Increasing melanoma incidence with unchanged mortality: more sunshine, better treatment, increased diagnostic activity, overdiagnosis or lowered diagnostic threshold?

ABSTRACT

BACKGROUND: Increasing melanoma incidence with less increasing mortality is observed in several countries. This discrepancy is not well understood. OBJECTIVES: In this study, our aim was to discuss factors [ultraviolet radiation (UVR) exposure, melanoma treatment, diagnostic activity, overdiagnosis, pathologists' diagnostic threshold and clinicians' propensity to remove suspect skin lesions] that might influence melanoma incidence and mortality in Denmark. METHODS: This was a register study with the number of melanocyte-related lesions and melanoma mortality based on comprehensive national pathology and mortality databases for the period 1999-2019. We investigated melanocyte-related diagnoses and mortality in a population of 5.5 million with a national healthcare system. Age-adjusted melanoma mortality and age-adjusted incidence of benign naevi, atypical lesion, or melanoma in situ and of invasive melanoma were computed for data analysis. RESULTS: In total, 1 434 798 biopsies were taken from 704 682 individuals (65% female). The mean age at biopsy was 39.8 years in males and 37.6 in females. In males and females, the incidence of invasive melanoma increased by 87% during the period 1999-2011. During the subsequent period it increased by 9% in males but remained unchanged in females. The incidence of melanoma in situ increased by 476% in males and 357% in females during the study period, while the increases for atypical melanocytic lesions were 1928% and 1686%, respectively. Biopsy rates increased by 153% in males and 118% in females from 1999 through 2011 but fell by 20% in males and 22% in females during the subsequent period. Mortality varied slightly from year to year without any significant time trend for males or females. We identified no evidence of increased UVR exposure over the latest 30 years in Denmark. Immunotherapy of advanced melanoma was introduced in Denmark in 2010 and came into general use in 2014. CONCLUSIONS: Comprehensive national data demonstrate increasing melanoma incidence correlated with increasing biopsy rates, but with no change in mortality. Previously suggested explanations for such a trend are a lowered threshold of melanoma diagnosis among pathologists, increased diagnostic activity in the presence of overdiagnosis and improved melanoma treatment. Because the study is observational and we have more explanatory factors than outcomes, the findings do not warrant conclusions about causal relationships.

Rates of melanoma have been increasing across several countries, with less increasing mortality. However, information is lacking surrounding which factors might be influencing this. This study aimed to discuss factors (e.g. ultraviolet radiation exposure, melanoma treatment, diagnostic activity, overdiagnosis, pathologists' diagnostic threshold and clinicians' propensity to remove suspect skin lesions) that might influence melanoma incidence and mortality in Denmark. The data demonstrated that increasing melanoma incidence was related to increasing biopsy rates, but with no change in mortality. Our findings suggest increased diagnostic activity, particularly in population groups with the lowest melanoma risk. The rapid increase in atypical/in situ in relation to melanoma could be associated with changes in pathologists' threshold for specifying these diagnoses. It is conceivable that the threshold for atypical/in situ as well as for melanoma have declined because of increased melanoma awareness. Overall, the present study indicates that changes in melanoma incidence may be explained by the interaction among sun exposure, the propensity to remove suspected melanoma lesions, lowered diagnostic thresholds and overdiagnosis.