Overdiagnosis of Melanoma

Overdiagnosis of Melanoma

Joy Stepinski, MSN, RN-BC

June 1, 2025

In a previous article we discussed the third assumption in Less Medicine More Health: 7 Assumptions that Drive Too Much Health Care by Dr. Gilbert Welch. In this assumption, screening is not always better. Before moving onto the fourth assumption, let’s delve into the example of melanoma screening.

Please note this article refers to general screening when people do not have symptoms of skin cancer. If you experience a site on your skin causing pain or discomfort, a strange color, or drainage, you should consult your healthcare provider.

When health screening takes place, there should also be evidence that the screening leads to better survival. In the example of melanoma, the incidence of disease has risen over the past decades, while the mortality rate has remained stable. The issue is well-depicted by the National Cancer Institute website for Surveillance, Epidemiology, and End Results Program (SEER) [1] using the following link in your browser: https://seer.cancer.gov/statfacts/html/melan.html The rate of new cases is increasing steadily, yet the death rate has remained the same since at least 1992. When incidence increases and the mortality rate stays the same, evidence of overdiagnosis exists.

In research published in JAMA Dermatology, the author states that “overdiagnosis is diagnosing disease that will never cause clinical symptoms, harm, or death during the patient’s lifetime” [2]. In a survey of dermatopathologists, two-thirds of providers believed overdiagnosis occurred for irregular-shaped moles (atypical nevi), half for superficial melanoma that has not grown into the deeper skin (melanoma in situ) and one-third for malignant melanoma. The author attributes these findings to unnecessary skin biopsies.

Why do unnecessary skin biopsies take place? One study reports that for dermatologists, this may be due to increasing biopsy rates, the vigilance of healthcare providers with legal liability fears and changes in histology criteria [3]. For example, previous non-malignant findings of atypical nevi are now classified as malignant when this finding is actually low-risk. Public perceptions and attitudes seeking screenings can also lead to higher incidence [2].

Revisiting Welch’s assumption that sooner is always better, the author states that screenings should have “sufficient benefit to warrant accepting possible harms” (p. 81) such as false positives, fear, and overtreatment [4]. In research of patient-reported problems of non-melanoma skin cancers, findings showed that 236 of 866 (27%) of patients perceived complications after office treatment (i.e., excision of area, Mohs surgery, cryotherapy). This included pain, numbness, problems with wound healing, infection, bleeding, issues with motor nerve function, scarring, and need for additional treatments [5]. Another issue is patient fear. One recommended approach is for clinicians to avoid using terms like cancer and malignant melanoma in instances that are unlikely to harm patients.

The rate of overdiagnosis is estimated to occur more than 50% of the time for fair-skinned tones. One study investigated the overdiagnosis of cutaneous melanoma using SEER data from 1975 to 2014 among white patients. The authors noted that while black patients can die from melanoma, people with this skin pigment are less likely than white patients to be subjected to skin screenings. The rate of skin screenings in this population has remained consistent. Results concluded that overdiagnosis occurred 59% of the time for white women and 60% for white men in 2014.

In 2023, the U.S. Preventative Task Force (USPTF) issued a recommendation statement [6]. The organization advised that “the USPTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adolescents and adults.” Potential medical harm caused by skin cancer screening include cosmetic injury due to scarring, psychosocial harms like unnecessary worry, and overtreatment (i.e., excision, chemotherapy, radiation).

In a separate article in Clinical Chemistry, Welch notes that the 6-fold increase of melanoma incidence since 1975 is related to excessive screening [7]. The American Academy of Dermatology has encouraged skin screenings since 1985, which has contributed to routine skin exams frequently done by primary care physicians. Early detection does not necessarily save lives due to unanticipated harm that may ensue.

Routine screening is a healthcare decision that should be made by the patient after weighing both benefits and drawbacks. With screening, there may be some benefit if cancer is detected early. Yet there also may be harm. If you choose to be screened, Welch suggests taking your time with abnormal results [4]. Consider waiting to best determine your treatment options before having immediate treatment or seeking out a second opinion. Being an informed healthcare consumer contributes to important health decisions!

References:

1.      National Cancer Institute. (n.d.) Cancer stat facts: Melanoma of the skin. https://seer.cancer.gov/statfacts/html/melan.html

2.      Kerr, K. F., Eguchi, M. M., Piepkorn, M. W., Radick, A. C., Reisch, L. M., Shucard, H. L., ... & Elmore, J. G. (2022). Dermatopathologist perceptions of overdiagnosis of melanocytic skin lesions and association with diagnostic behaviors. JAMA Dermatology, 158(6), 675-679.

3.      Frangos, J. E., Duncan, L. M., Piris, A., Nazarian, R. M., Mihm Jr, M. C., Hoang, M. P., ... & Kimball, A. B. (2012). Increased diagnosis of thin superficial spreading melanomas: a 20-year study. Journal of the American Academy of Dermatology, 67(3), 387-394.

4.      Welch, H. G. (2015). Less medicine, more health: 7 assumptions that drive too much medical care. Beacon Press.

5.      Linos, E., Wehner, M. R., Frosch, D. L., Walter, L., & Chren, M. M. (2013). Patient-reported problems after office procedures. JAMA Internal Medicine, 173(13). https://doi.org/10.1001/jamadermatol.2023.4334

6.      Mangione, C. M., Barry, M. J., Nicholson, W. K., Chelmow, D., Coker, T. R., Davis, E. M., ... & US Preventive Services Task Force. (2023). Screening for skin cancer: US Preventive Services Task Force recommendation statement. AMA, 329(15), 1290-1295. https://doi.org/10.1001/jama.2023.4342

7.      Welch, H. G., & Bergmark, R. (2024). Cancer screening, incidental detection, and overdiagnosis. Clinical Chemistry, 70(1), 179-189. https://doi.org/10.1093/clinchem/hvad127