian family physicians, sensitivity in the diagnosis of skin cancer types by whole-body examination was 100% for melanomas (n=1), 89% for basal cell carcinomas (n=62), 80% for dysplastic naevi (n=30), 58% for benign naevi (n=69), 42% for squamous cell carcinomas (n=18) and 10% for actinic keratoses (n=31), while specificity for these entities was 76 99%.

Deletion and inclusion in the background text

5.18. Evidence-based statement

In the diagnosis of melanoma by clinical examination, the sensitivity of non-dermatologically trained practitioners was 86 95% and the specificity 49 77%. Training in the diagnosis of melanoma did not produce any substantial increase in sensitivity and specificity in general practitioners.

Deletion and inclusion in the background text

5.19. Evidence-based statement

According to a systematic review, the available study data are insufficient to draw conclusions about statistically significant differences between dermatologists and primary care physicians in terms of accuracy in classifying suspected melanoma lesions.

In terms of diagnostic accuracy, the sensitivity of dermatologists was 0.81-1.0 and of primary care physicians 0.42‑1.00. In terms of biopsy or referral accuracy, the sensitivity was 0.82‑1.0 (dermatologists) and 0.70‑0.88 (primary care physicians).

8.6. Evidence-based statement

Modified 2020

8.2. Population-Based Skin Cancer Screening in Germany

5.20. Consensus-based recommendation

The person to be screened must be asked about skin changes at the beginning of the screening / presumptive diagnostic procedures.

8.8. Consensus-based recommendation

The person to be screened must be asked about skin changes at the beginning of the screening / presumptive diagnostic procedures.

Checked 2020

5.21. Evidence-based recommendation

The results of the self-examination of the person to be screened should be included at the beginning of the screening / presumptive diagnostic procedures to identify and differentiate between malignant and benign skin changes.

8.9. Evidence-based recommendation

The results of the self-examination of the person to be screened must be included at the beginning of the screening / presumptive diagnostic procedures to identify malignant and benign skin changes.

Modified 2020

8.15. Evidence-based statement

Data on skin cancer screening in Germany show that the population-wide offer of a standardized examination of the skin on the entire body by trained physicians leads to an initially emphasized increase in the incidence of detected cases of melanocytic and non-melanocytic skin cancer.

New 2020

8.16. Evidence-based statement

As a result of skin cancer screening, there is a more marked increase in the incidence of in situ carcinomas compared to invasive tumours. In the case of invasive melanomas, there is a shift in stage with a lower proportion of advanced tumours (stage T2-T4).

New 2020

8.17. Evidence-based statement

The incidence of advanced melanoma is declining after the introduction of population-based skin cancer screening.

New 2020

8.18. Evidence-based statement

Screening participants with unremarkable results are diagnosed with fewer invasive melanomas (in the sense of interval carcinomas) within two years of screening than would be expected without the intervention.

New 2020

8.19. Evidence-based statement

In the temporal context of a feasibility study on population-based screening, there was a significant decrease in documented melanoma mortality.

For nationwide skin cancer screening, no decrease in melanoma mortality could be observed in studies covering a maximum period of seven years after introduction.

New 2020

Presumptive diagnostic procedures

5.22. Evidence-based recommendation

Dermatoscopy should be performed in the presumptive diagnostic procedure. It should be used to improve the clinical diagnosis of melanocytic lesions.

8.48. Evidence-based recommendation

Dermatologists must offer dermoscopy in the presumptive diagnostic procedure of pigmented and non-pigmented skin and nail lesions.

Modified 2020

5.23. Evidence-based recommendation

Dermatoscopy must be performed only after appropriate practical training.

8.49. Consensus-based recommendation

Dermatologists must be trained in dermoscopy for the presumptive diagnostic procedure.

Modified 2020

5.24. Evidence-based recommendation

Dermatoscopy can be performed in people at increased risk undergoing an individualised check-up.

8.50. Evidence-based recommendation

Dermatoscopy can be performed in people at increased risk undergoing an individualised check-up.

Checked 2020

5.25. Consensus-based recommendation

For all lesions of the skin and the adjacent mucosae in the facial, genital or anal region that would be insufficiently investigated by diagnostic procedures involving the use of dermatoscopy, the patient must have a consultation with further specialist diagnostic procedures.

