Oliveria SA, Selvam N, Mehregan D, Marchetti MA, Divan HA, Dasgeb B, Halpern AC. Biopsies of Nevi in Children and Adolescents in the United States, 2009 Through 2013. JAMA Dermatol. 2015;151(4):447-448. doi:10.1001/jamadermatol.2014.4576
The increase in incidence and mortality of melanoma over the past 30 years has heightened public and physician awareness. It is suggested that the combination of increasing detection pressure and poor specificity of current diagnostic strategies is driving biopsy rates to alarming levels in younger individuals despite a low risk of melanoma.1 Nevertheless, the number of nevi biopsied in children and adolescents remains poorly characterized in the United States.
Institutional review board approval and informed consent were waived. No patient identifiable data were used, only statistical data based on the counts and year of diagnoses. All data were accessed and used in compliance with the Health Information Portability and Accountability Act of 1996 (HIPAA), and any regulation promulgated thereunder, to include the Privacy Rule, Title 45 of the Code of Federal Regulations, Part 160 and Subparts A and E of Part 164. To estimate the number of nevus biopsies in children and adolescents aged 19 years or younger in the United States during 2009 through 2013, we conducted analyses using (1) a large regional private dermatopathology laboratory database, the Pinkus Dermatopathology Laboratory database, and (2) a large commercial health insurance administrative claims database, the HealthCore Integrated Research Database (HIRD).
Surgical specimens used for pathologic analysis from the dermatopathology database were categorized by histopathologic diagnosis of (1) melanoma, (2) nevi (ie, acquired, congenital, blue, Spitz nevi), or (3) all other diagnoses, and age categories (0-9, 10-14, 15-19 years).
We identified all patients in HIRD with at least 1 Current Procedural Terminology code for excision, shave removal, or biopsy (referred to collectively as “biopsies”). Only the first biopsy in the calendar year counted for each individual. Multiple biopsies for the same individual that spanned calendar years were counted as distinct biopsies. Total biopsy counts were reduced by 41.9% on the basis of data from the dermatopathology database to account for the number of biopsies expected for diagnoses other than nevi (such as warts and rashes) (see Results). We then calculated rates of biopsies in the HIRD population and applied them to 2010 US Census data to estimate age-specific and sex-specific biopsy counts extrapolated to the US population.2 We used age-specific and sex-specific melanoma incidence rates from the Surveillance, Epidemiology, and End Results Program 2006-2010 (SEER)3 and applied them to extrapolated biopsy rates to quantify the expected number of melanomas. We calculated the number of nevi needed to biopsy (NNB) to detect 1 melanoma (NNB = number of nevus biopsies divided by number of melanomas) as a measure of accuracy and public health relevance.
A total of 18 601 surgical specimens were identified in the dermatopathology database from 2009 through 2013, with 16 melanomas (0.09%), 10 800 nevi (58.1%), and 7785 all other diagnoses (41.9%), resulting in an overall NNB of 676. In the HIRD, 133 431 biopsies for nevi were identified during the 5-year period. On the basis of age-specific and sex-specific SEER cancer rates, there were an estimated 136 melanomas, with a resulting NNB of 982 (Table). We estimated that 2 007 423 biopsies of nevi occurred in individuals 19 years or younger, along with 1940 melanomas and an overall NNB of 1035 during 2009 through 2013 in the United States, on the basis of HIRD and 2010 US Census data.
We used 2 robust US data sources to quantify the number of nevus biopsies in children and adolescents. Consistent with our findings, a study from Austria estimated an NNB of 594 in individuals 19 years or younger.4 In another study,5 the number needed to excise ranged from 149 to 224 for similarly aged patients being seen in specialized and nonspecialized clinics.
The generalizability of this study is limited by source databases, although results are similar to cited studies.4,5 Referring clinicians for the dermatopathology data comprised more than 95% dermatologists in private practice, with few samples from dermatologists in academic or surgical settings. The HIRD sample is representative of commercially insured populations.
The predictive value of any test depends on both diagnostic accuracy and disease prevalence, and the latter is very low for melanomas before age 18 years. The very high NNB is also likely attributable to reliance on “change” as an important criterion for recognizing melanoma. Evolution of nevi is common in childhood, and hence change is a poor predictor of melanoma in this age group.6 Understanding the normal evolution of nevi during childhood and adolescence, as well as development of novel noninvasive diagnostic tools, is important in helping to reduce unnecessary biopsies, health care costs, and morbidity in this age group.1
Corresponding Author: Susan A. Oliveria, ScD, MPH, Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 160 E 53rd St, New York, NY 10022 (firstname.lastname@example.org).
Accepted for Publication: October 21, 2014.
Published Online: December 10, 2014. doi:10.1001/jamadermatol.2014.4576.
Author Contributions: Drs Oliveria and Selvam had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Oliveria, Selvam, Marchetti, Dasgeb, Halpern.
Acquisition, analysis, or interpretation of data: Oliveria, Selvam, Mehregan, Marchetti, Divan, Dasgeb.
Drafting of the manuscript: Oliveria, Marchetti, Dasgeb, Halpern.
Critical revision of the manuscript for important intellectual content: Oliveria, Selvam, Mehregan, Marchetti, Divan, Dasgeb.
Statistical analysis: Oliveria, Selvam, Marchetti, Divan.
Obtained funding: Halpern.
Administrative, technical, or material support: Oliveria, Selvam, Mehregan.
Study supervision: Oliveria, Selvam, Mehregan, Halpern.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award R01-AR049342.
Role of the Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Additional Contributions: Ashfaq Marghoob, MD, Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, provided input on the study design and analysis, as well as feedback during manuscript preparation. He was not compensated for his contributions.