Clinical Review & Education
From The JAMA Network
Sunscreen Counseling by US Physicians Daniel G. Federman, MD; Robert S. Kirsner, MD, PhD; John Concato, MD
JAMA DERMATOLOGY Trends in Sunscreen Recommendation Among US Physicians Kristie L. Akamine, MD; Cheryl J. Gustafson, MD; Scott A. Davis, MA; Michelle M. Levender, MD; Steven R. Feldman, MD, PhD IMPORTANCE Sunscreen is an important part of sun protection to prevent skin cancer but may not be recommended as often as guidelines dictate.
OBJECTIVE To evaluate trends in sunscreen recommendation
among physicians to determine whether they are following suggested patient-education guidelines regarding sun protection, and to assess data regarding physician sunscreen recommendations to determine the association with patient demographics, physician specialty, and physician diagnosis.
RESULTS According to the National Ambulatory Medical Care Survey, there were an estimated 18.30 billion patient visits nationwide. Physicians mentioned sunscreen at approximately 12.83 million visits (0.07%). Mention of sunscreen was reported by physicians at 0.9% of patient visits associated with a diagnosis of skin disease. Dermatologists recorded the mention of sunscreen the most (86.4% of all visits associated with sunscreen). However, dermatologists reported mentioning sunscreen at only 1.6% of all dermatology visits. Sunscreen was mentioned most frequently to white patients, particularly those in their eighth decade of life, and least frequently to children. Actinic keratosis was the most common diagnosis associated with sunscreen recommendation.
DESIGN, SETTING, AND PARTICIPANTS The National Ambulatory Medical Care Survey was queried to identify patient visits to nonfederal outpatient physician offices at US ambulatory care practices (January 1, 1989–December 26, 2010) during which sunscreen was recommended.
CONCLUSIONS AND RELEVANCE Despite encouragement to provide patient education regarding sunscreen use and sun-protective behaviors, the rate at which physicians are mentioning sunscreen at patient visits is quite low, even for patients with a history of skin cancer. The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protective behaviors, which patients should be counseled about at outpatient visits.
MAIN OUTCOMES AND MEASURES Frequency of sunscreen
JAMA Dermatol. 2014;150(1):51-55.
recommendation.
doi:10.1001/jamadermatol.2013.4741.
Skin cancer affects 2 million individuals annually in the United States.1 Ultraviolet light is the primary cause of skin cancer and sunscreens provide UV protection when sun avoidance is not possible. Because skin cancers can result in substantial morbidity and mortality, it is generally recommended that patients be advised to use sunscreen whenever possible while exposed to sunlight. In the January 2014 JAMA Dermatology, Akamine and colleagues2 reported an analysis of the National Ambulatory Medical Care Survey (NAMCS) showing that physicians from a broad array of specialties rarely provide sunscreen recommendations during outpatient visits. Sunscreen counseling only occurred in 0.01% of visits with internal medicine or pediatric physicians and in 1.6% of visits to dermatologists. Given the known relationship between sunlight UV irradiation and skin cancer, these low numbers are concerning. However, given clinicians’ time constraints, competing demands, increasing emphasis on evidence-based medicine, and some limitations of this study, the findings might be explainable. Physicians are under immense pressure to be efficient and have limited amounts of time to spend with patients. General medicine physicians, family practitioners, internal medicine–primary care physicians, and pediatricians must manage known chronic diseases; per-
form time-consuming reviews of systems; counsel patients regarding diet, tobacco, alcohol, safe sexual practices, and exercise; pursue cancer screening; update immunizations; manage medications; and coordinate care among specialists. Given the multiplicity of tasks required during a single clinic encounter of limited duration, it is understandable that some aspects of what can be considered reasonable counseling are missed. Another explanation for the low rates of providing sunscreen counseling might be an emphasis on adhering to evidence-based medicine. The US Preventive Services Task Force (USPSTF) supports sun protection counseling for fair-skinned patients aged 10 to 24 years. For adults older than 24 years, they found insufficient evidence to recommend for or against counseling.1 Conceivably, the recommendation for adults has been misinterpreted by clinicians as meaning that counseling is not worth pursuing. Evidence-based medical practice is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”3 A limitation of this approach is that such practices may be “impaired by the restrictive quality of what is collected as ‘best available evidence’ and that such evidence may not always simulate ‘real-world’ encounters.”4 The
jama.com
JAMA July 2, 2014 Volume 312, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/30/2015
87
Clinical Review & Education From The JAMA Network
USPSTF rated sunscreen recommendations for adults older than 24 years as “I,” meaning that insufficient evidence exists for or against screening recommendations. In this context, the absence of evidence does not mean there is an absence of an effect5—only that studies done to date have not proven a definite relationship between providing sunscreen recommendations and reducing adverse outcomes from skin cancer. Randomized trials conducted in Australia6,7 have shown reductions in actinic keratosis, squamous cell cancers, and melanomas attributable to sunscreen use. However, Australia has very high UV exposure and cancer risk, and findings from Australia may not generalize elsewhere. Other observational studies did not find such an association.1 The bottom line is that too few studies are available in the literature to know if sunscreen recommendations are helpful. Given that it is known that UV radiation causes skin cancer and that sunscreen has few harms, it is probably reasonable to provide sunscreen counseling to patients at risk for developing skin cancer who will be exposed to strong sunlight. Perhaps clinicians do see it this way. Other studies have reported relatively high sunscreen counseling rates. In the Women Physicians’ Health Study (WPHS), a national sample of more than 3000 US female physicians, 76% of physicians reported discussing skin cancer and sunscreen use with their patients.8 This contrasts with 0.07% (ie,
From The JAMA Network
Sunscreen Counseling by US Physicians Daniel G. Federman, MD; Robert S. Kirsner, MD, PhD; John Concato, MD
JAMA DERMATOLOGY Trends in Sunscreen Recommendation Among US Physicians Kristie L. Akamine, MD; Cheryl J. Gustafson, MD; Scott A. Davis, MA; Michelle M. Levender, MD; Steven R. Feldman, MD, PhD IMPORTANCE Sunscreen is an important part of sun protection to prevent skin cancer but may not be recommended as often as guidelines dictate.
