The Screening Dilemma: Rethinking Melanoma Detection

At Dermatology Week 2025, Vishal Patel, MD, explored the complex and evolving landscape of melanoma screening, urging dermatologists to consider the broader implications of rising skin cancer diagnoses in the absence of increased mortality.

Dr Patel began his session, “When Cancer Reaches the Skin: Strategies to Identify Melanoma,” by emphasizing the scope of the issue: Skin cancer is more prevalent than all other cancers combined, with US treatment costs exceeding $8 billion annually. While nonmelanoma skin cancers dominate in volume, melanoma carries the greater burden in terms of potential lethality and clinical complexity.

Highlighting epidemiologic trends, Dr Patel noted that while the number of diagnosed invasive melanomas has increased by over 40% in the past decade, deaths from melanoma have remained stable or declined, thanks in part to advances in immunotherapy. This "diagnostic disconnect" raises a pressing public health question: Are more cases being identified simply because of enhanced screening practices and lowered pathologic thresholds, rather than a true rise in dangerous disease?

Referencing a New England Journal of Medicine article, Dr Patel pointed to factors such as increased biopsy rates and a shift in pathologic classification as drivers of this surge. He likened the situation to lung cancer trends, where incidence declined following anti-smoking efforts. In contrast, melanoma diagnoses are outpacing what would be expected even in worst-case UV exposure scenarios.

Dr Patel questioned whether current screening practices—especially routine total-body skin exams—are efficient or effective at reducing mortality. "We often assume early detection is inherently beneficial," he said, "but we need quantifiable data to prove that assumption." Overdiagnosis and overtreatment of indolent lesions may have unintended emotional and economic consequences for patients.

He cited the US Preventive Services Task Force's 2023 reaffirmation of its stance against routine melanoma screening in asymptomatic individuals, due to insufficient evidence. Instead, he emphasized risk-based assessment, particularly for patients with a personal or family history of skin cancer or suspicious, changing lesions.

Dr Patel also addressed the limitations of current screening tools. While dermoscopy improves diagnostic accuracy, its benefit is largely dependent on the expertise of the user. A lack of standardization in how clinicians perform skin exams further contributes to diagnostic variability.

Ultimately, Dr Patel called for a more nuanced and evidence-based approach to melanoma screening—one that prioritizes high-risk populations, balances costs and benefits, and integrates emerging technologies such as gene expression profiling. “We need to be more thoughtful and strategic,” he concluded, “because while screening has potential, it is not a one-size-fits-all solution.”

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Reference
Patel V. When cancer reaches the skin: strategies to identify melanoma. Presented at: Dermatology Week; May 14–16, 2025; Virtual