Study Reports Melanoma Overdiagnosis in White Patients

Study results recently published in JAMA Dermatology revealed that around 60% of melanomas in White men and women were 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

“Overdiagnosis is a problem,” said Adewole Adamson, MD, MPP, “and we need more research trying to figure out how big of a problem it is, and what if anything we should do about it.” He is assistant professor in the Division of Dermatology, Department of Internal Medicine, at the University of Texas, Austin’s Dell Medical School in Austin, Texas.

Since the 1970s, increases in both public awareness and skin-cancer screenings have delivered a double-edged sword of rising melanoma diagnoses that have had no apparent effect on mortality rates.² “When we screen for cancers,” Adamson said, “we end up finding a lot of things we call cancer that, if we didn’t go looking for, would not have harmed the patient at all.” Diagnosing people with cancers that would never have harmed them has implications for future surveillance efforts and healthcare-system costs, he added, not to mention patients’ physical, mental, and financial health.^3,4

“But it’s also possible that in screening people for cancer, you can improve mortality. Therefore, a harm of overdiagnosis might be (acceptable) if some people benefit from having their cancer found early and averting death or more morbidity,” Adamson said. “You have to balance those 2 things when you think about diagnosing melanoma, particularly in relationship to melanoma screening.”

Melanoma Incidence up Approximately 4-fold and 6-fold in White Men and Women

To approximate true cancer trends in White Americans, investigators compared Surveillance, Epidemiology, and End Results (SEER) incidence and mortality data from 1975 to 2014 for these patients to those of Black patients over the same interval. Versus 1975, 2014 incidence rate ratios (IRRs) for White men and women were 4.01 and 5.97, respectively, while IRRs for Black women (1.21) and men (1.17) held relatively steady.¹ Investigators only analyzed data through 2014 because after that, targeted therapy and immunotherapy began reducing melanoma mortality rates, making estimates less reliable.

In a previous article, Adamson and colleagues argue against routine population-wide skin-cancer screening— while also acknowledging the reduced clinical and pathological thresholds and imbalanced financial incentives that help drive this strategy.² Restricting screening to high-risk populations who are more likely to benefit could mitigate some of the harms of overdiagnosis, Adamson told Dermatology Times®.

Counseling lower-risk patients, however, can be tricky. “When I talk to patients who are at lower risk of melanoma, I explain that there are potential harms and benefits of screening, and it’s something they should consider,” he said. “But it’s also a challenging topic to discuss with patients because most people, from a cultural standpoint, think all screening is good.” Moreover, he noted that compared to breast and prostate exams, patients consider getting a skin examination relatively easy and painless, “so why not do it?”

In breast cancer and prostate cancer, validated decision aids can help patients make informed choices about screening. “There’s very little work in dermatology in trying to do that,” said Adamson. “And that should be an active area of investigation.”

Mortality Rate Ratio (MRR) up 50% in White Men

Whereas White patients benefited from early-detection efforts throughout the period studied, the fact that Black patients generally did not allowed researchers to adjust White incidence and mortality rates to what could have been expected had medical care not improved. Whereas MRR for Black men and women decreased around 25% (0.76 and 0.72, respectively) between 1975 and 2014, MRR for White women was stable (1.02). For White men, however, MRR increased nearly 50% (1.49).

Along with public-health implications, he added, the study bears implications for genetic exploration into early melanomas. Because many such melanomas will never advance to harming or killing anyone, he explained, being able to identify genetic markers of these nonaggressive melanomas would be ideal. When asked if this will happen soon, Adamson replied, “I don’t know about the next few years. But that should be an active area of research—not just what are the tumors that are definitely going to cause harm, but also what is the genetic signature of an overdiagnosed melanoma?” Adamson called for additional study of this issue and its ripple effect on patients and the health care system.

Disclosure:

Adamson reports no relevant financial interests.

References:

1. Adamson AS, Suarez EA, Welch HG. Estimating overdiagnosis of melanoma using trends among Black and White patients in the US. JAMA Dermatol. 2022;158(4):426-431. doi:10.1001/jamadermatol.2022.0139

2. Welch HG, Mazer BL, Adamson AS. The rapid rise in cutaneous melanoma diagnoses. N Engl J Med. 2021;384(1):72-79. doi:10.1056/NEJMsb2019760

3. Shapiro CL. Cancer survivorship. N Engl J Med. 2018;379(25):2438-2450. doi:10.1056/NEJMra1712502

4. Gilligan AM, Alberts DS, Roe DJ, Skrepnek GH. Death or debt? National estimates of financial toxicity in persons with newly-diagnosed cancer. Am J Med. 2018;131(10):1187-1199.e5. doi:10.1016/j.amjmed.2018.05.020