Leitlinienprogramm OnkologiePrevention of Skin Cancer

2. Introduction – Prevention of Skin Cancer

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

2.1 Scope and Purpose

2.1.1 Objective and Key Questions

The development of the S3 guideline „Prevention of skin cancer“ is intended to adapt the primary and secondary prevention of skin cancer to the current international scientific status. In doing so, the guideline should contribute both to an improvement in health and to a higher quality of life of the population. This goal is to be achieved primarily by reducing the incidence, morbidity and mortality of skin cancer.

In order for the S3 guideline „Prevention of skin cancer“ to achieve this goal, Chapter 4 describes the current international scientific and medical status quo on skin cancer required for this purpose. These explanations form the basis for the development of the questions and recommendations listed below. Specifically, the authors and editors of the S3 guideline „Prevention of skin cancer“ hope for broad consideration of the recommendations on the following points:

  • Primary prevention
  • Climate change and UV radiation
  • Occupational skin cancer
  • Secondary prevention
  • Screening/ Screening test
  • Suspicious diagnosis/ Confirmatory diagnosis
  • Doctor-patient communication
  • Communicative strategies and competences
  • Informing the population
  • Implementation of screening and quality assurance

In this context, the S3 guideline comments on the following questions, among others:

  • Which behaviours reduce the risk of developing skin cancer?
  • Which behaviours are recommended for certain groups of persons (e.g. persons at risk, children / adolescents and adults)?
  • Which behavioural and relational preventive measures are suitable for imparting knowledge and sustainably changing the behaviour of the population?
  • What changes in UV radiation can be expected as a result of climate change and what influence will this have on the risk of skin cancer?
  • Which urban planning measures should be taken into account in future UV prevention due to climate change?
  • What occupational cancer-related primary prevention measures should be recommended?
  • Are there effective population-based and individual measures for early skin cancer detection?
  • How should screening be conducted?
  • What recommendations can be made for screening at-risk individuals?
  • What diagnostic measures are available?
  • Which diagnostic measure (or which combination of measures) is suitable for screening?
  • What are the confirmatory diagnostic methods?
  • How should histopathological diagnostics be performed?
  • How should a doctor-patient discussion be set up (structure) and what content should be conveyed and in what form?
  • What information is necessary so that the citizen can make an informed decision for or against participation in a screening examination?
  • Which professional prerequisites are necessary or must be created for physicians & (health professionals) in order to be able to carry out screening?

2.1.2 Target Audience

The recommendations of the S3 guideline „Prevention of skin cancer“ are aimed at all health professionals and members of professional groups involved in the prevention and early detection of skin cancer. This includes practicing, preventively active physicians (dermatologists, general practitioners, general practitioners, physicians without a regional designation, general practitioners, gynecologists, urologists, surgeons, pediatricians, ENT physicians, oral and maxillofacial surgeons, histopathologists, dentists) as well as nurses and medical assistants (MFA). Further addressees are medical-scientific professional societies and professional associations, patient representatives and self-help groups of skin cancer, employers of outdoor workers as well as quality assurance institutions and institutions on federal and state level, such as the Federal Office for Radiation Protection (BfS), the Central Institute for Health Insurance Physicians in Germany (ZI), the Federal Joint Committee (G-BA), the National Prevention Conference (https://www.npk-info.de) as well as the Society of Epidemiological Cancer Registries in Germany (GEKID). (GEKID).

Finally, the S3 guideline „Prevention of skin cancer“ addresses the general population of the Federal Republic of Germany. A separate evidence-based patient guideline / health care guideline was created to directly address the population.

Interfaces to other guidelines

In Germany, three other guidelines exist that have interfaces with the guideline „Prevention of skin cancer“:

During the update process of version 2.01, these interfaces were systematically taken into account and identified.

2.1.3 Validity and Update Process

However, this version of the guideline is not valid for longer than 5 years until the next update. The current version of the guideline can be viewed on the website of the guideline program oncology: https://www.leitlinienprogramm-onkologie.de/leitlinien/hautkrebs-praevention/.

The current focus in the German health care system on prevention is leading to continuous realignments in a wide variety of decision-making bodies, institutions and professional societies, on the basis of projects carried out and corresponding publications.

The necessary consideration in this updating process, not only of the evidence-based literature, but also of the corresponding orientations in the National Cancer Plan (NKP), the National Decade against Cancer, the DKH Expert Committee on Cancer Prevention, the Alliance for Health Literacy and many others, leads to the realization that this prevention guideline can only achieve its goal – of providing up-to-date recommendations/information for the care of the population – by means of a continuous dynamic updating process. It is therefore the aim to transform the guideline into a „Living Guideline“ with regular (currently planned annual) updates.

