Experts Urge Reclassifying Some Melanoma as Precancer to Prevent Overtreatment

The push to detect cancer earlier has had an unintended consequence: a surge in diagnoses of melanoma in situ, an early form of skin cancer confined to the surface that rarely causes harm. Now, some clinicians say these expanded screenings and imaging have led to overdiagnosis, leaving many patients unnecessarily anxious.

In a viewpoint column published in JAMA Dermatology, researchers from NYU Grossman School of Medicine and the Icahn School of Medicine at Mount Sinai argue that this early, noninvasive form of melanoma should be reclassified as a “precancer” instead of true cancer. They say the change would preserve patient safety while reducing unnecessary biopsies, surgeries, and emotional distress.

Unlike invasive melanoma, which can spread and become deadly, melanoma in situ poses virtually no risk of death. Yet the diagnosis often carries the same emotional weight as cancer. “Fear of recurrence” is common among melanoma survivors, according to a recent study cited in the column, and may significantly diminish patients’ psychological well-being.

The authors, including Yaelle Shaked, M.S., Alyssa Swearingen, M.D., Jennifer A. Stein, M.D., Ph.D., and David Polsky, M.D., Ph.D., propose three changes to how dermatologists handle the condition: updating how it’s described to patients, reducing unnecessary biopsies of benign moles, and consider nonsurgical treatment options when appropriate.

“Entangled in the quandary between saving lives through the detection of early-stage, invasive melanoma and causing potential harm to patients, the question arises: where do we go from here?” the authors wrote. “The overall goal is to diminish the harms of overdiagnosis by reducing the emotional consequences and potential adverse effects from treatment.”

Before 1985, melanoma in situ was considered a precancer. It was reclassified as cancer based on microscopic features that some experts now say are overly sensitive, capturing many lesions that would never progress to invasive forms of the disease. As screening has expanded and new imaging tools such as total-body photography and dermoscopy have become common, dermatologists are detecting more early-stage and atypical lesions, many of which turn out to be harmless.

To improve communication, the authors recommend using the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) version 2.0, which places melanoma in situ in a category with severely atypical but benign lesions.

Unnecessary biopsies are another growing concern. Although a skin biopsy is a relatively simple procedure, it carries risks such as scarring, infection and financial cost, and it can increase patient anxiety. The paper points to research from Australia showing that a “watch and wait” approach, using digital dermoscopic imaging to track lesions for three months, reduced the number of biopsies by 56% without missing serious cases. Of the 374 atypical lesions studied, only one unbiopsied lesion later proved to be melanoma in situ.

Although surgery remains the recommended treatment for melanoma in situ on the trunk and extremities, the authors suggest alternative approaches should be considered for patients with limited life expectancy, surgical risk factors or large lesions in cosmetically sensitive areas. Currently, some patients are treated with radiation and the topical imiquimod, which is used off-label. Its use here is supported by multiple studies. Further clinical trials should be conducted to generate high-quality data to validate this approach, they said.

“Addressing melanoma overdiagnosis is a pressing and complex clinical concern due to the potential emotional and physical harms patients may experience from diagnostic evaluations and treatment choices,” the authors wrote. “Dermatologists have an ethical responsibility to adequately inform patients regarding management options so that patients can make decisions best aligned with their goals.”