Dermatopathologist Perceptions of Melanocytic Skin Lesion Overdiagnosis and Association With Diagnostic Behaviors
abstract
This abstract is available on the publisher's site.
Access this abstract nowImportance
Despite evidence of overdiagnosis of in situ and invasive melanoma, neither the perceptions of practicing dermatopathologists about overdiagnosis nor possible associations between perceptions of overdiagnosis and diagnostic practices have been studied.
Objective
To examine practicing US dermatopathologists' perceptions of melanoma overdiagnosis as a public health issue, and to associate diagnostic behaviors of dermatopathologists with perceptions of melanoma overdiagnosis.
Design, Setting, and Participants
This survey study included 115 board-certified and/or fellowship-trained dermatopathologists and their diagnostic interpretations on a set of 18 skin biopsy cases (5 slide sets comprising 90 melanocytic skin lesions). Participants interpreted cases remotely using their own microscopes. Survey invitations occurred during 2018 to 2019, with data collection completed 2021. Data analysis was performed from June to September 2021.
Main Outcomes and Measures
Agreement vs disagreement that overdiagnosis is a public health issue for atypical nevi, melanoma in situ, and invasive melanoma. Associations between perceptions regarding overdiagnosis and interpretive behavior on study cases.
Results
Of 115 dermatopathologists, 68% (95% CI, 59%-76%) agreed that overdiagnosis is a public health issue for atypical nevi; 47% (95% CI, 38%-56%) for melanoma in situ; and 35% (95% CI, 26%-43%) for invasive melanoma. Dermatopathologists with more years in practice were significantly less likely to perceive that atypical nevi are overdiagnosed, eg, 46% of dermatopathologists with 20 or more years of experience agreed that atypical nevi are overdiagnosed compared with 93% of dermatopathologists with 1 to 4 years of experience. Compared with other dermatopathologists, those who agreed that all 3 conditions are overdiagnosed were slightly more likely to diagnose study cases as mild to moderately dysplastic nevi (odds ratio, 1.26; 95% CI, 0.97-1.64; P = .08), but the difference was not statistically significant. Dermatopathologists who agreed that invasive melanoma is overdiagnosed did not significantly differ in diagnosing invasive melanoma for study cases compared with those who disagreed (odds ratio, 1.10; 95% CI, 0.86-1.41; P = .44).
Conclusions and Relevance
In this survey study, about two-thirds of dermatopathologists thought that atypical nevi are overdiagnosed, half thought that melanoma in situ is overdiagnosed, and one-third thought that invasive melanoma is overdiagnosed. No statistically significant associations were found between perceptions about overdiagnosis and interpretive behavior when diagnosing skin biopsy cases.
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Additional Info
Dermatopathologist Perceptions of Overdiagnosis of Melanocytic Skin Lesions and Association With Diagnostic Behaviors
JAMA Dermatol 2022 Apr 20;[EPub Ahead of Print], KF Kerr, MM Eguchi, MW Piepkorn, AC Radick, LM Reisch, HL Shucard, SR Knezevich, RL Barnhill, DE Elder, JG ElmoreFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Several lines of evidence have suggested that the incidence of melanoma has been steadily increasing since the 1970s, with melanoma-specific mortality remaining essentially unchanged. The increased incidence has been attributed to a variety of factors, including 1) growing exposure to ultraviolet radiation, 2) improved performance of pathologists and dermatopathologists in identifying early melanocytic lesions, 3) aging populations, predominantly in industrialized countries, and 4) skin cancer screening programs. In the changing landscape of medicine, overdiagnosis of melanoma is a serious concern, since the incorrect categorization of borderline or benign melanocytic lesions may result in morbidity and mortality from unnecessary therapeutic interventions.
Kerr et al have added a study to the rapidly expanding literature regarding the overdiagnosis of melanocytic skin lesions and “atypia.” In their paper, a survey of 115 US-based dermatopathologists showed that a clear majority thought that atypical melanocytic nevi are overdiagnosed, half of the participants thought that melanoma in situ is overdiagnosed, and one-third thought that invasive melanoma is overdiagnosed. Interestingly, recently trained dermatopathologists were more likely to hold these opinions compared with their more senior colleagues. This makes one wonder whether younger dermatopathologists are under the impression that they are overdiagnosing melanocytic lesions. Additionally, the legal system in the US has worse ramifications for those who underdiagnose a health condition.
These findings highlight the current challenge to the public health system and the difficulty and complexity of diagnosing melanocytic tumors. I agree and support the authors that new innovations such as 1) improvements in nomenclature and 2) greater standardization of diagnostic criteria may do much to alleviate the current crisis. We hope that the young and the old would agree to standardize.