Perspectives and Strategies to Minimize Harm From Melanoma Diagnosis

Kerr et al¹ report a study of pathologists who reviewed slides of melanocytic nevi and melanomas. The pathologists were asked to grade the atypia of lesions as low vs high and to distinguish them from invasive melanoma. Seeking to identify pathologist characteristics associated with tumor categorization, the authors found that dermatopathologists were more likely than general pathologists to classify lesions as higher grade and to diagnose low-risk (pT1a, nonmitogenic) invasive melanoma. This difference was not seen for intermediate- or high-risk melanomas. There were important limitations to the study. No outcomes data were available, including that it was not known whether the melanomas classified as low risk were indeed indolent. Furthermore, grading melanocytic nevi and grouping cases with high-grade atypia together with melanoma in situ is controversial.^2,3 Nonetheless, the findings of the study raise the question of whether subspecialization in dermatopathology may be a factor contributing to the epidemiologic phenomenon of overdiagnosis—that is, the discordance in the rise of melanoma incidence and relatively constant annual mortality rates over many decades.⁴ The findings also invite a discussion about strategies to minimize harm from overdiagnosis for both patients and the health care system.