We’re Too Scared of Skin Cancer

This image from “The Rapid Rise in Cutaneous Melanoma Diagnoses,” by Welch et al., New England Journal of Medicine, January 7, 2021, shows that the melanoma “epidemic” is driven by overtesting and overdiagnosis.

April 26, 2023. I had a cancer scare recently, which put me in an awkward position. For years I’ve argued that we Americans are too afraid of cancer. Our fears have fueled an epidemic of overdiagnosis, which results from detection of tumors and other anomalies that never would have compromised health if left alone. As I argue in a recent post, overdiagnosis has boosted the costs of cancer care without extending our lives.

The cancer industry fans our fears. Take, for example, “Crucial Catch,” a joint program of the American Cancer Society, a foundation supported by biomedical firms; and the National Football League. Making the dubious claim that screening people with no symptoms “saves lives,” Crucial Catch urges us to “intercept cancer” by getting screened for a wide range of cancers, including skin cancer.

Skin cancer terrifies people I know in their 50s and older. They get checked on a regular basis, once or more a year, and have suspicious lesions surgically removed. I’m not immune to these fears. I have risk factors for skin cancer: I’m 69, fair-skinned, freckly; I’ve spent lots of time outdoors; I was sunburned as a kid. But I’ve never been screened.

Last year, my sister, whom I hadn’t seen in a while, asked me about a dark spot on my right cheek. Looks funky, she said, I should get it checked, make sure it isn’t melanoma. I dismissed her concern. I wasn’t sure when the spot first appeared, I told her, but it’s probably just one of those harmless discolorations we get as we age.

After a friend asked me about the spot, I reluctantly googled skin cancer. Melanoma, the deadliest kind, comes in two forms: subcutaneous, which can occur anywhere in the body; and cutaneous, which is visible on the skin’s surface. Cutaneous melanoma lesions are quite variable, and some online photos look like my spot: black/brown, about the width of a pencil eraser, with an irregular border.

I found myself glancing at the spot whenever I looked in the mirror. Was it changing? Getting bigger? I finally decided to get it checked. The dermatologist recommended by my primary physician was booked for months; dermatologists are in demand these days. But a young associate in the same clinic could see me in a few weeks.

As my appointment neared, my dread grew. Then I found this eye-opening paper: “The Rapid Rise in Cutaneous Melanoma Diagnoses,” New England Journal of Medicine, January 7, 2021. The lead author, H. Gilbert Welch, is a physician and public-health scholar who has been warning about overdiagnosis for more than a decade. His melanoma paper, in spite of its enormous public-health implications, is behind a paywall. But here are highlights:

*Diagnoses of melanoma, once “rare,” surged six-fold in the U.S. between 1975 and 2017, from fewer than 10 people per 100,000 to over 50. Cutaneous melanoma accounts for almost all of this increase. Meanwhile, melanoma mortality has remained more or less flat since 1975, as indicated by the chart above. This pattern—big increase in diagnosis with no change in mortality—is the classic signature of overdiagnosis, which often results in unnecessary, expensive, traumatic overtreatment.

*The epidemic of overdiagnosis is self-perpetuating. The more we are diagnosed with skin cancer, the more we fear and get screened for it. Physicians, driven by desire for revenue and fear of lawsuits from patients, increasingly err on the side of caution when making diagnoses. Lesions that would have been judged as benign several decades ago are now diagnosed as melanoma or pre-melanoma.

*Defenders of screening argue that the rise in cases reflects increased exposure to ultraviolent radiation in sunlight and tanning salons. But Welch et al. cast doubt on this thesis, noting that the link between melanoma and ultraviolet radiation is “not particularly strong.” A “history of sunburns” doubles the risk of being diagnosed with melanoma, but “chronic sun exposure” confers a slightly decreased risk.

*Dermatologists have financial incentives to keep testing for skin cancer. “Screening is a great way to increase volume in terms of both new patients and more services per patient,” Welch et al. state. They nonetheless recommend ending “population-wide screening for skin cancer”; screening “should be reserved only for those groups at substantially high risk,” such as people with a family history of melanoma.

Although I found this review of the melanoma “epidemic” reassuring, my dread mounted as my appointment with the dermatologist approached. After all, people do die of melanoma. In 2021 my friend Eddie died after melanoma spread to his brain. Like me, he was fair-skinned, of Irish descent. He was three years younger than me. 

The dermatologist, when I finally saw her, seemed awfully young, but her brisk, matter-of-fact professionalism put me at ease. After examining my spot with a magnifying glass, she recommended a biopsy. Noting my alarm, she said my spot was almost certainly seborrheic keratosis, a harmless darkening of the skin common among the elderly; she wanted a biopsy just to be sure.

After giving me a shot to numb my cheek, the dermatologist used an instrument to slice off my spot. She would send the spot to a lab, which would have the results within a week. Before leaving, I asked if she was aware of the paper by Welch et al. on melanoma overdiagnosis, and she nodded. Yes, she said, overdiagnosis is a problem.

A few days later, the clinic called with the biopsy results: seborrheic keratosis, as my dermatologist suspected. My sister, who lost her husband to cancer, choked up when I called to give her the good news.

So where does this episode leave me? I don’t plan on getting screened for skin cancer. Welch et al. have convinced me that screening of asymptomatic people makes no sense. Moreover, I suspect that the linkage of fair skin and a history of sunburn to skin cancer is at least partially self-fulfilling; people with these risk factors get checked for and hence diagnosed with skin cancer more often than others.

But I’m glad I got my spot checked and removed. Yes, it was a false alarm, but it’s a relief not to see that spot on my cheek when I look in the mirror. If another funky spot appears on my face or elsewhere, I’ll probably see the same dermatologist; I trust her. I’ll also keep limiting my exposure to strong sunlight. No sense tempting fate.

Before posting this column, I emailed Gilbert Welch to ask three questions about his melanoma paper: 1. Have you seen new data that make you question your conclusions? 2. Has the dermatology community accepted your conclusions? 3. Have you persuaded people you know--friends, family and so on--not to be so worried about melanoma, and to forego screening?

Welch replied:

1. No. I have not seen any new data that would change our conclusion.

2. Some in the Dermatology community would not only accept, but wholeheartedly agree with our conclusions. [One of Welch’s co-authors, Adewole Adamson, is a dermatologist.]

3. I don't try to persuade people, I just try to show them the data. I do try to persuade physicians and policymakers that we have overinvested in screening.

I hope physicians, policymakers and football fans are listening.

Further Reading:

See my column, The Cancer Industry: Hype Versus Reality, and these articles by Welch and others: The Rapid Rise in Cutaneous Melanoma Diagnoses (behind a paywall, for now), Blame rising cancer overdiagnosis on ‘irrational exuberance’ for early detection, Epidemiologic Signatures in Cancer.