The results of the study were recently published in Gamma Dermatology revealed that about 60% of melanomas in white men and women are overdiagnosed.1These findings have implications in areas ranging from screening strategies to patient counseling and genetic research, according to the study’s lead author.
59% of white women and 60% of white men are overdiagnosed
Adewole Adamson, MD, MPP, said, “Overdiagnosis is a problem, and we need to do more research to try to figure out the extent of the problem, and what if we should do anything about it.” He is an assistant professor in the Department of Dermatology, Department of Internal Medicine, at the University of Texas, Dale Austin School of Medicine in Austin, Texas.
Since the 1970s, increases in both public awareness and skin cancer screenings have led to a double-edged sword from increasing skin cancer diagnoses that has had no apparent effect on mortality rates.2 “When we check for cancers, we end up finding a lot of things that we call cancer, which, if we don’t go looking for them, won’t hurt the patient at all,” Adamson said. He added that diagnosing people with cancers that would never have harmed them has implications for future surveillance efforts and the costs of the health care system, not to mention the physical, mental and financial health of patients.3,4
“But it is also possible that when you screen people for cancer, you improve mortality. Therefore, the harm of overdiagnosis may be[acceptable]if some people benefit from finding cancer early and avoiding death or further morbidity,” Adamson said. “You have to balance those two things when you’re considering a skin cancer diagnosis, especially in terms of skin cancer screening.”
The incidence of skin cancer is approximately 4 times and 6 times higher in white men and women
To approximate true cancer trends in white Americans, researchers compared surveillance, epidemiology, and end-results (SEER) data from 1975 to 2014 for these patients with those of black patients during the same period. Against 1975, the IRRs for white men and women were 4.01 and 5.97, respectively, while the IRRs for black women (1.21) and men (1.17) remained relatively constant.1 The investigators only analyzed data during 2014 because after that, targeted therapy and immunotherapy began to reduce melanoma mortality rates, making the estimates less reliable.
In a previous article, Adamson and colleagues argued against routine, population-wide melanoma screening—while also acknowledging the reduced clinical and pathological limits and unbalanced financial incentives that help drive this strategy.2 Adamson said that limiting screening to high-risk populations who are likely to benefit could mitigate some of the harms of overdiagnosis. Dermatology Times®.
However, counseling lower-risk patients can be challenging. “When I talk to patients who are at lower risk of developing skin cancer, I explain to them that there are potential harms and benefits of screening, and that is something they should consider,” he said. “But it’s also hard to discuss it with patients because most people, from a cultural point of view, think all checks are good.” Furthermore, he noted that compared to breast and prostate exams, patients consider the skin exam to be relatively easy and painless, “so why not?”
In breast and prostate cancer, approved decision-making techniques can help patients make informed choices about screening. “There’s a little bit of work in dermatology to try and do that,” Adamson said. “And this should be an active area of investigation.”
Mortality rate ratio (MRR): 50% in white men
While white patients benefited from early detection efforts throughout the period studied, the fact that black patients generally did not allow researchers to adjust white infection and death rates to what would have been expected had medical care not improved. While the MRR for black men and women decreased by about 25% (0.76 and 0.72, respectively) between 1975 and 2014, the MRR for white women was stable (1.02). As for white men, the MRR increased by about 50% (1.49).
Besides the public health implications, he added, the study has implications for genetic exploration of early melanomas. He explained that because many of these melanomas will never develop to harm or kill anyone, being able to identify genetic markers for these non-aggressive melanomas would be ideal. When asked if this will happen soon, Adamson replied, “I don’t know about the next few years. But this should be an active area of research – not just what tumors will definitely cause damage, but also what is the genetic signature of overdiagnosed melanoma?” Adamson called for additional study of this issue and its ripple effect on patients and the health care system.
Adamson does not state any related financial interests.
1. Adamson AS, Suarez EA, Welch HG. Estimation of melanoma overdiagnosis using trends among black and white patients in the United States. Gamma Dermatol. 2022; 158 (4): 426-431. doi: 10.1001/jamadermatol.2022.0139
2. Welch HG, Mazer BL, Adamson S. Rapid rise in skin cancer diagnoses. In Angel J Med. 2021; 384 (1): 72–79. doi: 10.1056/NEJMsb2019760
3. Shapiro CL. Surviving cancer. In Angel J Med. 2018; 379 (25): 2438-2450. doi: 10.1056/NEJMra1712502
4. Gilligan AM, Alberts DS, Rowe DJ, Skripnik GH. Death or religion? National estimates of financial toxicity in people with newly diagnosed cancer. I J Med. 2018; 131 (10): 1187–1199. e. doi: 10.1016/j.amjmed.2018.05.020