Melanoma Overdiagnosis: the Intersection of Public Health and Clinical Medicine

Steadily increasing incidence with stable to declining mortality is a hallmark of overdiagnosis of a disease. Melanoma is a particularly interesting example of these epidemiologic trends. Declining mortality may be attributed to improvements in treatments over the last decade but how do we explain the decades before where mortality remained stable and incidence steadily climbed.

While it may be a surprise, diagnostic uncertainty is still an issue in most cancers and particularly in early-stage melanoma. A major study by Elmore showed that as many as 50% of melanomas in-situ were not concordantly diagnosed by a second and separate pathology evaluation. Some argue Elmore’s methods but there are many studies that show similar disconcordance in early-stage melanomas.

There are multiple new technologies emerging to help sort these ambiguous cancers better.? These include genomic evaluation, better immunostains, and better imaging modalities. ?I am confident that incorporating these will make us more accurate but we have a long way to go and progress is slow (or slowly adopted).

So, I have an interesting perspective being trained in public health/epidemiology and having more than a decade of clinical experience diagnosing and treating melanoma.

From a public health point of view, we should be thoughtful about screening and biopsy. From a clinician’s point of view, if I see a suspicious pigmented lesion, I am going to test it either by biopsy or genomics. If a friend asks if they should have their “moles” checked. Again from a public health point of view Ill want to discuss risk factors and costs. From a clinician’s point of view – Ill usually say “yes”.

I don’t know the answer but enjoy the thought exercise of aligning my points of view. Clearly the answer is to screen appropriately and base treatment on mutual decision making after informing my patients. It’s not that simple, is it?