8.51. Consensus-based recommendation

Checked 2020

5.26. Evidence-based recommendation

Algorithms for describing pigmented lesions and instant cameras for observing the disease course with the aim of reducing the proportion of excised benign lesions relative to melanomas should not be used.

8.52. Consensus-based statement

Computer-based algorithms for the classification of (pigmented) skin lesions are currently being developed and investigated in many cases, but the guideline group is not yet in a position to make any statements in this respect.

Modified 2020

5.27. Evidence-based statement

The value of whole-body photography in melanoma risk patients remains unproven.

8.53. Evidence-based statement

The value of whole-body photography in melanoma risk patients remains unproven.

Checked 2020

5.28. Evidence-based statement

Special image processing programmes for the detection of melanomas have been developed, but their value remains unproven.

Deletion and inclusion in the background text

5.22 Evidence-based recommendation

Dermatoscopy should be performed in the presumptive diagnostic procedure.

It should be used to improve the clinical diagnosis of melanocytic lesions.

8.54. Evidence-based statement

Sequential digital dermoscopy can improve the early detection of malignant melanomas in follow-up control that do not have specific dermoscopic malignancy criteria.

Modified 2020

5.29. Evidence-based recommendation

Teledermatology can be used to assess benign and malignant skin tumours.

8.55. Consensus-based recommendation

Teledermatology can be used to assess benign and malignant skin tumours.

Modified 2020

5.30. Evidence-based statement

Spectrophotometric analysis of pigmented lesions has shown no improvement in sensitivity and specificity in the diagnosis of melanoma.

Deletion and inclusion in the background text (in alignment with the guideline Malignant Melanoma)

5.31. Evidence-based statement

The value of near-infrared spectroscopy in distinguishing melanocytic and non-melanocytic skin changes from one another and from normal skin remains unproven.

Deletion and inclusion in the background text (in alignment with the guideline Malignant Melanoma)

5.32. Evidence-based statement

Confocal laser scanning microscopy (CLSM) has a high resolution in assessing pigmented and non-pigmented skin lesions. Following suitable training, CLSM can improve the diagnostic accuracy of individual lesions

Deletion and inclusion in the background text (in alignment with the guideline Malignant Melanoma)

5.33. Consensus-based statement

The value of multiphoton laser tomography in the diagnosis of melanoma remains unproven.

Deletion and inclusion in the background text (in alignment with the guideline Malignant Melanoma)

5.34. Consensus-based statement

The value of optical coherence tomography (OCT) in distinguishing melanocytic and non-melanocytic skin changes from one another and from normal skin remains unproven.

Deletion and inclusion in the background text (in alignment with the guideline Malignant Melanoma)

5.35. Consensus-based statement

The value of multifrequency electrical impedance spectroscopy (EIS) in distinguishing melanocytic and non-melanocytic skin changes from one another and from normal skin remains unproven.

Deletion and inclusion in the background text (in alignment with the guideline Malignant Melanoma)

5.36. Consensus-based statement

The value of high-resolution ultrasonography in distinguishing melanocytic and non-melanocytic skin changes from one another and from normal skin remains unproven.

Deletion and inclusion in the background text (in alignment with the guideline Malignant Melanoma)

5.3. Confirmatory diagnostic procedures

5.37. Consensus-based recommendation

The histopathological examination of a suitable tissue sample is the standard confirmatory diagnostic method. The histopathological diagnosis must be used to confirm a suspicious lesion.

8.56. Consensus-based recommendation

The histopathological examination of a suitable tissue sample is the standard confirmatory diagnostic method. The histopathological diagnosis must be used to confirm a suspicious lesion.

Checked 2020

5.38. Consensus-based recommendation

At the time of tissue sampling, consideration must be given to the relevant specific functional features in each case (e.g. in the facial and genital region) to prevent a functional disorder (e.g. ectropion, facial nerve paralysis) simply as a result of the tissue sampling.

8.57. Consensus-based recommendation

Checked 2020

5.39. Consensus-based recommendation

On clinical suspicion of a malignant melanoma, this lesion must first of all be completely excised with a small safety margin.

8.58. Consensus-based recommendation

On clinical suspicion of a malignant melanoma, this lesion must first of all be completely excised with a small safety margin.

Checked 2020

5.40. Evidence-based statement

The optimal tissue sample for histopathological assessment of a skin lesion suspected of being malignant melanoma is the complete excision (excision biopsy) with a safety margin of 2 mm, including the removal of fatty tissue.