Comments and advice are explicitly welcome and can be sent to the following address: hautkrebs-praevention@leitlinienprogramm-onkologie.de

2.2 Methodology

A detailed description of the methodological approach can be found in the guideline report of the S3-guideline Prevention of Skin Cancer(https://www.leitlinienprogramm-onkologie.de/leitlinien/hautkrebs-praevention/).

2.2.1 Levels of Evidence (LoE) According

To classify the risk of bias of the identified studies, a modified system (see following table) based on the system of the Scottish Intercollegiate Guidelines Network (SIGN, see [1]) was used in this guideline. In the system presented, cross-sectional studies on diagnostic issues and before-and-after comparisons were added at level 2, as these were not previously explicitly listed there.

Scheme of the modified evidence classification according to SIGN:

Evidence class Description (modifications in italics)
1++ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of systematic error (bias).
1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with low risk of systematic error (bias)
1- Meta-analyses, systematic reviews of RCTs, or RCTs with high risk of systematic error (bias)
2++ High-quality systematic reviews of case-control or cohort studies(including before-after comparisons) orHigh-quality
case-control or cohort studies (including before-after comparisons) with very low risk of systematic bias (confounding, bias, „chance“) and high probability that the relationship is causal orHigh-quality
study with cross-sectional design to investigate diagnostic quality with very low risk of systematic bias.
2+ Well-conducted case-control studies or cohort studies(including before-after comparisons) with low risk of systematic bias (confounding, bias, „chance“) and moderate probability that the relationship is causal orStudy with
cross-sectional design investigating diagnostic accuracy with moderate risk of systematic bias.
2- Case-control studies or cohort studies(including before-after comparisons) with a high risk of systematic bias (confounding, bias, „chance“) and significant risk that the relationship is not causal or study
with cross-sectional design to investigate diagnostic goodness with high risk of systematic bias.
3 Non-analytic studies, e.g. case reports, case series, studies with cross-sectional design without investigations of diagnostic goodness.
4 Expert opinion

2.2.2 Grades of Recommendation (GoR)

The OL methodology provides for the assignment of grades of recommendation by the guideline authors within the framework of a formal consensus process. Accordingly, a multi-part nominal group process moderated by the AWMF was conducted.

In the guideline, the level of evidence (see 2.3.1) of the underlying studies and, in the case of recommendations, the strength of the recommendation (degree of recommendation) are reported for all evidence-based statements (see Chapter 2.3.3) and recommendations.

With regard to the strength of the recommendation, this guideline distinguishes between three grades of recommendation (see the following table), which are also reflected in the wording of the recommendations in each case.

Grades of recommendation used:

Degree of Recommendation Description Form of expression
A Strong recommendation shall/shall not
B Recommendation should/should not
0 Recommendation open may/can

 

2.2.3 Statements

Apart from the recommendations, the guideline contains evidence- or consensus-based statements. Statements are statements or explanations of specific facts or questions without an immediate call to action. They are adopted in accordance with the procedure for recommendations within the framework of a formal consensus process. The evidence-based statements are also assigned the modified evidence grading according to SIGN (see Section 2.3.1) described above.

2.2.4 Expert Consensus

Recommendations that were decided on the basis of expert consensus and not on the basis of a systematic search or guideline adaptation are shown as such with the graduation „EK“. Symbols to represent the strength of recommendation are not listed for expert consensus. The strength of the recommendation is implicitly derived from the wording in the sentence (should/should/could) according to the grading in the table "Grades of recommendation used" (see Section 2.3.2).

2.2.5 Independence and Disclosure of Possible Conflicts of Interest

German Cancer Aid provided the financial resources through the Guideline Program in Oncology (OL). These funds were used for personnel costs, office supplies, literature procurement, and the consensus conferences (room rental, technology, catering, moderator fees, travel expenses of participants). The guideline was developed in editorial independence from the funding organization. All members provided a written declaration of any conflicts of interest during the guideline process. The disclosed conflicts of interest are listed in the guideline report accompanying this guideline. The conflict of interest declarations were reviewed and evaluated by a working group established for this purpose with the assistance of a patient representative. The results of this review are also available in the guideline report.

References

[1] Scottish Intercollegiate Guidelines Network, SIGN 72: Cutaneous Melanoma - A national clinical guidelineScottish Intercollegiate Guidelines Network, 2003.