People like binaries and bright lines. Clear boundaries and distinctions make decisions easier. One desired binary distinction that comes into play in dermatology practice daily is the cancer/not cancer paradigm. Anatomic pathology is a robust tool that is central to making this distinction, but there is a growing recognition that there is often insufficient information on the glass slide to make unambiguous cancer/not cancer distinctions. This was highlighted in a recent editorial by Dr David Elder (1). This is not unique to skin malignancies, but it does create a unique challenge in dermatopathology because of the sheer volume of specimens and the low but real risk of bad outcomes in a small subset of pigmented lesions.
Many skin biopsies are conducted to rule out (or in) a diagnosis of skin cancer. In a substantial minority, the specific diagnostic question raised is whether a particular skin lesion could represent a melanoma. Recent work has highlighted that histological examination of pigmented lesions, especially small lesions, may yield tremendous diagnostic variability, ranging from frankly malignant to completely benign (2). Within the dermatopathology community, there has been an effort to address this ambiguity and recognize that it is often not possible to assign an unambiguous malignant or benign designation (3). To that end, there is some interest to utilize standard terminology that can acknowledge diagnostic uncertainty (4). However, this interest, reported in surveys, has not appeared to translate into any widespread and meaningful use in broader clinical communities.
There are at least 2 major barriers to adoption. First, despite any theoretical ameliorative effect on medical liability through formally acknowledging uncertainty of some pigmented lesions with new terminology, fear persists that expression of such uncertainty in specific cases where patients go on to be harmed by tumors that are biologically aggressive will result in claims against clinicians and pathologists who just “should have known” and acted differently. Defensive medicine and overdiagnosis will persist in the absence of tort reform.
A second barrier to widespread change of terminology in practice is the cancer/not cancer paradigm is hard wired into the AMA Current Procedural Terminology billing codes. Any changes in the terminology used by dermatopathologists that fall outside the cancer/not cancer paradigm will have major impact on billing and have substantial fiscal impact. All other things being equal, removal of tumors classified as cancer always pays more than ones classified as benign. Most if not all specimens previously classified as melanoma in situ would be reclassified as dysplastic precursor lesions. If not malignant, the billing code choices for excisions available fall under benign removal/destruction codes, which are reimbursed at substantial discount off malignancy codes, if reimbursed at all. This means that the chance of terminology change happening approaches zero. Few if any dermatopathologists without a captive client base could adopt this diagnostic framework without the risk of losing their client base.
Funding
No funding was used for this study.
Notes
Role of the funder: Not applicable.
Disclosures: None.
Author contributions: Robert Swerlick—conceptualization, writing—original draft, writing—review and editing.
Data availability
No new data were generated or analyzed for this correspondence.
References
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Associated Data
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Data Availability Statement
No new data were generated or analyzed for this correspondence.