Are physicians overdiagnosing melanoma?

In an editorial in the February 1 issue of American Family Physician, Dr. Jenny Doust and colleagues wrote about the problem of widening disease definitions, a common phenomenon in which the definition of a disease is "broadened over time to include milder and earlier cases," leading to harm "by exposing more patients to the adverse effects of treatments, triggering investigation and prescribing cascades, increasing anxiety, and placing a financial burden on patients and the wider society." Expanding the number of patients diagnosed with disease increases the burden on primary care physicians called on to manage these additional cases, even when it is uncertain if earlier interventions prevent morbidity or mortality. Illustrative examples of wider disease definitions include hypertension, polycystic ovary syndrome, breast cancer, and autism. What can family physicians do about it? The authors responded:

Recognizing the problem is the first step in tackling it. In particular, family physicians should not blindly accept new definitions and testing guidelines without an adequate understanding of the harms and benefits of the changes and the implications for our patients and wider practice.

Along similar lines, a recent analysis in the New England Journal of Medicine by Dr. H. Gilbert Welch and colleagues examined the drivers of the dramatically increased incidence of cutaneous melanoma in the U.S., which today is 6 times as high as in 1975 despite essentially no change in melanoma mortality. They pointed out that exposure to ultraviolent (UV) radiation (including tanning bed use) cannot account for more than a small portion of this increase. Instead, they argued that increased diagnostic scrutiny - "the combined effect of more screening skin examinations, falling clinical thresholds to biopsy pigmented lesions, and falling pathological thresholds to label the morphologic changes as cancer" - is most likely to be responsible for the epidemic of new diagnoses. Not only has the annual percentage of fee-for-service Medicare beneficiaries undergoing skin biopsies nearly doubled since 2004, but pathologists frequently upgraded skin biopsy specimens obtained in the late 1980s from benign to malignant when evaluating the same specimen two decades later. Primary care physicians contribute to widening the definition of cutaneous melanoma by performing or referring for biopsy small (<6 mm), incidentally detected skin lesions and screening patients with dermoscopy, which identifies more melanomas than visual inspection alone but is not well studied in primary care settings.

The U.S. Preventive Services Task Force (USPSTF) has concluded that current evidence is insufficient to assess the balance of benefits and harms of skin cancer screening in asymptomatic adults. Nonetheless, more than half of family physicians and general internists in a 2011 survey reported performing full-body skin examinations for skin cancer screening. In a 2020 AFP editorial, Drs. Michael Pignone and Adewole Adamson (Dr. Adamson also co-authored the NEJM analysis) observed that "compared with usual care, potential effects of screening on morbidity and mortality from keratinocyte carcinoma are at most small, and screening cannot be justified based on the impact on keratinocyte carcinoma alone." Dr. Welch and colleagues went one step further, arguing that the established harms of skin cancer screening already outweigh any potential benefits:

The increase in melanoma diagnoses by a factor of 6, with at least an order of magnitude more persons undergoing a biopsy and no apparent effect on mortality, is more than enough to recommend against population-wide screening. ... It [screening] has been effectively promoted under the guise of public health, with the combination of frightening messages about skin cancer and the premise that screening can only help. However, medical care should be driven by patient needs, not system needs. Now is not the time to add more anxiety and expense to an already anxious and expensive world.

Not surprisingly, dermatologists have a more positive view of skin cancer screening, as reported in a news story about the analysis by Dr. Welch and colleagues that quoted the president of the American Academy of Dermatology as stating that "an aggressive approach to prevention and treatment is entirely appropriate for a disease that kills 20 Americans each day." Of course, no one is urging clinicians to stop counseling patients on minimizing their exposure to UV radiation; indeed, the USPSTF recommends behavioral counseling to prevent skin cancer, particularly for children, their parents, and young adults. But screening for skin cancer, which has effectively widened the definition of cutaneous melanoma and driven widespread overdiagnosis - is a different story. To give Dr. Doust and colleagues the last word: "We [primary care physicians] are not here to passively enact specialist recommendations. Instead, we need to more assertively act as advocates for our patients and our communities."

