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In moving the second reading of the Sunbeds (Regulation) Bill,
Baroness Finley used the powerful argument, recorded by Hansard and quoted
in your report (Clare Dyer, BMJ 17 April, p 831), that “malignant melanoma
is the most common cancer in the 15 to 34 age group”. Fortunately, this
frightening “fact” is incorrect; but unfortunately, it may well have
helped the passage of an irrational and misguided piece of legislation
which, as your report notes, only “narrowly scraped through”. Even if the
Baroness Finley had said, more correctly, “...most common cancer of the
skin”, that would have simply replaced a gross error with a gross
irrelevance – since the other skin cancers (mostly basal and squamous, and
benign despite their name and histological appearance) do not occur before
middle age.
Baroness Findlay used data from a meta-analysis of reported cases of
melanoma, but the problem with this evidence, like most other evidence
associating UV with melanoma incidence, is that it relies on a
biologically blind epidemiology that failed to question reported
diagnosis, and missed the evidence that the reported increase in melanoma
is spurious – diagnostic error renaming simple, benign, “borderline”
lesions as malignant. Reliance on subjective histological appearance,
without validation by clinical outcome has allowed this, with the
diagnostic shift prompted by litigation1, the spurious diagnoses of error
amplification by sceening2, and the false association of melanoma by UV by
histological confusion with the benign increase in activity produced in
naevi by UV.
Unfortunately, the simple counting of numbers, without the necessary
biological reservations about their meaning, allowed epidemiologists to
miss the fact that the great increase in “melanoma” is all due to stage 1,
“borderline” lesions1, which have no mortality because they never were
malignant. Epidemiologists are good at numbers, but need biologists to
tell them which are the right ones to count. Until more absolute
diagnostic criteria are discovered by research graft and flair, the only
reliable end point is death: melanoma epidemiology could earn itself some
redemption if it turned to studying the associations of those who have
died of the disease, instead of constantly re-agitating the mountain of
dubious diagnoses on which the melanoma muddle is based. The aetiology of
melanoma remains wide open to serious biological research, but to start on
this, we will have to extricate ourselves from the sun-blinded alleyway up
which naïve number manipulation has taken us.
Meanwhile, Baroness Finlay’s reported statement needs urgent
correction; and even if it is now be too late to undo any effect it may
have had in easing the passage of an inappropriate piece of legislation,
I’m sure those who supported it will want to know the strength of their
argument.
Sam Shuster, Emeritus Professor of Dermatology, University of
Newcastle Upon Tyne
UV & Melanoma; getting the facts right
In moving the second reading of the Sunbeds (Regulation) Bill,
Baroness Finley used the powerful argument, recorded by Hansard and quoted
in your report (Clare Dyer, BMJ 17 April, p 831), that “malignant melanoma
is the most common cancer in the 15 to 34 age group”. Fortunately, this
frightening “fact” is incorrect; but unfortunately, it may well have
helped the passage of an irrational and misguided piece of legislation
which, as your report notes, only “narrowly scraped through”. Even if the
Baroness Finley had said, more correctly, “...most common cancer of the
skin”, that would have simply replaced a gross error with a gross
irrelevance – since the other skin cancers (mostly basal and squamous, and
benign despite their name and histological appearance) do not occur before
middle age.
Baroness Findlay used data from a meta-analysis of reported cases of
melanoma, but the problem with this evidence, like most other evidence
associating UV with melanoma incidence, is that it relies on a
biologically blind epidemiology that failed to question reported
diagnosis, and missed the evidence that the reported increase in melanoma
is spurious – diagnostic error renaming simple, benign, “borderline”
lesions as malignant. Reliance on subjective histological appearance,
without validation by clinical outcome has allowed this, with the
diagnostic shift prompted by litigation1, the spurious diagnoses of error
amplification by sceening2, and the false association of melanoma by UV by
histological confusion with the benign increase in activity produced in
naevi by UV.
Unfortunately, the simple counting of numbers, without the necessary
biological reservations about their meaning, allowed epidemiologists to
miss the fact that the great increase in “melanoma” is all due to stage 1,
“borderline” lesions1, which have no mortality because they never were
malignant. Epidemiologists are good at numbers, but need biologists to
tell them which are the right ones to count. Until more absolute
diagnostic criteria are discovered by research graft and flair, the only
reliable end point is death: melanoma epidemiology could earn itself some
redemption if it turned to studying the associations of those who have
died of the disease, instead of constantly re-agitating the mountain of
dubious diagnoses on which the melanoma muddle is based. The aetiology of
melanoma remains wide open to serious biological research, but to start on
this, we will have to extricate ourselves from the sun-blinded alleyway up
which naïve number manipulation has taken us.
Meanwhile, Baroness Finlay’s reported statement needs urgent
correction; and even if it is now be too late to undo any effect it may
have had in easing the passage of an inappropriate piece of legislation,
I’m sure those who supported it will want to know the strength of their
argument.
Sam Shuster, Emeritus Professor of Dermatology, University of
Newcastle Upon Tyne
sam@shuster.eclipse.co.uk
Woodbridge, IP12 IFE
1 Melanoma epidemic: a midsummer night’s dream? N.J. Levell, C.C.
Beattie, S. Shuster and D.C. Greenberg Br J Dermatol 2009; 161:630–4
2 Malignant melanoma: how error amplification by screening creates
spurious disease
S. Shuster. Br J Dermatol 2009; 161: 977-9
Competing interests:
None declared
Competing interests: No competing interests