Skin self-examination and the ABCDE rule in the early diagnosis of melanoma: is the game over? Reply from author

Abstract

We thank De Giorgi et al. for their letter,1 and for the opportunity to clarify our findings and conclusions.2 It is challenging to interpret the influence of screening on melanoma incidence and mortality rates. Recent data from developed areas, including the U.S.A. and much of Europe, generally show increases in melanoma incidence, with the greatest increases affecting older age groups.3, 4 Mortality rates have stabilized or decreased in the younger age groups, and increased in the older age groups.3, 4 In Australia, incidence is increasing overall, but stabilizing in the youngest age groups,5 whereas melanoma mortality is decreasing in the youngest age groups, levelling in the middle age groups and increasing in those aged ≥ 80 years.6 Worldwide, mortality rates have not kept pace with increasing incidence, giving rise to the notion of overdiagnosis – the unnecessary removal of indolent melanomas that are not life threatening. In support of overdiagnosis, De Giorgi et al. cite a recent U.S. ecological study showing elevated rates of biopsy and melanoma incidence in older age groups (≥ 65 years).7 Under the assumption that melanoma incidence rates are stable, these authors propose that rising biopsy rates are responsible for a spurious spike in incidence.7 It is impossible, of course, to determine the extent to which increasing melanoma incidence is due to excessive biopsy, or due to true increases in underlying incidence rates. However, we do know that melanoma mortality rates in the U.S.A.3 are increasing sharply in the same ≥ 65 years age group, especially among men, suggesting that true increases of incidence are responsible for the increased biopsy rates, rather than the other way around. Further evidence supporting true elevations in incidence is provided by a recent U.S. study showing rising incidence for deeper tumours, and increasing incidence across all socio‐economic strata, considered a surrogate for access to screening.4 Although the question of overdiagnosis will likely remain controversial, improvements in survival and mortality, where evident, may reflect a true benefit of early detection.4, 5, 8