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December 1999

Why Are People Still Dying From Melanoma?

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Arch Dermatol. 1999;135(12):1534-1536. doi:10.1001/archderm.135.12.1534

In 1985, Bernard Ackerman wrote an influential editorial entitled "No One Should Die of Malignant Melanoma."1 Ackerman suggested that more ambitious early detection efforts had the potential to identify melanoma before it had the chance to invade and lead to metastases and death. Since then, efforts to find melanomas at an early stage have been widespread and successful insofar as many studies have shown that a large proportion of melanoma is now discovered at a thinner, potentially curable stage.25 However, it is not clear that these efforts to uncover more melanomas at an earlier stage have succeeded in affecting the death rate from melanoma. The article in this month's ARCHIVES by Lipsker et al6 is a conservative analysis of increases in melanoma incidence within categories of Breslow thickness in Bas-Rhin, France. They show that the entire increase in melanoma incidence occurred among lesions that were thin (<1.00 mm), and that there has not been a significant change in the incidence of thick lesions or a significant decline in mortality from melanoma. As the authors point out, other investigators have called attention to a similar dramatic increase in the incidence of thin melanomas and a concomitant lack of change in the incidence of thick melanomas.3,4,7,8 Consideration of this paradox points out the major problems facing those trying to prevent melanoma: (1) differentiation of thin lesions without the capacity to metastasize from thin lesions with that capacity, and (2) disentanglement of the factors responsible for the decline in mortality rates among women and some younger male cohorts (eg, early detection, removal of an exposure, increased protection, a cohort effect, or some combination of all four). The article by Lipsker et al reminds the reader once again that the interpretation of the increased incidence in melanoma is complex.

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