THE KEY TO HEALTH CARE REFORM IS REDUCING CONSUMPTION:

ABOUT A DECADE AGO, when he was a first-year dermatology resident, Adewole Adamson learned that "exploding" rates of melanoma were a pressing problem. That was -- and still is -- the official position of the American Academy of Dermatology. Since the mid-1970s, the incidence rate of melanoma, a potentially deadly cancer, has skyrocketed sixfold; once relatively rare, melanoma is now one of the most commonly diagnosed cancers in the U.S., according to the American Cancer Society.

A few years later during a research fellowship, Adamson dug into what was behind the epidemic. He was surprised to find that diagnosing more cancers wasn't saving more lives. Mortality remained "stone-cold flat" for decades, said Adamson, who is now an assistant professor at the University of Texas at Austin's Dell Medical School. Only recently have melanoma deaths declined, thanks to new treatments for advanced cases. Furthermore, evidence suggested that the culprit most commonly blamed for skin cancer -- exposure to ultraviolet (UV) radiation from the sun or tanning beds -- couldn't account for the dramatic rise in melanoma diagnoses.

Adamson and collaborator H. Gilbert Welch, a senior investigator in the Center for Surgery and Public Health at Brigham and Women's Hospital in Boston, tried for a year without success to publish a paper showing that UV exposure wasn't the primary driver of the epidemic. Reviewers didn't dispute the science, but they expressed concern that the findings might deter people from protecting themselves against the sun.

To overcome deeply ingrained notions about UV exposure and melanoma, Adamson said they needed to tell a fuller story. If not UV, then what is responsible for pushing melanoma rates ever higher? In an analysis published in the New England Journal of Medicine earlier this month, Adamson, Welch, and Benjamin Mazer, a pathologist at Johns Hopkins Hospital, make the case that medical care is to blame. By screening more people, doing more biopsies, and classifying more ambiguous lesions as cancer, health care providers have been "overdiagnosing" melanoma, flagging too many harmless skin spots that would have never proved harmful.

Overdiagnosis is a well-established -- and many would say unavoidable -- consequence of screening the general population for disease. The problem is particularly pronounced with cancer, where increased surveillance and new diagnostic tools allow physicians to detect small irregularities that might not be destined to spread. In a 2019 analysis of four decades' worth of cancer statistics, Welch laid out how, for certain cancers, screening has driven up case numbers without reducing deaths. As with melanoma, for example, diagnoses of thyroid and kidney cancer have risen dramatically, while people are dying of those diseases at much the same rate as in 1975.

The pandemic pressed pause on many health screenings, providing an opportunity, I noted in a recent column, to look more closely at when routine checks help and when they are more likely to lead to unnecessary follow-up tests and treatments.

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