8.59. Evidence-based statement

Checked 2020

5.41. Consensus-based recommendation

In the case of large, extensive tumours on the face or acral skin that are suspicious for melanoma and for which a primary diagnostic excision is difficult, a sample biopsy or partial excision can be performed.

8.60. Consensus-based recommendation

Checked 2020

5.42. Evidence-based recommendation

On clinical suspicion of a basal cell carcinoma or a squamous cell carcinoma, the tumour can undergo complete primary excision with a small safety margin or a sample biopsy can be taken beforehand.

8.61. Evidence-based recommendation

On clinical suspicion of a basal cell carcinoma or a squamous cell carcinoma, the tumour can undergo complete primary excision or a sample biopsy can be taken beforehand.

Modified 2020

5.43. Consensus-based recommendation

Each histopathological report (cf. quality assurance agreement) must contain a description of the microscopic findings and the formulation of a diagnosis. The type of tumour must be stated in accordance with the WHO classification and the histological staging in accordance with the currently valid TNM classification (UICC).

8.62. Consensus-based recommendation

Checked 2020

5.44. Consensus-based statement

[In Germany,] the aspects of quality assurance are defined in accordance with the agreement on quality assurance measures laid down in section 135(2) SGB V[1] on the histopathological examination in association with skin cancer screening [432] of 12 August 2009.

Deletion

5.4. Doctor-patient communication

5.45. Consensus-based recommendation

Prior to the doctor-patient conversation, the patient should be issued with an information sheet on the early detection of skin cancer (skin cancer screening) that provides information about the pros and cons of early detection in simple language without engendering any anxiety. The subject matter should be kept to the checklist agreed in connection with the German National Cancer Control Plan Recommended content of information about early detection measures [439]. In addition, reference should be made to the possibility that outstanding queries can be clarified in the subsequent doctor-patient conversation.

During the doctor-patient conversation, which should take place in a quiet and undisturbed atmosphere, the checklist should also serve as a guide. Emphasisie should be placed on the following aspects:

Procedure of the skin cancer screening,

Pros and cons of skin cancer screening,

Primary prevention information,

Personal risk profile and resultant consequences (risk communication).

A period of time commensurate with the patient’s personal preferences should be allowed to elapse between the provision of information and the decision. Associated professional groups and, where applicable, relatives should be included in the communication process.

8.44. Consensus-based recommendation

(Chapter 8.4.)

Prior to the doctor-patient conversation, the patient must be issued with evidence-based information on the early detection of skin cancer (skin cancer screening) that provide information about the pros and cons of early detection in comprehensible language without engendering any anxiety. The subject matter must be kept to the checklist agreed in connection with the German National Cancer Control Plan Recommended content of information about early detection measures (Federal Ministry of Health, 2010). In addition, reference must be made to the possibility that outstanding queries can be clarified in the subsequent doctor-patient conversation.

During the doctor-patient conversation, which must take place in a quiet and undisturbed atmosphere, the checklist must also serve as a guide. Emphasisie must be placed on the following aspects:

Procedure of the skin cancer screening,

Pros and cons of skin cancer screening,

Primary prevention information,

Personal risk profile and resultant consequences (risk communication).

A period of time commensurate with the patient’s personal preferences must be allowed to elapse between the provision of information and the decision. Associated professional groups and, where applicable, relatives must be included in the communication process.

Modified 2020

5.46. Consensus-based recommendation

A negative examination result must be communicated to the patient personally by the doctor carrying out the early detection in a counselling immediately after the examination.

It must be pointed out that the result of the examination reflects the current status.

In addition, the patient’s individual risk factors must be explained to him and he must be motivated to practise primary preventive behaviour and skin self-examination. The patient must also be informed that he can visit the doctor again at any time in the event of any uncertainties about self-recorded skin findings.

8.45. Consensus-based recommendation

(Chapter 8.4.)

If the screening does not reveal any suspicion of skin cancer, this must be communicated to the patient personally by the doctor carrying out the early detection in a counselling immediately after the examination.

It must be pointed out that the result of the examination reflects the current status.

Modified 2020

5.47. Consensus-based recommendation

The suspicion of skin cancer must be communicated to the patient personally by the doctor carrying out the early detection in a counselling immediately after the examination.