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This post first appeared on the AFP Community Blog.

Don't put me in a (political) box

On any given day, several hundred people read one or more of my blog posts. I don't have a good sense of who they are or where they stand on the various health and health policy issues that I've been writing about for the past decade. Since I turned off the blog Comments function a few years ago because it was being deluged in spam advertisements for cut-price Viagra and such, the only way I receive feedback about what I've written is when a reader reaches out directly, through an e-mail or private social media message, to let me know what they thought. The exception is my wife, who isn't a regular reader but does me the favor of promoting my blog within her social and professional circles from time to time. That isn't to say that we see eye to eye on all or even most of these topics. In fact, recently she shared, after not reading the blog for quite a while, that she was surprised by how "political" my posts had become. It wasn't only the recent Donald Trump post, which I'll freely admit is out of character for Common Sense Family Doctor and not likely to recur in the post-Trump Presidency era, but also posts about COVID-19 where I've seemed to come down on one partisan side or the other regarding elements of the public health response.

I don't feel that I've become more "political," but rather that public health and scientific evidence have been increasingly politicized. For example, wearing a mask indoors to slow the spread of SARS-CoV-2 wasn't a Republican or Democratic issue until the President declined to wear one and starting mocking rival politicians who did. Closing and re-opening public schools with safety protocols wasn't a liberal or conservative issue until the President, months prior to the results of definitive studies that confirmed that schools can re-open safely, insisted that they all re-open immediately and threatened to withhold federal funding if they didn't. And it became more politicized when teachers' unions, bastions of Democratic support, disregarded the science and insisted on conditions such as having children vaccinated prior to teachers returning, which effectively would keep school online for the remainder of this academic year and likely most of the next one.

I resist being categorized as partisan based on my position on any single issue. I am not currently registered with any political party, and though I voted for Joe Biden for President in 2020, eight years ago I voted for Mitt Romney and would probably vote for Romney again if he chose to run in 2024, based not only on his principled opposition to Trump's unchecked lawbreaking but his role as one of the original architects of Obamacare when he was the governor of Massachusetts. I am as vocal about my support of mask mandates as I am about opening schools. I criticized President Obama's health policy team for suppressing the U.S. Preventive Services Task Force's politically inconvenient statement on prostate cancer screening, and I criticized President Trump's first Secretary of Health and Human Services, Tom Price, for trying to do the same thing when he was a member of Congress. I praised Obama's health officials for aiming to de-stigmatize substance use disorders and later bemoaned the Biden administration's recent decision to block implementation of a proposal to expand access to medication-assisted treatment for opioid use disorder by no longer requiring clinicians to hold a special waiver to prescribe buprenorphine.

In short, I've been on both sides of the partisan divide. My health policy views hew not to any political identity or ideology, but have always been guided by my interpretation of what the evidence says or doesn't say. So when you read something I write, here or anywhere else, please don't automatically put me into a political box and assume that because I'm for this, I must be for or against that. I'm a family doctor, and my goal is to take a commonsense, less-is-more approach to health care.

How state policies influence how long you live

Last summer, I temporarily moved from one of the most politically liberal places in America to one of the most conservative. In the 2020 Presidential election, Joe Biden carried DC's 3 electoral votes with more than 92% of ballots cast, while Donald Trump carried Utah's 6 electoral votes over Biden by a comfortable 58% to 38% margin. As the COVID-19 pandemic became increasingly politicized, the orientations of DC and Utah predicted their public health responses. Although nearly all public and private schools in both places initially switched to online learning, most Utah schools re-opened for in-person learning last fall, while DC public schools stayed closed and are only beginning to re-open this month. DC's mayor instituted a mask-wearing mandate on July 22, while Utah's governor did not do so until November 9, when its hospitals were nearly full and the per capita incidence of COVID-19 was among the top 5 states in the nation. DC has also kept in place more restrictive rules on operating restaurants (including closing indoor dining entirely from Dec. 18 to Jan. 22) and other "non-essential" businesses than most parts of Utah.

