Dermatology: Practical and Conceptual Commentary | Dermatol Pract Concept. 2023;13(4):e2023248 1 How to Combat Over, diagnosis of Melanoma Harald Kittler1 1 Department of Dermatology, Medical University of Vienna, Vienna, Austria Citation: Kittler H. How to Combat Overdiagnosis of Melanoma. Dermatol Pract Concept. 2023;13(4):e2023248. DOI: https://doi.org/10.5826/dpc.1304a248 Accepted: August 7, 2023; Published: October 2023 Copyright: ©2023 Kittler et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Corresponding Author: Harald Kittler, Department of Dermatology, Medical University of Vienna, Austria E-mail: harald.kittler@meduniwien.ac.at The diagnostic criteria for melanoma have undergone significant changes over time, encompassing clinical, der- matoscopic, and histopathologic criteria [1]. It is undeni- able that the increase in melanoma incidence can partly be attributed to changes in disease definitions and enhanced screening efforts. However, over-diagnosis of melanoma can be categorized into two types. The first involves incorrectly labeling nevi as melanomas through pathology, while the second pertains to overtreatment of flat, mostly non-invasive melanomas that progress slowly and pose no immediate harm if left untreated for an extended period. When discuss- ing over-diagnosis of melanoma, it is crucial to specify which type is being referred to. The article by Betz-Stablein and Soyer addresses the second type and acknowledges it as a genuine concern [2]. On the other hand, Navarrete-Dechent and Lallas do not explicitly specify the type of over-diagnosis, but their arguments seem to encompass both types [3]. Inter- estingly, both articles propose similar solutions to combat over-diagnosis: the implementation of more technology. They suggest that sequential dermatoscopy, total body photogra- phy, and artificial intelligence-powered decision support can enhance specificity, thereby reducing the need for unneces- sary excisions and subsequently decreasing over-diagnosis. While I agree that technology has the potential to decrease over-diagnosis, I believe it cannot effectively address both types. Misdiagnosis of nevi as melanomas by pathology can be reduced by minimizing unnecessary nevus excisions, but overtreatment of slowly progressing in situ melanomas like lentigo maligna cannot be adequately addressed by these measures. Sequential dermatoscopy and total body photog- raphy may even lead to an increased detection and treatment of in situ melanomas. This viewpoint aligns with Welch et al., who recently suggested a reduction in technology as a strategy against over-diagnosis [4]. Welch also recommended refraining from excising melanocytic lesions smaller than 6 mm to combat over-diagnosis. However, size alone is a crude and imperfect indicator of prognostic significance. For instance, lentigo maligna can grow to a large size while still maintaining an excellent prognosis. Conversely, some rap- idly growing melanomas can be small in size yet exhibit in- creased thickness and a worse prognosis. The challenge lies in identifying reliable indicators that can guide the decision to leave certain melanomas untreated. This necessitates re- search combining clinical and dermatoscopic criteria with prognostic factors. To combat over-diagnosis, a conceptual shift is also required. Clinicians and pathologists should not be excessively concerned about missing thin melanomas or be driven by the fear of malpractice lawsuits resulting from 2 Commentary | Dermatol Pract Concept. 2023;13(4):e2023248 the oversight of non-invasive melanomas. Additionally, a policy shift is needed concerning incentives and oversight. As mentioned before, clinicians who perform an excessive number of biopsies to detect a single melanoma should have their reimbursements limited, and pathology labs with a dis- proportionately high number of melanoma diagnoses should have their slides reviewed by an expert panel. Implementing these measures requires the involvement of all stakeholders, including healthcare professionals, consumers, insurance agencies, and healthcare policymakers. References 1. Kittler H. Evolution of the Clinical, Dermoscopic and Patho- logic Diagnosis of Melanoma. Dermatol Pract Concept. 2021; 11(Suppl 1):e2021163S. DOI: 10.5826/dpc.11S1a163S. PMID: 34447612. PMCID: PMC8366309. 2. Betz-Stablein B, Soyer HP. Overdiagnosis in melanoma screening: Is it a real problem? Dermatol Pract Concept., in press 3. Navarrete-Dechent C, Lallas A. Overdiagnosis in melanoma screening: Is it a real problem? Dermatol Pract Concept., in press 4. Welch HG, Mazer BL, Adamson AS. The Rapid Rise in Cutane- ous Melanoma Diagnoses. N Engl J Med. 2021;384(1):72-79. DOI: 10.1056/NEJMsb2019760. PMID: 33406334.