Family physicians (specialists in general medicine working in family practice, internal specialists, medical practitioners and non-specialist practitioners): following the communication of a suspicion, the subsequent procedure must be explained, including a referral to the dermatologist for further investigations.

Dermatologist: the subsequent diagnostic investigations of the clinical suspicion must be communicated and explained.

The patient must be informed that the findings will be communicated in a personal conversation and that he has the possibility of including a person of trust in this conversation. The patient must be asked about resources for psychological support during the waiting period and encouraged to practise self-care.

The detailed interview must take place following receipt of the histological report.

Information about the exclusion or demonstration of skin cancer (following histological confirmation of the findings) must not be given over the telephone.

8.46. Consensus-based recommendation

(Chapter 8.4.)

If the screening results in a suspicion of skin cancer, this must be communicated to the patient personally by the doctor carrying out the early detection in a counselling immediately after the examination.

Dermatologist: the subsequent diagnostic investigations of the clinical suspicion must be communicated and explained.

The detailed interview must take place following receipt of the histological report.

Modified 2020

5.48. Consensus-based recommendation

The period between the measures to confirm the diagnosis and the communication of the diagnosis must be kept as short as possible.

Exclusion of skin cancer: the patient must be told of the histological exclusion of skin cancer. In addition, the patient must be given an explanation about his individual risk factors and he must be encouraged to practise primary preventive behaviour and skin self-examination. The patient must also be informed that he can visit the doctor again at any time in the event of any uncertainties about self-recorded skin findings.

Confirmation of skin cancer: the finding of skin cancer must be communicated to the patient in detail with the diagnosis and grading in a personal (face-to-face) conversation. The existing diagnostic and therapeutic steps consistent with the current state of scientific knowledge must be conveyed comprehensibly to the patient over several sessions.

8.47. Consensus-based recommendation

(Chapter 8.4.)

The period between the measures to confirm the diagnosis and the communication of the diagnosis must be kept as short as possible.

Exclusion of skin cancer: The patient must be told of the histological exclusion of skin cancer. In addition, the patient must be given an explanation about his individual risk factors and he must be encouraged to practise primary preventive behaviour and skin self-examination. The patient must also be informed that he can visit the doctor again at any time in the event of any uncertainties about self-recorded skin findings.

Confirmation of skin cancer: The finding of skin cancer must be communicated to the patient in detail with the diagnosis and grading in a personal (face-to-face) conversation. The existing diagnostic and therapeutic steps (including benefits and harms) consistent with the current state of scientific knowledge must be conveyed comprehensibly to the patient.

Modified2020

5.5. Implementation and quality assurance of skin cancer screening

5.49. Consensus-based recommendation

Skin cancer screening must be conducted only by qualified physicians who have successfully completed a recognised advanced education course lasting several hours on the conduct of skin cancer screening.

8.22. Consensus-based recommendation

Skin cancer screening must be conducted only by qualified physicians who have successfully completed a quality-assured, accredited education course on the conduct of skin cancer screening.

Modified 2020

5.50. Consensus-based recommendation

A counselling approach and/or further advice on skin cancer screening can be offered and carried out by health professionals who are not medical practitioners (health assistants, practice nurses, nursing professions, other specialist professions within the healthcare system).

The precondition for this is:

completion of appropriate professional training and

successful completion of a recognised advanced education course lasting several hours on counselling in connection with skin cancer screening.

8.23. Consensus-based recommendation

A counselling approach and/or further advice on skin cancer screening cannot be offered and carried out by health professionals who are not medical practitioners (health assistants, practice nurses, nursing professions, other specialist professions within the healthcare system).

The precondition for this is:

completion of appropriate professional training and

successful completion of a recognised quality-assured education course on counselling in connection with skin cancer screening.

Checked 2020

5.51. Consensus-based recommendation

Advanced education/advanced education programmes in skin cancer screening for physicians and other health professionals (health assistants, practice nurses, nursing professions, other specialist professions in the healthcare system) must be extensively offered and carried out by certified trainers.

