Behavioral Counseling to Prevent Skin Cancer: A Systematic Review for the U.S. Preventive Services Task ForceJennifer S. Lin, MD, MCR; Michelle Eder, PhD; and Sheila Weinmann, PhD, MPHBackground: More than 2 million cases of skin cancer are diag- nosed annually in the United States, and melanoma incidence is increasing.Purpose: To assist the U.S. Preventive Services Task Force in up- dating its 2003 recommendation on behavioral counseling to pre- vent skin cancer.Data Sources: Existing systematic reviews, database searches through February 2010, and outside experts.Study Selection: English-language, primary carerelevant counsel- ing trials to promote sun-protective behaviors and studies examin- ing the association between sun-protective behaviors and skin can- cer outcomes or potential adverse effects were included.Data Extraction: Each study was appraised by using design-specific quality criteria. Important study details were abstracted into evi- dence tables.Data Synthesis: 11 fair- or good-quality, randomized, controlled trialsexaminedthecounselinginterventionseffectonsun- protective behaviors. In young women, appearance-focused behav- ioral interventions decrease indoor tanning and ultraviolet exposure. In young adolescents, computer support can decrease midday sunexposure and increase sunscreen use. Thirty-five mainly fair-quality observational studies examined the relationship between ultraviolet exposure or sunscreen use and skin cancer. Increasing intermittent sun exposure in childhood is associated with an increased risk for squamous cell carcinoma, basal cell carcinoma, and melanoma. Evidence suggests that regular or early use of indoor tanning may increase melanoma risk. On the basis of 1 fair-quality trial, regular sunscreen use can prevent squamous cell carcinoma, but it is yet unclear if it can prevent basal cell carcinoma or melanoma.Limitations: There are limited rigorous counseling trials. Observa- tional studies are limited by the complexity of measuring ultraviolet exposure and sunscreen use, and inadequate adjustment for impor- tant confounders.Conclusion: Randomized, controlled trials suggest that primary carerelevant counseling can increase sun-protective behaviors and decrease indoor tanning.Primary Funding Source: Agency for Healthcare Research and Quality.Ann Intern Med. 2011;154:190-201.www.annals.org For author affiliations, see end of text.Editors Note: As part of the U.S. Preventive Services Task Forces (USPSTF) ongoing commitment to clarity about its work and methods, the USPSTF is inviting public comment on all draft recommendation statements. The USPSTFs draft recommendation statement on behavioral counseling to pre- vent skin cancer will soon be available for public comment at www.uspreventiveservicestaskforce.org/tfcomment.htm. As a result, the recommendation on behavioral counseling to pre- vent skin cancer does not appear with this accompanying back-ground review. Once finalized, the recommendation statementwill reflect any changes made based on the public comments received. A summary of these changes will be included in anew section of the final recommendation statement. In the United States, more than 2 million cases of non- melanoma skin cancer are diagnosed each year. Of these cases, about two thirds are basal cell carcinoma and one quarter are squamous cell carcinoma (1). Although mela-noma is considerably less common than basal cell or squa- mous cell carcinoma, it now accounts for about 75% of skin cancer deaths (1). Age-adjusted incidence rates for melanoma among white Americans have increased from approximately 8.7 per 100 000 in 1975 to 25.3 per 100 000 in 2007 (2). Several factors may contribute to this increase in incidence, including increased ultraviolet expo- sure, increased public awareness of the warning signs of melanoma, and increased screening by clinicians (35). Skin cancer has well-known host and environmental risk factors. Several phenotypic characteristics are associ- ated with skin cancer risk, including hair and eye color, freckles, and tendency to sunburn (6, 7). Exposure to solar ultraviolet radiation is the most important environmental risk factor for all types of skin cancer (8). Therefore, the primary strategies for preventing skin cancer include limit- ing ultraviolet exposure by avoiding midday sun, wearing protective clothing and broad-brimmed hats, applying sun- screen, and avoiding indoor tanning (7). However, sun- protective counseling in primary care varies in frequency and content (911), despite data suggesting that these be- haviors need to be improved (12). Among adolescents in the United States, for example, about 83% reported at least 1 sunburn during the previous summer, only 34% re- ported sunscreen use, and nearly 10% of adolescents and 20% of young adults reported indoor tanning during the previous year (13, 14).See also:Web-Only Appendix Tables Appendix Figures Conversion of graphics into slidesAnnals of Internal Med