[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I have the great honor and pleasure of speaking with Dr. Adewole Adamson. He goes by Ade. Dr. Ade Adamson is a dermatologist, researcher and advocate. He is currently an Assistant Professor of Internal Medicine in the Division of Dermatology and Director of the Pigmented Lesion Clinic at Dell Medical School at the University of Texas at Austin. He attended Morehouse College and then earned his MD with Honors at Harvard Medical School where he also participated in the Health Sciences and Technology Program with the Massachusetts Institute of Technology. He actively studies skin cancer, evidence based medicine, and health policy. He is passionate about how effectively and efficiently care is delivered to patients with skin cancer. You can learn more at adeadamson.com. That link will be in the show notes, and you can also follow him on Twitter @AdeAdamson. And that link will also be in the show notes. So welcome to Ade.
[00:00:56] Ade Adamson: Hey, thanks so much for having me. I get to finally meet you after reading some of the textbooks that you've authored, especially when I was a resident learning dermatopathology.
[00:01:05] Christine Ko: Thank you. Hopefully they helped you.
[00:01:08] Ade Adamson: Yeah. And as somebody who's into melanoma and the pathology related to melanoma, you definitely were involved in that growth and progression that I've made in thinking about the disease.
[00:01:18] Christine Ko: Oh, thank you. Thank you. That means a lot. I think sometimes in academics it's hard to really know if what you're doing is having any sort of impact, so that's very nice.
[00:01:31] Ade Adamson: Sometimes it's good, sometimes it's bad. Because if you do something controversial, some people will give you a lot of feedback, and sometimes it's not pretty. I've had that experience and then I've had the opposite of people being very supportive of some of the stuff that I have written.
[00:01:46] Christine Ko: Yes. Do you want to share one or the other? Either a supportive story or a not so supportive story?
[00:01:51] Ade Adamson: Let's hear the not supportive story right now.
[00:01:54] Christine Ko: Sure.
[00:01:54] Ade Adamson: Because I feel like that is what has given me a little bit more notoriety. And that's related to melanoma overdiagnosis. Diagnosis of melanomas that if left unbiopsied or untouched wouldn't have progressed or caused mortality or morbidity to the patient in which it was discovered. The way I got in this kind of path actually started when I was a resident at the North Texas VA. I was a resident at the University of Texas Southwestern, and the VA there is one of the largest and biggest dermatology VAs in the country. I think the only one that's of comparable size is at the University of Miami.
[00:02:35] There are a lot of skin cancers. There's so many that the department had to hire physician assistants to help do a lot of the screenings. But one thing that was interesting there is that if a physician assistant biopsied a melanoma, that was then reported to the residents who then had to call and follow up with the patients.
[00:02:57] And when I was a senior resident there, I kind of discovered that most of the melanoma in situs in particular were being diagnosed by the physician assistant. And I just wondered, Are we doing a disservice to our patients on the MD side or in our screenings? Are we not picking up enough? Are we not biopsying enough?
[00:03:19] That's what led me down the rabbit hole of the melanoma epidemic. And the more I read, the more I thought about it, the more I came to the conclusion that a lot of this is an epidemic of diagnosis and not necessarily an epidemic of disease.
[00:03:34] That is influenced by how hard we look for what we call cancer. And I co-authored an article in the New England Journal about it this last year. And I received a lot of pushback particularly from fellow dermatologists. I even had letters sent to my Dean here.
[00:03:53] Christine Ko: Oh, wow.
[00:03:54] Ade Adamson: Quietly, I also had a lot of support from a lot of people. I have to call out Bob Swerlick who's Chairman at Emory, who was one of the first to do at least in the United States.
[00:04:02] Christine Ko: Yes.
[00:04:03] Ade Adamson: And so that's one line of research that I've been doing that has gotten me some notoriety.
[00:04:07] Christine Ko: Can I ask how you feel about that?
[00:04:09] Ade Adamson: I'm conflicted. Before that paper was published, I was somewhat scared, right? Because I am going at the heart of one of the things that make dermatologists feel like we're saving lives. Because a lot of disorders we treat aren't necessarily fatal. They do impact quality of life, which is really important, don't get me wrong. But this is one area where it's a disease that's relatively common, and it potentially can kill someone. And so to question the seriousness of the increase in diagnosis of melanoma really can make dermatologists feel attacked. And I can understand that.