8.24. Consensus-based recommendation

Checked 2020

5.52. Consensus-based recommendation

Advanced education provision in skin cancer screening for physicians or other health professionals (health assitants, practice nurses, nursing professions, other specialist professions in the healthcare system) must impart practical and theoretical knowledge and methods. To this end, the following content matter must be included in a curriculum:

Epidemiology of skin cancer (MM, NMSC),

Aetiology, risk factors and groups,

Clinical pictures (MM, NMSC),

Definition of prevention (primary, secondary and tertiary prevention),

Early detection of cancer as a screening measure,

Legal framework conditions,

Benefit and harms of early detection measures/screening programmes,

Criteria for assessing early detection measures,

Key performance indicators of a screening test,

Skin cancer screening,

Measures for targeting potential participants,

Requirements for advice about an informed decision in the context of skin cancer screening,

Screening test: visual standardised whole-body examination,

Targeted case history-taking,

Reporting of findings and advice,

Quality assurance of pathology (histopathological differential diagnoses),

Quality requirement of histopathology,

Histopathological diagrams,

The histopathological report (completeness, significance of contents),

Referral,

Documentation,

Invoicing,

Notification to cancer registries,

Interdisciplinary co-operation,

Principles of communication,

Communication between family physician and dermatologist, dermatologist and pathologist, physician and patient,

Communication tools for conversation techniques.

Deletion and inclusion in the background text

5.53. Evidence-based recommendation

Curricula for the training, advanced education and continuing professional development of physicians or other health professionals (health assistants, practice nurses, nursing professions, other specialist professions in the healthcare system) in primary care provision can include the following subject areas in relation to the primary and secondary prevention of skin cancer:

Epidemiology,

Diagnostic procedures including dermatoscopy and clinical algorithms, aided by photographic images of skin lesions,

Advice (primary and secondary prevention),

Communication,

Treatment.

Curricula can be divided into one of more intervention units and incorporate the following educational means and conditions: course attendance, web-based, interactive, multimedia, role play, conveyed theoretically and/or practically.

8.25. Evidence-based statement

Curricula for the training, advanced education and continuing professional development of physicians or other health professionals (health assistants, practice nurses, nursing professions, other specialist professions in the healthcare system) in primary care provision should include the following subject areas in relation to the primary and secondary prevention of skin cancer:

Epidemiology,

Diagnostic procedures including dermatoscopy and clinical algorithms, aided by photographic images of skin lesions,

Advice (primary and secondary prevention),

Communication,

Treatment.

Modified 2020

5.54. Evidence-based recommendation

Pharmacy staff can be trained in primary skin cancer prevention.

Deletion and inclusion in the need for research in chapter 5.4

5.55. Consensus-based recommendation

In skin cancer screening, participating physicians must collect the following data for each patient examined for skin cancer:

Family physician (specialists in general medicine working in family practice, internal specialists, medical practitioners, non-specialist physicians):

Clear personal identification of the examinee (screening ID or pseudonym in the cancer registry),

Identification of the physician,

Age and sex of examinee,

Date of examination,

Presumptive diagnosis, differentiated by type of skin cancer (malingnant melanoma, squamous cell carcinoma, basal cell carcinoma).

Dermatologists (specialists in skin and venereological diseases) must record the following data in addition to those mentioned above:

On referral: presumptive diagnosis of the referring physician and date of first examination,

Date of examination (dermatologist),

Presumptive diagnosis (dermatologist), differentiated by type of skin cancer (malingnant melanoma, squamous cell carcinoma, basal cell carcinoma),

Following excision: excision date, histopathological findings and where applicable tumour stage (tumour thickness or spread, where applicable TNM stage, grading).

5.56. Consensus-based recommendation

If an invitation system is introduced for skin cancer screening, the following data on the invitation of the general population must be recorded:

Agency issuing the invitation (central agency or health insurance company):

Clear personal identification of the invitee (screening ID or pseudonym in the cancer registry),

Date of invitation

Age and sex of invitee,

Rejection / exclusion (active rejection of skin cancer screening or skin cancer screening not applicable, e.g. with prevalent skin cancer).

Deletion and inclusion in the background text

5.57. Dessenting opinion of DEGAM

In view of the unconfirmed evidence for skin cancer screening and the in any case already high level of doctor-patient contacts in general practices compared to international standard, the German College of General Practitioners and Family Physicians (DEGAM) does not recommend an invitation system.

Deletion

5.58. Consensus-based recommendation

Data recorded about skin cancer screening must be forwarded by family physicians and dermatologists to an evaluation centre where, together with the invitation data where applicable, they must be collated and evaluated for the quality management of skin cancer screening.

In order to determine interval carcinomas and to evaluate mortality, a comparison must be undertaken with the cancer registry. The comparative data must be provided for the purposes of scientific evaluation.