A research study in Science Advances examined the relationship between social mobility, community COVID-19 incidence, and partisan differences. Logically, people should be more likely to stay at home when viral spread is higher, and more likely to go out when viral spread is lower. Instead, the researchers found that there was only a weak association of mobility with COVID-19 activity over time; a far stronger predictor of people's willingness to leave home to socialize with others outside of their immediate family was party affiliation:

Using daily data on the reported activities of 1,135,638 U.S. adults collected starting on 4 April 2020, we show that partisanship is 27 times more important than the local incidence of COVID-19 in explaining mobility. Moreover, all else equal, Democrats are 13.1% less likely to be socially mobile over time compared to independents, while Republicans are 27.8% more likely to be mobile.

This study's findings correlate with my own experience. I can't remember seeing anyone indoors in DC who wasn't wearing a mask after mid-March, but outside of Salt Lake City (which leans liberal and has a Democratic mayor) it was common to see unapologetically maskless people shopping in stores where mask-wearing was required by law. In a recent article in The New Yorker, Dr. Atul Gawande reported on the debate surrounding mask mandates in Minot, North Dakota, which in mid-October 2020 held the unenviable distinction of being the county seat of "the worst-hit county in the worst-hit state in the worst-hit country" in the world in new COVID-19 cases and deaths per capita. From a public health perspective, a mask mandate ought to have been a no-brainer. Instead, as the city council debated a mask mandate motion for an hour, a YouTube chat of residents watching the proceedings online erupted with angry comments such as "unconstitutional," "tyrannical," and threats of "mass protests." (The council ultimately adopted a mask mandate with no penalties or other means of enforcement.) A few weeks later, Donald Trump easily carried Ward County over Joe Biden, 65% to 32%.

The influence of partisanship on states' public health approaches to the coronavirus is just the tip of the health policy iceberg, though. A study in Pediatrics showed that higher state and local expenditures on non-health care services such as social services, environment and housing were associated with lower infant mortality from 2000 to 2016. Another, more ambitious study graded state policies on a conservative to liberal continuum from 1970 to 2014 ("liberal was defined as expanding state power for economic regulation and redistribution or for protecting marginalized groups, or restricting state power for punishing deviant social behavior, conservative was defined as the opposite") and found that people consistently live longer in states with more liberal policies than in those with conservative ones. The authors estimated that overall U.S. life expectancy (which since the 1990s has been at or near the bottom of the world compared to other high-income countries) would be nearly 3 years longer among women and 2 years longer among men "if all states enjoyed the health advantages of states with more liberal policies," and would mostly erase the current U.S. life expectancy disadvantage. A few years may not seem like that much, but consider this: the 350,000 excess deaths that the U.S. experienced in 2020 due to COVID-19 reduced life expectancy at birth by just over a year, enough to lower U.S. life expectancy to its lowest level since 2003.

In a recent perspective in The Milbank Quarterly, Dr. Jennifer Karas Montez observed that as states became increasingly polarized to the right or the left in their politics, the range of state life expectancies widened from 5.4 to 7 years between 1980 and 2017. She hypothesized that two major factors have driven the widening disparities between liberal and conservative states: devolution (transferring federal oversight and fiscal responsibilities to the state level) and state preemption laws, which "prohibit or severely restrict local governments from legislating on certain issues," such as social distancing and mask regulations in Florida, Mississippi, and Georgia in 2020. Of course, millions of people immigrate from outside of the U.S. and move from one state to another every year, which complicates the picture: it's possible that healthier people move to certain states in order to enjoy the benefits of more livable environments or liberal policies, rather than those environments or policies creating better health. But all things considered, it's important to recognize that what my Georgetown family physician colleague Ranit Mishori calls "the political determinants of health" act powerfully at the state level, not only through national legislation and executive actions.