title: Sun protection for preventing basal cell and squamous cell skin cancers.
abstract: BACKGROUND
  'Keratinocyte cancer' is now the preferred term for the most commonly identified skin cancers basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC), which were previously commonly categorised as non-melanoma skin cancers (NMSC). Keratinocyte cancer (KC) represents about 95% of malignant skin tumours. Lifestyle changes have led to increased exposure to the sun, which has, in turn, led to a significant increase of new cases of KC, with a worldwide annual incidence of between 3% and 8%. The successful use of preventive measures could mean a significant reduction in the resources used by health systems, compared with the high cost of the treatment of these conditions. At present, there is no information about the quality of the evidence for the use of these sun protection strategies with an assessment of their benefits and risks.
  
  
  OBJECTIVE
  To assess the effects of sun protection strategies (i.e. sunscreen and barrier methods) for preventing keratinocyte cancer (that is, basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) of the skin) in the general population.
  
  
  METHODS
  We searched the following databases up to May 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trial registries and the bibliographies of included studies for further references to relevant trials.
  
  
  METHODS
  We included randomised controlled clinical trials (RCTs) of preventive strategies for keratinocyte cancer, such as physical barriers and sunscreens, in the general population (children and adults), which may provide information about benefits and adverse events related to the use of solar protection measures. We did not include trials focused on educational strategies to prevent KC or preventive strategies in high-risk groups. Our prespecified primary outcomes were BCC or cSCC confirmed clinically or by histopathology at any follow-up and adverse events.
  
  
  METHODS
  Two review authors independently selected studies for eligibility using Early Review Organizing Software (EROS). Similarly, two review authors independently used predesigned data collection forms to extract information from the original study reports about the participants, methods of randomisation, blinding, comparisons of interest, number of participants originally randomised by arm, follow-up losses, and outcomes, and they assessed the risk of bias. We resolved any disagreement by consulting a third author and contacted trial investigators of identified trials to obtain additional information. We used standard methodological procedures expected by Cochrane.
  
  
  RESULTS
  We included one RCT (factorial design) that randomised 1621 participants.This study compared the daily application of sunscreen compared with discretionary use of sunscreen, with or without beta-carotene administration, in the general population. The study was undertaken in Australia; 55.2% of participants had fair skin, and they were monitored for 4.5 years for new cases of BCC or cSCC assessed by histopathology. We found this study to be at low risk of bias for domains such as allocation, blinding, and incomplete outcome data. However, we found multiple unclear risks related to other biases, including an unclear assessment of possible interactions between the effects of the different interventions evaluated (that is, sunscreen and beta-carotene). We found no difference in terms of the number of participants developing BCC (n = 1621; risk ratio (RR) 1.03, 95% confidence interval (CI) 0.74 to 1.43) or cSCC (n = 1621; RR 0.88, 95% CI 0.50 to 1.54) when comparing daily application of sunscreen with discretionary use, even when analyses were restricted to groups without beta-carotene supplementation. This evidence was of low quality, which means that there is some certainty that future studies may alter our confidence in this evidence.We reported adverse events in a narrative way and included skin irritation or contact allergy.We identified no studies that evaluated other sun protection measures, such as the use of sun-protective clothing, sunglasses, or hats, or seeking the shade when outdoors.
  
  
  CONCLUSIONS
  In this review, we assessed the effect of solar protection in preventing the occurrence of new cases of keratinocyte cancer. We only found one study that was suitable for inclusion. This was a study of sunscreens, so we were unable to assess any other forms of sun protection. The study addressed our prespecified primary outcomes, but not most of our secondary outcomes. We were unable to demonstrate from the available evidence whether sunscreen was effective for the prevention of basal cell carcinoma (BCC) or cutaneous squamous cell carcinoma (cSCC).Our certainty in the evidence was low because there was a lack of histopathological confirmation of BCC or cSCC in a significant percentage of cases. Amongst other sources of bias, it was not clear whether the study authors had assessed any interaction effects between the sunscreen and beta-carotene interventions. We think that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
authors.affiliation: Instituto de Evaluación Tecnológica en Salud, Bogotá D.C., Colombia.
authors.forename: Guillermo
authors.initials: G
authors.lastname: Sánchez
authors.forename: John
authors.initials: J
authors.lastname: Nova
authors.forename: Andrea Esperanza
authors.initials: AE
authors.lastname: Rodriguez-Hernandez
authors.forename: Roger David
authors.initials: RD
authors.lastname: Medina
authors.forename: Carolina
authors.initials: C
authors.lastname: Solorzano-Restrepo
authors.forename: Jenny
authors.initials: J
authors.lastname: Gonzalez
authors.forename: Miguel
authors.initials: M
authors.lastname: Olmos
authors.forename: Kathie
authors.initials: K
authors.lastname: Godfrey
authors.forename: Ingrid
authors.initials: I
authors.lastname: Arevalo-Rodriguez
mesh_terms: D000328:Adult; D001315:Australia; D002280:Basal Cell Carcinoma / Q000517:prevention & control*; D002294:Carcinoma, Squamous Cell / Q000517:prevention & control*; D002648:Child; D006801:Humans; D009381:Neoplasms, Radiation-Induced / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D012878:Skin Neoplasms / Q000517:prevention & control*; D013472:Sunlight / Q000009:adverse effects*; D013473:Sunscreening Agents / Q000008:administration & dosage* / Q000009:adverse effects; D014466:Ultraviolet Rays / Q000009:adverse effects; D014815:Vitamins / Q000008:administration & dosage / Q000009:adverse effects; D019207:beta Carotene / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D013473:Sunscreening Agents; D014815:Vitamins; D019207:beta Carotene