AAD 2025: Approaching Skin Cancer Diagnosis

In this feature interview, Adewole Shomari Adamson, MD, MPP, FAAD, discusses how melanoma diagnosis is evolving, with rising incidence and ongoing debates about under- and overdiagnosis. In this session, experts will break down the key challenges, including how molecular diagnostics may shape the future of melanoma detection and risk assessment. Gain practical insights on improving diagnostic accuracy, minimizing unnecessary interventions, and refining patient-centered strategies for melanoma screening in daily practice.

Dr Adamson is a board-certified dermatologist and assistant professor in the department of internal medicine at the University of Texas at Austin, TX.

Transcript:

Melanoma epidemiology is evolving. Based on current data, what trends do you find most concerning or clinically relevant for practicing dermatologists?

There has been a sixfold increase in the amount of melanoma that's diagnosed in the United States, and that's been dubbed an epidemic. And there's been a lot of controversy as to why the amount of melanoma or the incidence of melanoma is going up over time. And there have been numerous hypotheses for that. Some of it is sun exposure, some of it is an aging population. Some of it is that we're getting better at detecting it. And so, the session that we're doing at the AAD is trying to tease apart some of those reasons and potentially some of the ramifications to our patients.

Can you elaborate on the most pressing challenges in accurate diagnosis, and how under- or overdiagnosis impacts patient outcomes?

So, there's both under diagnosing and over diagnosing that happens. We can debate how much of either is the case. So let's start with under diagnosis. There are certain demographics of individuals that get late stage diagnosis to their disease. Often it's people of lower socioeconomic status, people in rural communities where they have less access to care as well as in patients with darker skin types. And in these populations, we have not yet found a way to improve those outcomes and we need to do some more research in that aspect. Now, over-diagnosis, that's also a huge problem. I mean, estimates anywhere from 30% to 70% of early melanomas may be overdiagnosed, meaning patients are receiving the diagnosis of a cancer that if we didn't go looking for, may never have caused any symptoms. Now, what I would say is we can't tell after a diagnosis which would progress or which wouldn't. So we treat all of them. But for sure, over-diagnosis is a large problem and a pressing problem, in my opinion, in dermatology.

With increasing interest in molecular diagnostics, how do you see these advancements integrating into clinical practice? Do you foresee molecular tools supplementing or eventually replacing traditional histologic evaluation?

So, I think that molecular tools are welcome. They're becoming more robust. But I think that we need to run more studies to see whether these molecular tests are actually just causing us to call more things melanoma that wouldn't progress at all. So increasing our sensitivity so much that we're actually harming patients by labeling things cancer that in fact are not. But I think molecular diagnosis, perhaps maybe in the future, it'll allow us to determine with more fidelity, which cancers are destined, early cancers are destined to progress versus not currently. We really don't have great tests in order to tease those 2 things apart.

A patient-centered approach to melanoma detection requires balancing accuracy with minimizing unnecessary interventions. What strategies do you recommend for dermatologists to improve patient communication and shared decision-making in this context?

I think photography is something that's really important. In my clinic, I run a high risk melanoma pigment and lesion clinic in Austin, Texas where we do total body photography to try to monitor lesions over time. And I think that has the benefit of helping the rheumatologists really focus on things that are evolving, which is probably the most important harbinger of a cancer that may progress. And so that's one way that at least I practice so that I can try my best to balance both being not being too sensitive and biopsy everything, but also making sure that I do biopsy things that are evolving and changing.

For dermatologists looking to refine their approach to melanocytic lesions, what are the key takeaways from your session that they can immediately apply in their daily practice?

Well, I think they'll be able to get a better understanding of the challenges in pathologists and using molecular tools to make the diagnosis of melanoma. They'll get an understanding of how the epidemiology of the melanoma landscape has changed over the last 40 years. They'll also get a sense of some of the controversies related to melanoma overdiagnosis. And we'll also have some discussions about where do we go from here? How does this affect our patients and our patients' psychological wellbeing? What are the harms and the benefits of screening for melanoma? And I think the audience will get a better appreciation of just how challenging it is a task to screen for melanoma. And it has upsides as well as downsides. And we need to fully appreciate that as dermatologists.

Is there anything else you’d like to share with your colleagues regarding approaches to melanoma diagnosis?

It's hard. It's challenging, and I think that everyone's trying to do their best. Melanoma is a potentially lethal disease that you want to catch early. And I think coming to our session, we'll give our colleagues some comfort and appreciation of that challenge as well as really have a discussion about ways to improve some of the uncertainty around melanoma diagnosis and screening.