The melanoma epidemic. Is increased surveillance the solution or the problem?
Melanoma has a very bad reputation, and rightfully so. Until relatively recently, the prognosis for melanoma was dismal and, very reasonably, early detection has been proposed as a viable approach to preventing melanoma deaths. On the surface, this simple approach appears to have been a stellar success, with melanoma survival rates improving markedly. There is no question that there has been a dramatic increase in the number of people with a diagnosis of melanoma. On careful scrutiny, the numbers reflected in the increased incidence may not add up. Mortality rates and the diagnosis rate for thick tumors ( > 1.5 mm thick) have not gone up commensurate with the growing rate of diagnosis. The obvious explanation for this discrepancy is that we are doing a great job! However, this explanation must assume that an overwhelming percentage of those at risk for melanoma are in a position to benefit from our service. It is very unlikely that this is the case. It is not clear whether the increase in the number of melanoma cases diagnosed reflects an actual increase in real disease. Could this increase be in part a product of aggressive surveillance resulting in the identification of "atypical" pigmented skin tumors of limited or nonexistent potential for malignant behavior? Could the dramatic improvement in the prognosis of melanoma simply be a consequence of removing biologically benign pigmented tumors that are inadvertently classified as malignant?
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