10.5826/dpc.1304a248
text/xml
2160-9381
3749
en
Harald  Kittler
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
How to Combat Overdiagnosis of Melanoma
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Kramer vs Kramer
2023-10-31
2023-08-07
2023-10-31
2024-01-16
e2023248
Dermatol Pract Concept
Harald  Kittler
2023/10/31
10.5826/dpc.1304a248
e2023248
Department of Dermatology, Medical University of Vienna, Austria
2160-9381
en
e2023248
Welch et al, on the other hand, reached a different conclusion to fight overdiagnosis: less technology Welch HG, Mazer BL, Adamson AS. The Rapid Rise in Cutaneous Melanoma Diagnoses. N Engl J Med. 2021 Jan 7;384(1):72-79.
How to Combat Overdiagnosis of Melanoma
https://dpcj.org/index.php/dpc/article/download/3749/2331
        How to Combat Over, diagnosis of Melanoma
                                                         Harald Kittler1


1 Department of Dermatology, Medical University of Vienna, Vienna, Austria



Citation: Kittler H. How to Combat Overdiagnosis of Melanoma. Dermatol Pract Concept. 2023;13(4):e2023248.
DOI: https://doi.org/10.5826/dpc.1304a248
Accepted: August 7, 2023; Published: October 2023
Copyright: ©2023 Kittler et al. 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: Harald Kittler, Department of Dermatology, Medical University of Vienna, Austria
E-mail: harald.kittler@meduniwien.ac.at




   The diagnostic criteria for melanoma have undergone                over-diagnosis, I believe it cannot effectively address both
significant changes over time, encompassing clinical, der-            types. Misdiagnosis of nevi as melanomas by pathology can
matoscopic, and histopathologic criteria [1]. It is undeni-           be reduced by minimizing unnecessary nevus excisions, but
able that the increase in melanoma incidence can partly be            overtreatment of slowly progressing in situ melanomas like
attributed to changes in disease definitions and enhanced             lentigo maligna cannot be adequately addressed by these
screening efforts. However, over-diagnosis of melanoma can            measures. Sequential dermatoscopy and total body photog-
be categorized into two types. The first involves incorrectly         raphy may even lead to an increased detection and treatment
labeling nevi as melanomas through pathology, while the               of in situ melanomas. This viewpoint aligns with Welch
second pertains to overtreatment of flat, mostly non-invasive         et al., who recently suggested a reduction in technology as a
melanomas that progress slowly and pose no immediate                  strategy against over-diagnosis [4]. Welch also recommended
harm if left untreated for an extended period. When discuss-          refraining from excising melanocytic lesions smaller than
ing over-diagnosis of melanoma, it is crucial to specify which        6 mm to combat over-diagnosis. However, size alone is a
type is being referred to. The article by Betz-Stablein and           crude and imperfect indicator of prognostic significance. For
Soyer addresses the second type and acknowledges it as a              instance, lentigo maligna can grow to a large size while still
genuine concern [2]. On the other hand, Navarrete-Dechent             maintaining an excellent prognosis. Conversely, some rap-
and Lallas do not explicitly specify the type of over-diagnosis,      idly growing melanomas can be small in size yet exhibit in-
but their arguments seem to encompass both types [3]. Inter-          creased thickness and a worse prognosis. The challenge lies
estingly, both articles propose similar solutions to combat           in identifying reliable indicators that can guide the decision
over-diagnosis: the implementation of more technology. They           to leave certain melanomas untreated. This necessitates re-
suggest that sequential dermatoscopy, total body photogra-            search combining clinical and dermatoscopic criteria with
phy, and artificial intelligence-powered decision support can         prognostic factors. To combat over-diagnosis, a conceptual
enhance specificity, thereby reducing the need for unneces-           shift is also required. Clinicians and pathologists should not
sary excisions and subsequently decreasing over-diagnosis.            be excessively concerned about missing thin melanomas or
While I agree that technology has the potential to decrease           be driven by the fear of malpractice lawsuits resulting from




Commentary | Dermatol Pract Concept. 2023;13(4):e2023248                                                                          1
the oversight of non-invasive melanomas. Additionally, a       References
policy shift is needed concerning incentives and oversight.
As mentioned before, clinicians who perform an excessive       1. Kittler H. Evolution of the Clinical, Dermoscopic and Patho-
                                                                  logic Diagnosis of Melanoma. Dermatol Pract Concept. 2021;
number of biopsies to detect a single melanoma should have
                                                                  11(Suppl 1):e2021163S. DOI: 10.5826/dpc.11S1a163S. PMID:
their reimbursements limited, and pathology labs with a dis-
                                                                  34447612. PMCID: PMC8366309.
proportionately high number of melanoma diagnoses should       2. Betz-Stablein B, Soyer HP. Overdiagnosis in melanoma screening:
have their slides reviewed by an expert panel. Implementing       Is it a real problem? Dermatol Pract Concept., in press
these measures requires the involvement of all stakeholders,   3. Navarrete-Dechent C, Lallas A. Overdiagnosis in melanoma
including healthcare professionals, consumers, insurance          screening: Is it a real problem? Dermatol Pract Concept., in press
                                                               4. Welch HG, Mazer BL, Adamson AS. The Rapid Rise in Cutane-
agencies, and healthcare policymakers.
                                                                  ous Melanoma Diagnoses. N Engl J Med. 2021;384(1):72-79.
                                                                  DOI: 10.1056/NEJMsb2019760. PMID: 33406334.




2                                                                    Commentary | Dermatol Pract Concept. 2023;13(4):e2023248
