EDITOR'S PICK: Overdiagnosis and Overtreatment in Melanoma.
A paper advocating against routine skin screening "for all".
EDITORS’S PICK
In this section, we present a paper that cought our attention, it can be recent, seminal, historical, a point of view, a commentary, a clinical trial, any publication that we feel is important!
Welch and colleagues review the data on melanoma incidence and trends in mortality over time, and draw important conclusions.
The paper
Firstly, the authors show that the trend in incidence of melanoma diagnosis cannot be explained by UV exposure.
It must therefore be explained by something else, which is likely an “epidemic of diagnosis” due to increased awareness and a lower threshold to classify lesions as melanomas. They showed a total disconnection between a continuous increase in incidence and a flat (or even slightly decreasing) mortality over time. This is a classic epidemiological signature of overdiagnosis.
They also show how the increased incidence is mostly driven by thin melanomas (≤ 1 mm or in situ).
They perfectly describe what they call the “cycle of melanoma overdiagnosis”: people feeling they are being saved, doctors feeling like saviors, and higher 5-year survival rates (which is almost automatic if you diagnose more indolent lesions).
They finally propose several solutions to break the cycle, including the following:
In their conclusion:
“Thus, although the conventional response has been to recommend regular skin checks, it is far more likely that more skin checks are the cause of the epidemic — not its solution.”
Everyone interested in screening, cancer, and epidemiology should read this paper in detail. The paper is, of course, much more detailed than our summary. It is beautifully and logically constructed. You can access the full paper here!
The authors
The lead author, H. Gilbert Welch, is a general internist and an academic researcher whose work on epidemiology and cancer has been pioneering in the field of overdiagnosis and overtreatment. He has authored several books, including “Overdiagnosed: Making People Sick in the Pursuit of Health”. He is also a great communicator, and you should definitely check out his outstanding talks available on Youtube.
Benjamin L. Mazer is a pathologist at Johns Hopkins University. He is passionate about screening, overdiagnosis, and the “pathology” component of it.
Adewole Adamson is a dermatologist and health services researcher and an assistant professor of Internal Medicine (Division of Dermatology) at Dell Medical School at the University of Texas at Austin. He studies skin cancer, evidence-based medicine, and health policy. He is also the director of the Melanoma and Pigmented Lesion Clinic at Dell Seton Medical Center. He is a prolific academic researcher and very active on social media. Here is the interview in the Plenary Session Podcast that followed the NEJM paper with Dr. Adamson and Dr. Mazer.