10.5826/dpc.1304a250
text/xml
2160-9381
3751
en
Iris Zalaudek
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Overdiagnosis, Overtreatment or Oversurveillance of Melanoma: Is There a Way Out?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Kramer vs Kramer
2023-10-31
2023-08-07
2023-10-31
2024-01-16
e2023250
Dermatol Pract Concept
Iris Zalaudek
2023/10/31
10.5826/dpc.1304a250
e2023250
Department of Dermatology and Venereology, University of Trieste, Italy
2160-9381
en
e2023250
Adamson AS. The USPSTF I Statement on Skin Cancer Screening Not a Disappointment but an Opportunity. JAMA Dermatol. 2023;159(6):579-581. doi:10.1001/jamadermatol.2023.0706).
Overdiagnosis, Overtreatment or Oversurveillance of Melanoma: Is There a Way Out?
https://dpcj.org/index.php/dpc/article/download/3751/2333
 Over-diagnosis, Overtreatment or Oversurveillance
         of Melanoma: Is There a Way Out?
                                                            Iris Zalaudek1


1 Department of Dermatology and Venereology, University of Trieste, Trieste, Italy



Citation: Zalaudek I. Overdiagnosis, Overtreatment or Oversurveillance of Melanoma: Is There a Way Out? Dermatol Pract Concept.
2023;13(4):e2023250. DOI: https://doi.org/10.5826/dpc.1304a250
Accepted: August 7, 2023; Published: October 2023
Copyright: ©2023 Zalaudek. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Corresponding Author: Iris Zalaudek, Department of Dermatology and Venereology, University of Trieste, Trieste, Italy.
E-mail: iris.zalaudek@gmail.com




    Timely detection and prompt treatment have been declared             we failed entirely to step forward in our ability to predict
as the key for reducing melanoma mortality. Dermoscopy and               outcome. The single most important and reliable prognostic
digital monitoring improves early melanoma diagnosis com-                factor for melanoma progression remains level of invasion
pared to the naked eye, which explains its wide use in almost            and thickness, which has been introduced more than 50
all dermatological practices worldwide. However, epidemio-               years ago by Alexander Breslow [2].
logic studies reporting a significant increase in the incidence              However obtaining reliable morphological information
thin melanomas without a significant impact on mortality led             and to link it with biological outcome becomes increasingly
to the discussion on melanoma over-diagnosis [1].                        complicated because of the introduction of effective treat-
    In this issue, Betz-Stablein et al. and Navarette Dechent            ments in adjuvant settings and the multidisciplinary approach
et al. discuss several valid arguments related to melanoma               in melanoma management today. Those specialties, who are
over-diagnosis and conclude that intensified use of integrated           primarily involved in diagnosis (pathologists and dermatol-
clinical approach combined with even more innovative tech-               ogists) are not necessarily those, who care about treatment
nologies such as 3D Total Body Photography, sequential                   and follow up. Consequently, there is the natural risk of
dermoscopy images and whole slide pathology images sup-                  inter-disciplinary loss of information between “holders” of
ported by AI will have the power to resolve the dilemma of               image collections and long-term outcomes. Clinical trials on
over-diagnosis. I doubt their conclusion because the current             melanoma represent powerful documentation tools on treat-
design and application of all innovative technologies focus              ment efficacy and progression, but they rarely include the
on early melanoma detection and do not address the true                  validation of pathological and/or clinical-dermoscopic docu-
problem in dermato-oncology today: how to identify bio-                  mentation of the primary tumor. In my view, the most signif-
logically “dangerous” melanomas and how to differentiate                 icant problem of melanoma over-diagnosis is not related to
them for biologically “indolent” ones. After decades of in-              the diagnostic dilemma nor to treatment of equivocal lesions,
tense research and technical progresses enabling us to diag-             but to the consequences that arise from it: namely a world-
nose melanoma at all stages (from earliest to ­latest stage),            wide over-surveillance.   Most clinicians and pathologists




Commentary | Dermatol Pract Concept. 2023;13(4):e2023250                                                                            1
agree on the problem of over-diagnosis but consider a simple        dermatologist for a concerning symptomatic mole, this is not
re-excision of an equivocal melanocytic neoplasm diagnosed          considered a screening examination but a diagnostic exam-
eventually as “early melanoma” an acceptable compromise             ination. Thus, the relevant central clinical question in the dis-
in the management path. While this might be true for an             cussion on over-diagnosis is whether individuals at average
individual patient, the problem gains a much more signifi-          to low risk without symptomatic lesions of concern should
cance when it comes to follow up after melanoma diagnosis.          be offered regular visual skin examination for melanoma
Individuals diagnosed with melanoma are believed to be at           prevention”[13]. In conclusion, over-diagnosis and over-
higher risk for developing a subsequent melanoma, although          surveillance are hot topics in dermatology and pathology, es-
most never do [3,4]. Only roughly 10%-20% of melanoma               pecially in the post-Covid era. Clinical trials on melanoma,
patients will be diagnosed with subsequent melanoma,                if starting to include clinical – pathologic images in their
whereby the risk of subsequent melanoma is highest within           ­design, may provide powerful tools to gain more insights into
the first 3 years after initial melanoma diagnosis [5]. Not-        the value of morphology as potential predictive marker for
withstanding this evidence, most guidelines and dermatolo-          patterns of progression and response to treatment. ­However,
gists advocate lifelong surveillance with at least annual visits    solid data may not be expected earlier than after 5-10 years
for all melanoma, irrespective of tumor thickness, effective        from now.
risk of recurrence/progression or presence of additional risk
factors [6,7]. Addressing the problem of melanoma over-di-
agnosis in this light, which refers to early melanomas that
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Commentary | Dermatol Pract Concept. 2023;13(4):e2023250                                                                                 3