[00:04:50] But I would also say that it also feels good when people engage with your ideas. And think about them. And subsequent to this manuscript there have been more and more publications now throughout the literature across the world looking at this problem. That to me is deeply fulfilling, as a researcher, that people are engaging with ideas that I wrote down on a piece of paper.
[00:05:16] Christine Ko: Yes, the power of the pen.
[00:05:18] Ade Adamson: Yeah, I agree a hundred percent.
[00:05:20] Christine Ko: Is there a way that you stay strong in your convictions when you do get a lot of pushback or non-support?
[00:05:27] Ade Adamson: I do more work and I push the issue even further. Now that I've thought about this so much for so many years, written so many things about it, had to respond to reviewer feedback over and over again, given dozens of talks to audiences around the world.... this might sound maybe too confident. I believe I'm right. I think I'm right. Okay. And it's almost a little more that. I know I'm right. And that's why I keep writing and saying stuff about it and giving you evidence that this is an issue.
[00:06:00] Overdiagnosis is happening. It is a problem that is not small or trivial. We're calling things cancer now that we wouldn't have 10 years ago. The only question to me that's up for debate is whether we should do something about it. What is this actually doing to patients?
[00:06:19] Christine Ko: Yeah. I will go on the record here as saying that you're preaching to the choir in a sense here, just with me at least, because I do think that melanoma, also squamous cell carcinoma, are overdiagnosed. I am part of the problem, even, I would say, I don't mean to be a hypocrite.
[00:06:35] Ade Adamson: I am too. I'm a director of a pigmented lesion clinic, and I biopsy patients, and I diagnose melanoma in situ too routinely. So let that be on the record as well.
[00:06:45] Christine Ko: I think the hard thing for me as a dermatopathologist, as someone who is making these diagnoses, standing at the microscope, is that it is subjective, unfortunately, and there is no objective test right now that we can use to improve or really prove that I'm right and you're wrong. Both of us actually right here are in agreement that there's overdiagnosis, but for a given patient and a given patient's biopsy, how to know? If there's two right in front of us and we had a crystal ball and was like one of these is not melanoma and one of them is, I would say that there's nothing objective right now. And we just mainly right now still rely on expert opinion, " "expert" in quotes. Dr. X says it's a melanoma, and it is, and honestly, sometimes that's my opinion. It's Oh, Christine read the slide, and she says it is.
[00:07:41] Ade Adamson: You're describing some of my further experience in residency at UT Southwestern where we sat at the scope for consensus conference and before my eyes, the diagnosis moved from benign to malignant, back to benign. And I was like, this is subjective here. There's no correct answer here. We're dealing with something that is potentially life altering. Is this cancer or not cancer? This can affect a lot in a patient's life.
[00:08:05] What you're asking dermatopathologists to do is really make a risk prediction.
[00:08:10] Christine Ko: Yes.
[00:08:10] Ade Adamson: To look at a static slide, to make a prediction on a dynamic process. And that dynamic process is the development of an invasive tumor that's going to kill somebody just based on one image. Or a couple cuts. At one point in time. That is really hard to do. And you're only given negative feedback, i.e. If you "miss a diagnosis", then you'll get slapped on the wrist or worse. You're not told negative things if you upgrade and diagnose something as a melanoma in situ or a melanoma.
[00:08:46] Christine Ko: I thank you for trying to exonerate to some degree dermatopathologists. You touched on feedback and that we can't really improve unless we get the right feedback in anything, right? Part of the problem, at least for me, is I don't get enough feedback on what's really happening with the patient, with an individual patient, when the diagnosis goes out as cancer or when it goes out as not cancer. You're right, we get mainly the misses, right? The negative feedback in the sense that this, now the patient has a metastasis, it's spread. And then, so we'll go back sometimes and look at the different biopsies that a patient has had and realize, oh, sometimes we can't find it.
[00:09:24] There's an unknown source of the spread of cancer, but sometimes you'll say, Oh, but look, there was this, spot and this was called benign. It was called nevus, not cancer. And looking back at it, yeah, maybe this is worse. So sometimes you can find things like that. But we never go back and look at people who do well, cause it's Yay! They had a bad cancer and they're doing really well. And maybe that cancer diagnosis was correct, but maybe it was never cancer to begin with and that's why they're doing well. And we never see those.
