INTRODUCTION
In 2006, an article titled "Who benefits from calling a solar keratosis a squamous cell carcinoma" was published in the British Journal of Dermatology. The author, Robin Marks, expressed concern about the risks to patients and the broader community posed by overdiagnosing solar keratoses as true cancers.1
We wrote this article out of a similar concern, the risk to patients and the broader community posed by the overdiagnosis of atypical melanocytic lesions as melanomas.
In 2024, Lindsay et al published an article titled "Estimating the magnitude and healthcare costs of melanoma in situ and thin invasive melanoma overdiagnosis in Australia." The investigators estimated that approximately 22,600 to 24,000 melanomas may have been unnecessarily diagnosed and treated in 2021, resulting in a total cost of AUD $20.2 to 21.4 million. They also observed an increase in overdiagnosed melanomas from 2017 to 2021, suggesting a growing public health concern in Australia.2
Melanoma is a major global public health concern. Lentigo maligna (LM) is a melanoma in situ (MIS) that grows on chronically photodamaged skin, most commonly on the head and neck. According to a report from the American Cancer Society, there will be 107,240 new cases of melanoma in situ on the skin by 2025.3 This raises the question: Is it necessary to excise all newly diagnosed MIS cases?
Half of all melanomas diagnosed in the United States are stage 0, also referred to as MIS.4 Patients diagnosed with MIS or early invasive melanoma (stage I) have a relative survival rate of greater than 100%, indicating that their survival rate from all causes is higher than that of age-, sex-, and race-matched controls without melanoma.5,6
The Ethical Dilemma
An 85-year-old male presented with a longstanding pigmented macule on the left cheek, reportedly present for over 15 years. Upon clinical examination and history, the lesion was deemed suspicious for melanoma, and a biopsy was performed.
The patient inquired about the nature of the lesion and the appropriate course of action. As is often the case in dermatologic practice, this question implicitly reflected a deeper concern: whether the lesion represented cancer and posed a threat to the patient's life. The clinician's role, particularly in dermatologic surgery, is to provide both diagnostic clarity and therapeutic guidance. A biopsy was performed, and the pathology report, signed by the dermatopathologist, described an atypical junctional melanocytic proliferation (AJMP), consistent with early evolving melanoma in situ. Upon reviewing the report, the question arose: who ultimately benefits from labeling such lesions as early melanoma? This dilemma calls into question not only clinical decision-making but also broader implications in nomenclature and management.
In 1985, Ackerman published an article titled "No One Should Die of Malignant Melanoma," underscoring the importance of judicious diagnosis and treatment.7 Can we prevent death in every patient with early evolving MIS?
Who is Defining Cancer Now ?
The American Association of Cancer Research defines cancer as a group of diseases characterized by uncontrolled cell proliferation. The Cancer Research Institute of the United Kingdom defines cancer as the uncontrolled division of abnormal cells, noting that some cancers eventually spread to other tissues.
The term cancer is now largely defined by specialists consulted by clinicians, rather than by the primary care providers patients initially approach for diagnosis and treatment. In effect, those entrusted by the community to address disease have assumed the authority to define it. However, the resulting definitions may not align with the community's understanding of illness. For example, an AJMP does not exhibit the aggressive behavior typically associated with conditions the public perceives as cancer, such as uncontrolled growth and tissue invasion.
It appears that the community-appointed advisors have decided, based on various in vitro investigations, that an AJMP, which previously had not been called a cancer, is now a cancer—early evolving melanoma in situ. In response to the fact that AJMP
We wrote this article out of a similar concern, the risk to patients and the broader community posed by the overdiagnosis of atypical melanocytic lesions as melanomas.
In 2024, Lindsay et al published an article titled "Estimating the magnitude and healthcare costs of melanoma in situ and thin invasive melanoma overdiagnosis in Australia." The investigators estimated that approximately 22,600 to 24,000 melanomas may have been unnecessarily diagnosed and treated in 2021, resulting in a total cost of AUD $20.2 to 21.4 million. They also observed an increase in overdiagnosed melanomas from 2017 to 2021, suggesting a growing public health concern in Australia.2
Melanoma is a major global public health concern. Lentigo maligna (LM) is a melanoma in situ (MIS) that grows on chronically photodamaged skin, most commonly on the head and neck. According to a report from the American Cancer Society, there will be 107,240 new cases of melanoma in situ on the skin by 2025.3 This raises the question: Is it necessary to excise all newly diagnosed MIS cases?
Half of all melanomas diagnosed in the United States are stage 0, also referred to as MIS.4 Patients diagnosed with MIS or early invasive melanoma (stage I) have a relative survival rate of greater than 100%, indicating that their survival rate from all causes is higher than that of age-, sex-, and race-matched controls without melanoma.5,6
The Ethical Dilemma
An 85-year-old male presented with a longstanding pigmented macule on the left cheek, reportedly present for over 15 years. Upon clinical examination and history, the lesion was deemed suspicious for melanoma, and a biopsy was performed.
The patient inquired about the nature of the lesion and the appropriate course of action. As is often the case in dermatologic practice, this question implicitly reflected a deeper concern: whether the lesion represented cancer and posed a threat to the patient's life. The clinician's role, particularly in dermatologic surgery, is to provide both diagnostic clarity and therapeutic guidance. A biopsy was performed, and the pathology report, signed by the dermatopathologist, described an atypical junctional melanocytic proliferation (AJMP), consistent with early evolving melanoma in situ. Upon reviewing the report, the question arose: who ultimately benefits from labeling such lesions as early melanoma? This dilemma calls into question not only clinical decision-making but also broader implications in nomenclature and management.
In 1985, Ackerman published an article titled "No One Should Die of Malignant Melanoma," underscoring the importance of judicious diagnosis and treatment.7 Can we prevent death in every patient with early evolving MIS?
Who is Defining Cancer Now ?
The American Association of Cancer Research defines cancer as a group of diseases characterized by uncontrolled cell proliferation. The Cancer Research Institute of the United Kingdom defines cancer as the uncontrolled division of abnormal cells, noting that some cancers eventually spread to other tissues.
The term cancer is now largely defined by specialists consulted by clinicians, rather than by the primary care providers patients initially approach for diagnosis and treatment. In effect, those entrusted by the community to address disease have assumed the authority to define it. However, the resulting definitions may not align with the community's understanding of illness. For example, an AJMP does not exhibit the aggressive behavior typically associated with conditions the public perceives as cancer, such as uncontrolled growth and tissue invasion.
It appears that the community-appointed advisors have decided, based on various in vitro investigations, that an AJMP, which previously had not been called a cancer, is now a cancer—early evolving melanoma in situ. In response to the fact that AJMP
