The Skin Cancer Foundation - FALL / WINTER 2009, Vol. 27, No. 3

FALL / WINTER 2009, Vol. 27, No. 3

In this issue of The Melanoma Letter, Dr. Shawn Allen presents a thorough, balanced overview of this complicated and clinically important topic. While presenting the issues raised against widespread screening, Dr. Allen explains why it is so intuitively attractive for melanoma. He also summarizes recent studies supporting melanoma screening that were unfortunately not yet available or not considered when the USPSTF made its latest recommendations.

In a companion piece, Dr. Allen explores the integrally related concept of overdiagnosis. Acknowledging the growing recognition in both the scientific literature and the public media that overdiagnosis is a legitimate concern, he calls for tempering our approach to cancer screening in general and melanoma screening in particular. The very ease with which melanoma lends itself to early detection by simple visual inspection holds both the promise of effective screening and the risk of overdiagnosis.

FALL / WINTER 2009, Vol. 27, No. 3 - From the Editors

Frequent skin self-examination (SSE) and periodic professional total-body examination (TBSE) are considered by many dermatologists an almost mandatory part of “secondary prevention” of melanoma. This belief stems from the notion that wider public screening results in the detection of earlier and more treatable melanomas. However, the United States Preventative Services Task Force (USPSTF) has continued to withhold making a recommendation for or against SSE or TBSE, triggering a storm of controversy.

Melanoma Screening Saves Lives

Shawn Allen, MD
Director and Founder
Dermatology Specialists of Boulder, PC
Assistant Clinical Professor
Department of Dermatology
University of Colorado School of Medicine

Melanoma is by far the deadliest form of skin cancer (causing more than 75 percent of all skin cancer deaths) and a major public health concern. The American Cancer Society estimates that about 68,720 new melanomas will be diagnosed in the US during 2009, resulting in about 8,650 deaths, almost one per hour.¹ The disease is currently the sixth most common cancer in the US and the number one cancer in young adults aged 25-29.²

Early detection of melanoma can significantly reduce both morbidity and mortality. The risk of dying from the disease, in fact, is directly related to the depth of the cancer, which is directly related to the amount of time it has been growing unnoticed. Hence, earlier detection leads to thinner cancers and saves lives. Fortunately, unlike most other cancers, skin cancers present on the skin and are most often readily visible to the patient and the examiner. Patient skin self-examination (SSE), physician-directed total-body skin exams (TBSE), and patient education are the keys to early detection.

A Question of Overdiagnosis

Shawn Allen, MD

In declining to endorse skin self-examination (SSE) and physician total-body skin examination (TBSE), the United States Preventive Services Task Force (USPSTF) has said that “Current evidence is insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a primary care clinician or patient skin cutaneous melanoma. . .”¹ This brings to mind a basic question: Just what are the “harms” in seeking to detect a dangerous skin cancer like melanoma early, when it is most treatable?

While the USPSTF acknowledges that information on the negative aspects of screening is limited, a major fear, they point out, is overdiagnosis: “Potential harms of screening for skin cancer include misdiagnosis, overdiagnosis, and the resultant harms from biopsies and overtreatment.”¹Overdiagnosis is diagnosing a disease that never would have dangerously advanced or caused death during a patient’s expected lifetime. Unlike misdiagnosis, overdiagnosis is a correct but irrelevant diagnosis since it presumably would not have affected the patient had it gone undetected.