My Melanoma Melodrama

Here’s the biopsy report on the spot on my back. That “MALIGNANT MELANOMA” diagnosis scared me at first, but then it pissed me off, when I realized that it might be an overdiagnosis.

March 10, 2024. I was recently diagnosed with “malignant melanoma.” In this column, I’ll talk about what my diagnosis really means and what I plan to do about it.

First, a little backstory. A while back, a mole appeared on my right cheek. I tried to ignore it, because I’ve argued that we Americans are far too fearful of cancer. But after people close to me bugged me to get the mole checked, I saw a dermatologist, Dr. M, in the fall of 2022. She sliced the mole off, and days later a biopsy confirmed her suspicion that it was only seborrheic keratosis, a benign skin growth, not cancer.

That happy outcome made me trust Dr. M. In January of this year, I asked her to examine a persistent and occasionally bloody pimple on my left thigh. After she sliced off the pimple for a biopsy, she asked if she could check me for other suspicious spots. I said sure. She found something funky on my back and asked if she could take a slice for a biopsy. I said sure.

Days later, Dr. M called with the biopsy results. The pimple on my thigh is basal-cell carcinoma. No big deal, basal-cell carcinomas are rarely if ever fatal and quite treatable; she could burn it off in a quick, painless procedure. But the spot on my back is malignant melanoma. It is stage pt1a, with a maximum thickness of 0.6 millimeters, or 1/40th of an inch (see biopsy write-up above).

With this stage of melanoma, Dr. M told me, there’s no need to check whether the cancer has spread to my lymph nodes, and no need for chemotherapy or radiation; but the tumor should be “excised,” meaning that the tumor and an inch or two of surrounding skin is surgically removed. She can’t do that surgery herself, but she can recommend an in-network surgeon.

What if I do nothing? I asked. Although I’d already mentioned my cranky views of cancer care, Dr. M seemed taken aback by my question. Melanoma can metastasize to other parts of my body and kill me. Excision can be done on an out-patient basis and has a high success rate. Why wouldn’t I get treated? That was Dr. M’s response.

Here’s why I asked, What if I do nothing? Between 1975 and 2017, diagnoses of melanoma rose six-fold, while mortality rates have remained more or less constant. This pattern indicates that melanoma is being overdiagnosed, which means that physicians are flagging anomalies that would never have harmed patients if untreated.

That is the conclusion of a 2021 New England Journal of Medicine study led by H. Gilbert Welch, an authority on cancer overdiagnosis. I wrote about the NEJM study last year in a column, “We’re Too Scared of Skin Cancer.”

Since then, more evidence has emerged that “Melanoma is being overdiagnosed at ‘alarming’ rates,” as journalist Meryl Davids Landau put it in National Geographic last month. Landau cites a BMJ Evidence-Based Medicine study whose lead author is dermatologist Adewole Adamson (who also contributed to the 2021 NEJM study of melanoma).

Adamson et al examined melanoma among white adults, who are especially at risk of melanoma. The BMJ study estimates that in 2018, “49.7% of melanomas diagnosed in white men and 64.6% in white women were overdiagnosed.” Overdiagnosis is particularly high among those diagnosed with in-situ (also called stage 0) melanoma, which occurs only in the epidermis, the skin’s outermost layer. The BMJ study estimates that 89.4% of white men and 85.4% of white women diagnosed with in situ melanoma “were likely overdiagnosed.”

The next stage above in situ melanoma is known as pt1a (or t1a) melanoma (“pt” stands for “primary tumor”). This is the diagnosis I received. T1a melanoma is called “invasive,” because the tumor has spread below the epidermis; but the tumor is less than 0.8 millimeter thick and shows no signs of metastasis (spreading to other sites) or ulceration (breakage of the skin).

T1a melanomas, as well as in situ ones, account for many overdiagnoses. That is the conclusion of a 2022 study in Dermatopathology (cited by Landau) and a 2023 study in Pathology. The latter asserts that “a large fraction of the melanomas that are currently diagnosed would not cause the death of patients, even if they had not been excised.” Italics in the original!

The prognosis for those diagnosed with “localized” melanoma, which includes in situ and type t1a cancers, is extremely, even suspiciously good. The five-year survival rate is 99.6 percent, according to the National Cancer Institute.

That almost perfect survival rate means that melanoma like mine is “highly curable,” according to promoters of screening like the Melanoma Research Alliance. The implication is that “early detection” and treatment save lives. But clearly, many people “cured” of localized melanoma were never at risk of dying from the disease and hence were treated unnecessarily.

So what should I do about the spot on my back? I hate to contribute to the epidemic of cancer overtreatment. As I reported last year, Americans are being overtested, overdiagnosed and overtreated for a variety of cancers on a massive scale. This problem exacerbates the sky-high costs and poor outcomes of U.S. health care.

But if I don’t get the surgery, I’ll keep brooding over that damned spot. Melanoma does kill people: 7,990 in 2023, according to the National Cancer Institute. Although that number accounts for only 1.3 percent of all cancer-related deaths, I have risk factors for melanoma, such as fair skin and blue eyes; members of my family have been treated (successfully) for with melanoma. For these reasons, I’m going to get the spot on my back excised by a cancer surgeon recommended by Dr. M. [Update: The surgeon cut out the spot on April 19, 2024.]

If I notice another weird spot on my skin, I’ll probably have Dr. M check it out. I do not, however, plan to get my skin checked every three to six months, which is what dermatologists recommend for the 1,413,976 (as of 2020) Americans who have been diagnosed with melanoma. That’s how I plan to balance my fear of dying with my outrage over melanoma overdiagnosis.

Dr. M responds: Hi John, I enjoy your analyses and perspective, thanks for sharing! The only issue about melanoma biology is that it is not a linear progression model like certain other skin cancers (i.e. basal cell carcinoma tends to grow slowly over time and rarely metastasize). We do not know if this T1a melanoma would have turned into a T1b or T2, or would always stay as a T1a over your lifetime and be truly harmless. Then there are the cases of metastatic melanomas that the first diagnosis is brain or lung metastasis, without ever finding a lesion on the skin. I think we need more research into figuring out which subtypes molecularly are more dangerous and more prone to metastasis in order to identify which ones needs more aggressive interventions. Fear is never a good thing, I appreciate a healthy dose of respect for certain medical conditions.  

Further Reading:

I’ve posted a bunch of un-paywalled critiques of cancer care on this site, including:

The Cancer Industry: Hype Versus Reality

Mammography Screening Is a Failed Experiment

Do Colonoscopies Really Save Lives?

We’re Too Scared of Skin Cancer

Also check out Meryl Davids Landau’s National Geographic article, “Melanoma is being overdiagnosed at ‘alarming’ rates,” which is loaded with links to relevant studies—and is too important to be paywalled!

Finally, for a broad overview of the consequences of our excessive fear of cancer, see journalist David Ropeik’s new book “Curing Cancerphobia.”