OBJECTIVE To evaluate trends in sunscreen recommendation
among physicians to determine whether they are following suggested patient-education guidelines regarding sun protection, and to assess data regarding physician sunscreen recommendations to determine the association with patient demographics, physician specialty, and physician diagnosis.
RESULTS According to the National Ambulatory Medical Care Survey, there were an estimated 18.30 billion patient visits nationwide. Physicians mentioned sunscreen at approximately 12.83 million visits (0.07%). Mention of sunscreen was reported by physicians at 0.9% of patient visits associated with a diagnosis of skin disease. Dermatologists recorded the mention of sunscreen the most (86.4% of all visits associated with sunscreen). However, dermatologists reported mentioning sunscreen at only 1.6% of all dermatology visits. Sunscreen was mentioned most frequently to white patients, particularly those in their eighth decade of life, and least frequently to children. Actinic keratosis was the most common diagnosis associated with sunscreen recommendation.
DESIGN, SETTING, AND PARTICIPANTS The National Ambulatory Medical Care Survey was queried to identify patient visits to nonfederal outpatient physician offices at US ambulatory care practices (January 1, 1989–December 26, 2010) during which sunscreen was recommended.
CONCLUSIONS AND RELEVANCE Despite encouragement to provide patient education regarding sunscreen use and sun-protective behaviors, the rate at which physicians are mentioning sunscreen at patient visits is quite low, even for patients with a history of skin cancer. The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protective behaviors, which patients should be counseled about at outpatient visits.
MAIN OUTCOMES AND MEASURES Frequency of sunscreen
JAMA Dermatol. 2014;150(1):51-55.
recommendation.
doi:10.1001/jamadermatol.2013.4741.
Skin cancer affects 2 million individuals annually in the United States.1 Ultraviolet light is the primary cause of skin cancer and sunscreens provide UV protection when sun avoidance is not possible. Because skin cancers can result in substantial morbidity and mortality, it is generally recommended that patients be advised to use sunscreen whenever possible while exposed to sunlight. In the January 2014 JAMA Dermatology, Akamine and colleagues2 reported an analysis of the National Ambulatory Medical Care Survey (NAMCS) showing that physicians from a broad array of specialties rarely provide sunscreen recommendations during outpatient visits. Sunscreen counseling only occurred in 0.01% of visits with internal medicine or pediatric physicians and in 1.6% of visits to dermatologists. Given the known relationship between sunlight UV irradiation and skin cancer, these low numbers are concerning. However, given clinicians’ time constraints, competing demands, increasing emphasis on evidence-based medicine, and some limitations of this study, the findings might be explainable. Physicians are under immense pressure to be efficient and have limited amounts of time to spend with patients. General medicine physicians, family practitioners, internal medicine–primary care physicians, and pediatricians must manage known chronic diseases; per-
form time-consuming reviews of systems; counsel patients regarding diet, tobacco, alcohol, safe sexual practices, and exercise; pursue cancer screening; update immunizations; manage medications; and coordinate care among specialists. Given the multiplicity of tasks required during a single clinic encounter of limited duration, it is understandable that some aspects of what can be considered reasonable counseling are missed. Another explanation for the low rates of providing sunscreen counseling might be an emphasis on adhering to evidence-based medicine. The US Preventive Services Task Force (USPSTF) supports sun protection counseling for fair-skinned patients aged 10 to 24 years. For adults older than 24 years, they found insufficient evidence to recommend for or against counseling.1 Conceivably, the recommendation for adults has been misinterpreted by clinicians as meaning that counseling is not worth pursuing. Evidence-based medical practice is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”3 A limitation of this approach is that such practices may be “impaired by the restrictive quality of what is collected as ‘best available evidence’ and that such evidence may not always simulate ‘real-world’ encounters.”4 The
jama.com
JAMA July 2, 2014 Volume 312, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/30/2015
87
Clinical Review & Education From The JAMA Network
USPSTF rated sunscreen recommendations for adults older than 24 years as “I,” meaning that insufficient evidence exists for or against screening recommendations. In this context, the absence of evidence does not mean there is an absence of an effect5—only that studies done to date have not proven a definite relationship between providing sunscreen recommendations and reducing adverse outcomes from skin cancer. Randomized trials conducted in Australia6,7 have shown reductions in actinic keratosis, squamous cell cancers, and melanomas attributable to sunscreen use. However, Australia has very high UV exposure and cancer risk, and findings from Australia may not generalize elsewhere. Other observational studies did not find such an association.1 The bottom line is that too few studies are available in the literature to know if sunscreen recommendations are helpful. Given that it is known that UV radiation causes skin cancer and that sunscreen has few harms, it is probably reasonable to provide sunscreen counseling to patients at risk for developing skin cancer who will be exposed to strong sunlight. Perhaps clinicians do see it this way. Other studies have reported relatively high sunscreen counseling rates. In the Women Physicians’ Health Study (WPHS), a national sample of more than 3000 US female physicians, 76% of physicians reported discussing skin cancer and sunscreen use with their patients.8 This contrasts with 0.07% (ie,