When a malignant finding is obtained, the responsible cancer registry must be notified by the examining physicians (including pathologists).

8.26. Consensus-based recommendation

When a malignant finding is obtained, the responsible cancer registry must be notified by the examining physicians (including pathologists).

Checked 2020

5.59. Consensus-based recommendation

Skin cancer screening data must be recorded electronically by all those involved and transmitted electronically.

Deletion and inclusion in the background text

5.60. Consensus-based recommendation

Documentation of the examination results for participants in skin cancer screening must be done under pseudonymised conditions taking due accounts of suitable methods and data protection concepts. The additional collection of a declaration of consent must be omitted. For non-participants, time-limited pseudonymised data storage of the invitation data is recommended for the purpose of evaluating outcomes (particularly skin cancer-related mortality). All data recording, data storage and transmission processes must be closely agreed with the data protection authorities.

Deletion and inclusion in the background text

5.61. Consensus-based recommendation

Quality assurance measures for skin cancer screening must include structure, process and outcome quality. Because of the absence of scientifically-based quality assurance measures, quality indicators must be confirmed by evidence-based methods and where necessary new indicators developed.

8.27. Consensus-based recommendation

Checked 2020

8.28. Consensus-based recommendation

Awareness of statutory skin cancer screening should be increased among the population through targeted measures. Different communication channels should be used to reach different target groups.

New 2020

8.29. Consensus-based recommendation

Information about and motivation to take up skin cancer screening should be addressed in a gender-specific way.

New 2020

6. Informing the general population / public

6.1. Informing the general population / public

8.3. Communicative Strategies and Communication Channels of Secondary Prevention

6.1. Consensus-based recommendation

Information about the early detection of skin cancer must be guided by the recommendations of the [German] National Cancer Control Plan on an „informed decision“ to enable the potential screenee deciding for or against participation in skin cancer screening examination.

8.30. Consensus-based recommendation

Information about the early detection of skin cancer must be guided by the recommendations of the [German] National Cancer Control Plan on an „informed and participatory decision“ to enable the person seeking advice deciding for or against participation in skin cancer screening examination.

Modified 2020

6.2. Consensus-based recommendation

Strategies and measures whose aim is to reach the population with prevention messages and to allow an “informed decision“ for or against participation in skin cancer screening must be tailored to the different target groups.

8.31. Consensus-based recommendation

Strategies and measures aimed at enabling the population to make an “informed and participatory decision" for or against participation in skin cancer screening must be tailored to the different target groups. Different characteristics of the target groups (such as their risk perception and self-efficacy) are to be taken into account.

Modified 2020

8.32. Consensus-based recommendation

The communication strategy for secondary prevention measures must be oriented towards the information and communication needs and routines as well as the living environments of the respective target group.

New 2020

6.3. Evidence-based statement

Informing the adult population in a social setting can help promote cancer awareness.

8.33. Evidence-based statement

Informing the adult population in their immediate environment can help to promote skin cancer awareness.

Modified 2020

8.34. Consensus-based recommendation

Family members or multipliers can be involved in measures, for example, to carry out self-examination and to promote informed participation in skin cancer screening.

New 2020

8.35. Evidence-based recommendation

Interventions to promote skin self-examination and inform about skin cancer screening should be multimedia, interactive, integrate multiple communication channels, and be repetitive.

New 2020

6.4. Evidence-based recommendation

Children, adolescents and young adults with computer or online skills can be informed via computer or online.

Deletion due to inclusion in other recommendations

6.5. Consensus-based recommendation

Information can also be given via agents of socialisation, peers and other multiplicators.

5.32. Consensus-based recommendation (chapter 5.4.)

Information can be provided via parents, teachers, educators, peers and other multipliers.

Modified 2020

6.6. Evidence-based recommendation

Adults should be informed repeatedly.

Deletion due to inclusion in other recommendations

6.7. Evidence-based recommendation

Adults should be informed by means of multimedia.

Deletion due to inclusion in other recommendations

6.8. Evidence-based recommendation

People at increased risk should be informed by means of tailored communication.

Deletion due to inclusion in other recommendations

6.9. Evidence-based recommendation

Schoolchildren should be offered information via multiple media, along with information for their teachers.

Deletion due to inclusion in other recommendations

6.10. Evidence-based recommendation

Educational and training programmes on primary and secondary prevention of skin cancer should be structured multimedially and interactively and incorporate several channels of communication.

