Overdiagnosis of melanoma
I learned two things from a recent journey into the healthcare system:
- Melanomas are overdiagnosed; and
- Always discuss cost with your physician.
Earlier this summer I shared that I had a small mole removed from my leg. I didn’t like the look of it, so I thought it prudent to have it checked out.
I had to wait almost a month for an answer, because it turned out to be an unusual pathology and had to be sent off for an expert opinion.
Turns out I had something called an “atypical Spitz nevus.”
My primary care provider advised me to see a dermatologist and have the area re-excised to make sure all the atypical cells were completely removed.
I liked the dermatologist very much, and as his wife was also a nurse we had a discussion about the healthcare industry as he worked on my leg.
He told me Spitz nevi are most common in children, and although benign used to be called “juvenile melanoma.”
They are much less common in adults my age, and because this particular one was labeled “atypical,” no one could accurately predict if it would morph into a true melanoma in the future.
He also said that about 30% of pathologists would probably have diagnosed my mole as a melanoma. There can be that much disagreement among specialists! Luckily, my first pathologist had enough doubt that she sent the specimen to another pathologist in San Francisco, a pathologist who apparently is “the guy” when it comes to discerning a benign lesion from a malignant one.
I can only be grateful that she took the extra time and care to do this.
Especially because a few days after my re-excision I read an article that said melanomas were being overdiagnosed.
Not only do pathologists disagree, but more and more lesions are being biopsied thanks to the use of technology like dermatoscopes and AI-based diagnosis, and the aggressive promotion of skin cancer screening (even though it’s not recommended for the general public).
Bottom line: Diagnosed with melanoma or another skin cancer? Consider a getting a second opinion from another dermatologist or pathologist.
Perverse incentive: Doctors get paid more to do more
My dermatologist brought up another reason more skin cancers are being diagnosed and treated: the perverse incentive in healthcare that doctors get paid more if they do more.
They are also less likely to get sued (that’s called “cover your a**” medicine).
At the Lown Institute conference last spring, a dermatologist spoke out about the changes in the specialty over the last two decades:
- Aggressive screening, even in the very elderly
- Increased use of the Mohs procedure, even on non-melanoma lesions
- Diagnostic drift, or calling more lesions melanomas even if they aren’t. It’s very telling that, like breast cancer, more melanomas are being diagnosed but the death rate has stayed basically the same.
I have a huge deductible ($7,000) so it’s important to me to spend my health care dollars wisely.
I mentioned cost to the dermatologist and he was very receptive to my concern. He, too, was upset at the trend of higher and higher deductibles.
Because my lesion (or the wound left from the scrape biopsy) was so small, he was fine with doing a much smaller excision than he normally would have done. He thought it would cost about $300 rather than $2,000, and he was confident it would remove any atypical cells around the margins.
He did caution it would probably leave a slightly larger scar, but I said I didn’t care and was fine with the lesser procedure.
(I was skeptical that he really knew the costs of these procedures, and I was actually charged $600 rather than $300. I wonder what the more complicated procedure would have cost??)
We talked about these perverse incentives that encourage doctors to do more and patients and insurance companies to pay more. Where will it end? Neither of us had an answer.
But I’m glad I spoke with him about cost as a factor.
Physicians often have a variety of options when deciding on a care plan. Don’t be afraid to bring up any information you think is relevant to helping him or her make those decisions. If you stay quiet, doctors will naturally make choices that benefit them financially and professionally.
Bottom line: Worried about costs? Before deciding on a care plan or treatment, discuss the cost and ask for your options.
This has been an eventful summer of health care for myself and my husband. We’re still waiting for all the medical bills related to his burst appendix to come in. I’m hoping there will be no surprises, but you never know.
At least I will have plenty of material for future posts 😉
Want more help navigating our healthcare system? Here are some great books!