No One Should Die of Melanoma: Time for This Vision to Be Realized?

In 1985, Ackerman said: “With big enough hopes and serious enough convictions, no human being need die of malignant melanoma” [1]. During the previous years, he had introduced the concept of “melanoma in situ” and proposed that melanoma can be histopathologically diagnosed when still confined within the epidermis. Based on this, he hypothesized that all melanomas could be diagnosed before invading the dermis and acquiring metastatic potential and, therefore, melanoma mortality would be eliminated. It seems, however, that Ackerman was a bit ahead of his time. Even if melanoma could be histopathologically diagnosed before invading the dermis, how could such early melanomas be clinically recognized and excised? In that era, many melanomas were diagnosed only when ulcerating or bleeding. The ABCD clinical rule, which was introduced in the mid 80s, significantly helped clinicians to recognize melanoma earlier and patients to seek medical advice earlier. But even the ABCD rule is not usually sufficient to uncover melanoma in situ. This is because when the natural asymmetry of melanoma becomes visible to the naked eye, it is quite likely that the tumor has already invaded the dermis. In the years that followed, a new diagnostic revolution occurred in the field of skin cancer: dermoscopy. The investigation of the sub-macroscopic morphology enabled the recognition of melanomas that did not have macroscopically detectable criteria. With the improvement of knowledge of dermoscopic morphology, thinner and thinner melanomas became recognizable. Therefore, approximately 30 years after Ackerman expressed his vision, it seems that clinicians are now equipped with the necessary tools and knowledge to realize it. Today, melanoma can finally be recognized when still in situ or minimally invasive and, as such, people might stop dying from it. However, the harsh reality is that, although the incidence of thin melanoma has dramatically increased over the last decades, the incidence and mortality rates of thick melanoma seem to remain stable. What are the main barriers to Ackerman’s vision becoming reality? Whose fault is it that people still die of melanoma, and what can be done? No One Should Die of Melanoma: Time for This Vision to Be Realized?