Deletion due to inclusion in other recommendations

6.11. Evidence-based recommendation

Educational and training programmes on primary and secondary prevention of skin cancer should use the simplest, most realistic and vivid forms of visualisation possible in structuring materials and take account of the limits to the acquisition of new skills by individual target groups beyond the transmission of knowledge.

8.36. Evidence-based recommendation

Educational and training programmes on secondary prevention of skin cancer should use the simplest, most realistic and vivid forms of visualisation possible in structuring materials and take into account the competence of individual target groups.

Modified2020

6.12. Evidence-based recommendation

Educational and training programmes on primary and secondary prevention of skin cancer should address the target persons individually (individual-level interventions) and at the same time include individualised information and feedback elements.

5.32. Evidence-based recommendation

(Chapter 5.4.)

Educational and training programmes on primary prevention of skin cancer should address the target persons individually (individual-level interventions) and at the same time include individualised information and feedback elements.

8.37. Evidence-based recommendation

Measures to promote skin self-examination and to inform about the opportunities and risks of skin cancer screening must address the target persons individually (“individual-level-interventions") and include individualized/personalized information and feedback elements.

Modified 2020

6.13. Consensus-based recommendation

Communication interventions in connection with primary and secondary skin cancer prevention should be evaluated formatively and summatively

The evaluation parameters used should be derived from a theoretically established model.

8.38. Consensus-based recommendation

Intervention projects and programmes in the context of secondary skin cancer prevention should be evaluated formatively and summatively.

The evaluation parameters used should be derived from a theoretically based model.

Modified 2020

6.14. Consensus-based recommendation

Evaluations of interventions in connection with primary and secondary skin cancer prevention must work with empirically established measurement procedures geared specifically to the particular outcomes.

8.39. Consensus-based recommendation

Evaluations of interventions in connection with secondary skin cancer prevention must work with empirically established measurement procedures geared specifically to the particular outcomes.

Modified 2020

6.15. Evidence-based recommendation

In evaluating the efficacy of interventions for the primary prevention of skin cancer, skin cancer prevention-specific attitude and behaviour parameters should be used, as well as indicators of contact frequency/intensity, to assess methods of communication and their quality and effectiveness.

8.40. Evidence-based recommendation

In evaluating the efficacy of interventions for the secondary prevention of skin cancer, skin cancer prevention-specific attitudinal and behavioural parameters should be used, as well as indicators of contact frequency/intensity, to assess methods of communication and their quality and effectiveness.

Modified 2020

6.16. Consensus-based recommendation

To evaluate the effectiveness of a communication-based intervention in terms of informed decision-making in connection with primary and secondary skin cancer prevention, at least the following parameters must be determined:

relevant knowledge,

attitude towards the measure, action or behaviour,

participation or behaviour.

8.41. Consensus-based recommendation

To evaluate the effectiveness of a communication-based intervention in terms of informed decision-making in connection with secondary skin cancer prevention, at least the following parameters must be determined:

relevant knowledge about opportunities and risks of the measure,

attitude towards the measure, action or behaviour,

participation or non-participation.

Modified 2020

8.4. Doctor-Patient Communication

8.42. Consensus-based recommendation

A patient-centered form of communication must take place in doctor-patient conversations.

New 2020

8.43. Consensus-based recommendation

The doctor-patient conversation should be divided into two phases. The first phase should serve to clarify the patient's concerns (patient agenda). The second phase of the discussion is the doctor's agenda and should contain precise information for decision-making on examinations, therapies (including the benefits and harms of the various options), and the further course of action.

New 2020

9. Health Economic Evaluation

9.1. Health Economic Evaluations of Measures for the Primary Prevention of Skin Cancer

8.62. Consensus-based recommendation

The less sunbeds are used, the fewer sunbed-induced illness costs arise; therefore, the use of sunbeds must be avoided.

New 2020

8.63. Consensus-based recommendation

Various measures of primary skin cancer prevention show both an economic benefit and a health-related benefit. Therefore, investments in such measures should be increased.

New 2020

9.2. Health Economic Evaluation of Measures of Secondary Prevention of Skin Cancer

8.64. Evidence-based statement

Various measures of skin cancer screening can be classified as cost-effective based on international evidence. Screening of high-risk individuals has a more favourable cost-effectiveness ratio than population-based screening.

New 2020