10.5826/dpc.1304a246
text/xml
2160-9381
3746
en
Aimilios Lallas
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Overdiagnosis of Melanoma: Is it a Real Problem?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Kramer vs Kramer
2023-10-31
2023-08-07
2023-10-31
2024-01-15
e2023246
Dermatol Pract Concept
Aimilios Lallas
2023/10/31
10.5826/dpc.1304a246
e2023246
First Department of Dermatology, School of Medicine, Aristotle University, Thessaloniki, Greece
2160-9381
en
e2023246
Kittler H. Evolution of the Clinical, Dermoscopic and Pathologic Diagnosis of Melanoma. Dermatol Pract Concept 2021;11:e2021163S.
Overdiagnosis of Melanoma: Is it a Real Problem?
https://dpcj.org/index.php/dpc/article/download/3746/2329
  Overdiagnosis of Melanoma: Is It a Real Problem?
                                   Cristian Navarrete-Dechent1,2, Aimilios Lallas3


1 Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
2 Melanoma and Skin Cancer Unit, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
3 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece



Citation: Navarrete-Dechent C, Lallas A. Overdiagnosis of Melanoma: Is it a Real Problem? Dermatol Pract Concept.
2023;13(4):e2023246. DOI: https://doi.org/10.5826/dpc.1304a246
Accepted: August 7, 2023; Published: October 2023
Copyright: ©2023 Navarrete-Dechent 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.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Aimilios Lallas, First Department of Dermatology, School of Medicine, Aristotle University, Thessaloniki, Greece.
Tel.: +302313308879 E-mail: alallas@auth.gr




    “The best physician is also a philosopher”                           Additionally, in last decades, early melanoma detection is
                                              Claudius Galen             considered a supreme task by healthcare systems world-
                                                                         wide and numerous efforts to increase screening and public
                                                                         awareness have been applied [7,8]. Furthermore, diagnostic
Is Melanoma Over-diagnosis
                                                                         tools evolved to allow earlier melanoma recognition. Der-
a Reality?                                                               matoscopy played a major role in changing practice, since
Overdiagnosis in cancer is the correct diagnosis of a can-               the dermatoscope is a hand-held device available at any set-
cer that, if left untreated, would never cause symptoms or               ting [9]. Finally, because of a diagnostic shift in the histo-
morbidity. Over-diagnosis is caused by both over-detection               pathologic diagnosis, tumors that were previously labelled
(i.e. screening) and overdefinition (ie expanding disease defi-          as non-melanoma (i.e. ‘dysplastic’ nevi) are now classified as
nitions of diagnostic tests) [1]. The sine qua non requisite for         melanoma, usually in situ [3]. The latter is highlighted by the
establishing over-diagnosis of a cancer is a disproportionate            disproportionate incidence increase of melanoma in situ as
increase in incidence without an accompanying increase in                compared to invasive melanoma [2].
mortality (Figure 1).
    All these conditions are met in the case of melanoma and             Melanoma Over-diagnosis Exists.
explain to some extent the tremendous increase in incidence
                                                                         So What?
[2,3]: Evidence suggests that many melanomas grow slowly
and might remain intraepidermal for a long period [4]. One of            Considering all the above, there is little doubt that
the most frequent subtypes, lentigo maligna (LM), might re-              over-diagnosis of melanoma exists. In addition to causing
main in the epidermis for several years or even decades, with            an epidemiological artifact, over-diagnosis induces a vicious
only a small proportion (< 5%) evolving into invasive mel-               cycle of increased awareness, more screening, more biopsies
anoma, making it an ideal paradigm of overdiagnosis [5,6].               and more over-diagnosis with significant impact on health



Opinion | Dermatol Pract Concept. 2023;13(4):e2023246                                                                                     1
                        Figure 1. Evolution of melanoma incidence (red line) and melanoma mortality (blue line).
                        Mortality has remained stable as incidence dramatically increases, characteristic of
                        over-diagnosis. If there is a relevant increase in melanoma incidence, one should expect
                        an accompanying increase in melanoma mortality (a, red dashed line). Should screening
                        programs be effective, one should expect a decrease in mortality (b, green dashed line).


and insurance sources and possibly unneeded emotional                 surgery followed by adjuvant imiquimod allows for excel-
stress [3]. Although these parameters should not be underes-          lent cure rates, akin margin-controlled excisions, offering
timated, the most relevant question is whether o
                                               ­ ver-diagnosis        an example of how the problem of “over-diagnosis”, which
has a negative impact on patients’ health and if we should            in fact is a problem of “over-treatment”, could be partially
modify our clinical practice to address it.                           addressed [15]. Similar considerations could be made for
    The vast majority of the so-called ‘over-diagnosed mela-          non-melanoma skin cancers, which although usually not
nomas’ are intra-epidermal or minimally invasive lesions and          biologically aggressive, are often treated with sophisticated
their definitive treatment usually implies a wide local exci-         and costly surgery [16].
sion with 5-10 mm margins, which usually translates into
a small scar and almost zero morbidity [10]. Subsequently,            Can We Do Something Else
these patients usually enter a prospective surveillance that al-      to Address Over-diagnosis?
lows an early detection of subsequent melanomas and other
skin cancers that develop in a considerable proportion [11].          Although not causing significant harm to the individual
Overall, overdiagnosis does not cause any significant medi-           patients, the negative economic and emotional effects of
cal harm to the individual patients, probably the opposite.           over-diagnosis justify some efforts to address it, provided
                                                                      of course that these efforts will not put patient outcomes

Over-diagnosis or Over-treatment?                                     at risk. In the last decades, total body photography (TBP)
                                                                      and sequential digital dermatoscopy (SDD) are increasingly
Let’s go back to the “paradigm” of over-diagnosis, LM. LM             used [17]. In contrast to static examinations, these techniques
typically arises on sensitive areas and any surgical treatment        provide information on the biologic dynamic of lesions, im-
might cause aesthetic or functional concerns [12]. Addition-          prove the sensitivity for melanoma diagnosis and reduce
ally, LM tends to extend subclinically, which explains the in-        the number of excisions by revealing the biologic stability
creased recurrence rates when 5-mm margins are used [13].             of lesions that might have been considered as suspicious at
For this reason, melanoma guidelines recommend wider                  baseline [18]. A wider use of TBP and SDD might help to
margins or, ideally, staged excisions with margin control, that       minimize over-diagnosis, but is limited by the significant re-
usually have significant requirements in time and costs [14].         quirement in time and expertise. Therefore, the use of these
All this for a tumor that has very low chance to invade the           techniques is limited to individuals at very high risk, which
dermis even if left untreated [5]. To our understanding, the          restricts their impact [17]. The new generation of 2D TBP
real problem results not from the ‘early diagnosis’ of LM,            and the development of 3D TBP offer a fast documentation
but from the exaggerated treatment for a tumor that is min-           of the total skin surface at an unprecedented quality, and
imally aggressive. Recent data suggest that conservative              the addition of artificial intelligence (AI) has the potential



2                                                                                Opinion | Dermatol Pract Concept. 2023;13(4):e2023246
to improve the diagnostic accuracy of clinicians. This new         use of TBP and SSD and the re-consideration of treatment
era might allow a wider application of TPB and maximize            recommendations for minimally aggressive tumors seem
its impact [19].                                                   reasonable for now, until more accurate tools to predict the
   Other solutions proposed to address over-diagnosis are          biologic potential of individual tumors emerge.
to downgrade the histopathologic terminology and increase
the threshold for biopsy/excision of suspicious lesions.3 Al-
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