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April 6, 2022

Melanoma Screening—Intuition and Hope Are Not Enough

Author Affiliations
  • 1Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
JAMA Dermatol. 2022;158(5):483-485. doi:10.1001/jamadermatol.2022.0082

In this issue of JAMA Dermatology, Matsumoto et al1 present their observations of a large patient cohort in a quality improvement study examining melanomas diagnosed within the University of Pittsburgh Medical Center (UPMC) system. The objective of this study was “to compare thickness-specific incidence of melanoma in screened vs unscreened patients following the initiation of a primary care–based skin cancer screening initiative.” Patients were divided into 2 groups, a cohort receiving primary care skin examination and a control group without a skin examination, and followed up for 5 years. The main findings were increased detection of thin melanomas observed patients in the primary care–based melanoma screening group compared with the control group. Fewer thick melanomas (>2 and >4 mm) were observed in screened vs unscreened patients, but this difference was not statistically significant.

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3 Comments for this article
A clinical trial will not address the issue of over diagnosis
Linda Titus, PhD, MA | Geisel School of Medicine at Dartmouth
Dr. Swerlick suggests that the efficacy of melanoma screening might be addressed through a randomized clinical trial. Presumably the plan would be to compare melanoma mortality in screened and unscreened groups. Even if a large, high risk population could be identified, randomized, and followed, a clinical trial will not be informative. Once detected, a melanoma must be removed. Consequently, whether the lesions would have progressed would remain unknown. The only way to assess the biological potential or lethality of thin melanomas, including those identified through screening, is to leave them intact. This is not something we can do.
Legal Issues Will Never Allow this change
Joseph Shaffer, MD |
There is simply no way we will risk stopping skin exams in melanoma patients in the USA (not that this is specifically being promoted). If you can do it with a guarantee we won't be sued then fine; but until that day the "standard of care" will continue. The follow up frequencies are based on guidelines, go ahead and try to change the guidelines if you want to protect physicians.

Also, many (unscientific I know) of our patients have numerous other non-melanoma skin cancers that we deal with at those skin checks. Some additional data around that would
be helpful for a more complete picture of what happens in the skin exam.
The Australian Experience
Ian McColl, FACD | John Flynn Private Hospital Tugun Gold Coast Australia
In Australia we have the highest incidence of melanoma diagnosis in the world. We also have a culture of regular screening by both Dermatologists, General Practitioners and specialist General Practitioners who only deal with skin cancer. What we are finding in an ageing white population is a massive increase in insitu melanoma, Lentigo maligna and so called lentiginous melanoma. These patients are virtually all treated by shave or excisional biopsy followed by formal re excision with many having flap or graft closures particularly on the face and scalp areas. I suspect many of these lesions could have been shaved and just left with very few progressing to an invasive lesion in the patient's lifetime. We have the numbers to conduct a randomised trial. Our screening mainly picks up these variants of melanoma but we also see a lot of keratinocytic tumours in the same group of patients and treat these with both surgical and non surgical modalities. Recently the use of PRAME stains have lead to upgrading of diagnoses to thin invasive lesions rather than insitu which generate even larger excisions and repairs. Hopefully gene studies of easily aquired skin samples of these lesions will lead to a more nuanced approach of when lesions can be safely left.
The question still remains. Who do you screen and why? Some groups in Australia are investing in a large trial of VECTRA machines from Canfield screening younger people with multiple nevi and a past history of melanoma to pick new lesions early and if dermatoscopy suggests melanoma remove them before they become significantly thick and metastasise. This type of screening is more likely to be beneficial and cost effective in a population still contributing financialy to society.