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Behavioral counselling to prevent skin cancer: a systematic review for the U.S. Preventive Services Task Force |
Lin JS, Eder M, Weinmann S |
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CRD summary The authors concluded that primary care-relevant counselling could increase sun-protective behaviours and decrease indoor tanning, but that more research is needed. The limitations of the included trials and relevance of the findings to clinical practice should be borne in mind when interpreting the authors' conclusions. Authors' objectives To update a previous review assessing the effects of behavioural counselling on sun-protective behaviours for the prevention of skin cancer. Searching An updated search (2001 to February 2010) was undertaken in MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify English language articles. Search terms were reported. The previous review (see Helfand & Krages in Other Publications of Related Interest) was scanned for relevant studies. Reference lists of relevant articles and systematic reviews were searched. Experts in the field were contacted for additional information. Study selection Randomised and non-randomised controlled trials that evaluated the effectiveness and harms of behavioural counselling interventions to prevent skin cancer in individuals without current or past skin cancer, or pre-cancerous skin lesions, were eligible for inclusion. Eligible trials were required to assess interventions relevant to primary care settings (defined in the paper) and had to be conducted in English speaking countries similar to the USA. Trials with over 40% attrition rates were excluded.
Outcomes of interest were: skin cancer incidence or associated morbidity or mortality; intermediate outcomes (sunburns, nevi, or actinic keratosis); behavioural outcomes (self-report or directly observed measures of sun-protective behaviours); and adverse outcomes at up to three months or more follow-up.
There were some differences between the trials reported in the full report (see Lin, Eder, et al in Other Publications of Related Interest) and those reported in the journal paper; this abstract is based on those reported in the journal paper. Included trials assessed the effects of counselling on sun-protective behaviours. Primary care settings were home, school, dermatology departments, and universities. Most of the participants were white and at high risk. Interventions were directed at adults, young adults, children and parents of newborns. Counselling formats included written materials, telephone sessions, computer sessions, appearance-focused videos, peer-counselling sessions, or primary care physician counselling (with or without computer support). Participants received one to four intervention sessions, which lasted between 11 and 30 minutes (where reported). Control groups received usual care, initial assessment only, or physical activity and diet intervention (where reported).
Two reviewers independently screened trials for inclusion. Assessment of study quality Two reviewers independently assessed trial quality according to the US Preventive Services Task Force (USPSTF) criteria, including items on randomisation, allocation concealment, blinding, comparability of groups at baseline, and withdrawals/loss to follow-up. Trials were rated as good quality (met all criteria), fair quality (did not meet, or it was not clear that it, met at least one criterion, but had no important limitations to invalidate the results) or poor quality (had important limitations). All poor quality trials were excluded. Data extraction One reviewer extracted sun protection behaviour scores at baseline and follow-up. A second reviewer checked data extraction for accuracy. Methods of synthesis Due to clinical and methodological heterogeneity, findings were reported narratively by population. Results of the review Eleven randomised controlled trials (RCTs; n=10,020 participants) were included in the paper; three were cluster RCTs. All RCTs were reported to be of fair quality (although reported to be of fair or good quality in the abstract). Follow-up was between three and 36 months; 64 to 96% of the trial populations were followed up.
No trials reported cancer or intermediate outcomes.
Three of five RCTs (reported as four of five RCTs in the text) showed that primary care counselling with tailored feedback (with or without computer support) lead to a statistically significant improvement of self-reported sun-protective behaviours, as measured by composite behaviour scores.
Three of four RCTs in young adults showed that appearance-focused counselling successfully reduced indoor tanning at three to six month follow-up among women who tan indoors.
One RCT of adolescents showed that brief counselling by their primary care provider in addition to computer support gave a statistically significant improvement of composite self-reported sun protection scores up to 24 months follow-up, but for individual behaviour scores, only avoiding or limiting exposure to midday sun were significantly reduced.
One RCT of parents of newborns showed that the provision of counselling and written materials statistically improved composite sun-protection scores at 36 month follow-up, but none of the individual behaviour scores were statistically significant.
There was no evidence of adverse effects from counselling interventions. Authors' conclusions A limited number of RCTs suggested that primary care-relevant counselling could minimally increase sun-protective behaviours and decrease indoor tanning, but more research is needed. CRD commentary The review question and supporting inclusion criteria were clearly stated. However, it was unclear why the trials included in the journal paper differed from those included in the full report. The literature search involved two electronic databases and other relevant sources, but was restricted to English language articles, which meant that language bias may have been introduced. Each stage of the review was conducted in duplicate, reducing the potential for reviewer error and bias.
Trial quality was assessed using previously published criteria, but the included trials were only of fair quality. The decision to combine trials narratively was appropriate given the clinical and methodological heterogeneity among trials. The authors highlighted some of the limitations of the included trials, such as the small number of trials for some age groups, short duration of interventions, and short follow-up durations for some trials. Most trials only reported composite scores, which made it difficult to untangle the behaviours that were changed.
The limitations of the included trials and relevance of the findings to clinical practice should be borne in mind when interpreting the authors' conclusions. Implications of the review for practice and research Practice: The authors stated that it is unclear whether the small differences in composite scores of self-reported sun-protective behaviours translate into clinically meaningful behavioural change to prevent skin cancer or sunburns. They also stated that the generalisability of the findings from different tailored interventions remains unclear and findings could vary for gender and non-white populations, and among different age groups.
Research: The authors stated that more trials are needed in primary care relevant counselling to promote sun-protective behaviours, especially directed at younger individuals. Funding Oregon Evidence-based Practice Centre under contract to the Agency for Healthcare Research and Quality, contract HHS-290-2007-10057-I. Bibliographic details Lin JS, Eder M, Weinmann S. Behavioral counselling to prevent skin cancer: a systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2011; 154(3): 190-201 Other publications of related interest Helfand M, Krages KP. Counseling to Prevent Skin Cancer: A summary of the evidence. Rockville, U.S. Preventive Services Task Force recommendation. Rockville, MD, USA: Agency for Healthcare Research and Quality (AHRQ Publication number 03-521B). 2003.
Lin JS, Eder M, Weinmann S, Zuber SP, Beil TL, Plaut D, Lutz K. Behavioral counselling to prevent skin cancer: systematic evidence review to update the 2003 U.S. Preventive Services Task Force recommendation. Rockville, MD, USA: Agency for Healthcare Research and Quality. Evidence Synthesis; 82 (AHRQ Publication No. 11-05152-EF-1). 2011. Indexing Status Subject indexing assigned by NLM MeSH Behavior Therapy; Carcinoma, Basal Cell /etiology /prevention & Carcinoma, Squamous Cell /etiology /prevention & Counseling /methods; Health Behavior; Humans; Melanoma /etiology /prevention & Primary Health Care; Risk Factors; Skin Neoplasms /etiology /prevention & Sunlight /adverse effects; Sunscreening Agents /therapeutic use; Suntan; Ultraviolet Rays /adverse effects; United States; control; control; control; control AccessionNumber 12011000788 Date abstract record published 09/02/2011 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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