[00:09:53] Ade Adamson: And everybody gets a little bit of money in their pocket too, you can't remove that from the equation. I don't think it dominates it. I think that doctors, whether it's pathologists or dermatologists, fundamentally are altruistic and they want to do right. They want to find cancer early, they want to cure cancer. You pair that with a little financial incentive, and it's a lot harder to step back from that as well. But yeah, and we wrote about that in that New England Journal article as well.
[00:10:22] Christine Ko: How do you think we can, as doctors, dermatologists, but also as patients, try to fix this issue of overdiagnosis?
[00:10:33] Ade Adamson: Whew. It's really hard, but this is another reason why I like to study this issue because it is hard, weighty, meaty, and you can do this over a whole career. So, to me, what I think needs to happen is there needs to be a randomized control trial of melanoma. I think that is the only way we can really adjudicate whether it works or doesn't work.
[00:10:59] Some say that it's just too hard to do. The trial would just have to be so big and so expensive, take so much time. But if that's the case, if it saves so much time, so big, so expensive, you have to ask yourself, is it a worthwhile endeavor to do anyway?
[00:11:15] And we're using resources now, right? Doing our kind of opportunistic ad hoc screening that might be wasteful and might be harming patients because patients that don't have that we aren't seeing for screening because our focus is on low value care. And as dermatologists, we are very rare too, so we need to make sure that our focus is in areas that provide the highest value.
[00:11:39] Christine Ko: There really aren't very many of us dermatologists and so we need to spend our time wisely, especially as everyone's limited by time. You've touched on so many things. In terms of trying to get at the problem of overdiagnosis, I think I know what you're doing. You're writing about it, you're researching it, you're studying it, you're putting important information out there and really getting, as you mentioned earlier, other people to study this problem as well and get at it. So that's wonderful. Is there something else that I can do, a patient can do?
[00:12:11] Ade Adamson: More people need to talk about it. I'm not quite sure what the best way to talk about it with patients is yet, actually, this is an area of study that I've a grant to study to figure out how much do patients understand about it, how can we message around it. I'm borrowing a lot from the prostate cancer and breast cancer literature where overdiagnosis has been an issue that has been discussed and attempts have been made to tackle it for many years now.
[00:12:37] I would say that for patients and their physicians, they should discuss the pros and the cons of them continuing screening.
[00:12:50] I think just seeing it as an unparalleled good with no downside is not giving patients the accurate information. I think we have enough information, at a population level especially, and I would argue at a patient level as well. And I have some data, forthcoming on that and others have looked at this at a patient level screening and overdiagnosis does present harms. Talking about potential harms of patients coming in every single year is something that I think patients deserve to discuss.
[00:13:24] I always ask my residents this, what age should we start screening and stop screening? What is a time interval? Is there a Fitzpatrick skin type or racial or ethnic breakdown that we should have? Et cetera, et cetera. Then I'll ask them, What about colon cancer? What about breast? What about prostate? And they'll be able to say, Oh yeah, you start at 40 or 50, you do every other year.
[00:13:46] You stop at 75, blah, blah, blah, blah, blah. And I'm like, You see the difference there? That's important. And we haven't even adjudicated that in dermatology. Makes no sense to just be like everyone over 18, just all the way to 100, just screen every year. We wouldn't even have enough dermatologists to do that. It defies logic, honestly.
[00:14:06] Do you have any final thoughts?
[00:14:08] I guess a couple. One is that I care about patients just as much as dermatologists who also want to screen people every single year. We're both after the same thing. Trying to maximize the health of our patients. And I think that it's worthwhile in engaging in some of these conversations because they're important in informing what we all care about, right? And that's maximizing quality and health equity for everyone.
[00:14:36] And then finally, I would say that from writing about this, so many years talking about it, tweeting about it, my goal is to get the minds of the future. Try to convince the young people that these ideas are worthwhile. Before they've been entrenched in some of this ideology and faith and hope that's not rooted in evidence-based medicine. And, maybe, 15 years from now, 20 years from now my ideas will look like just pedestrian.
[00:15:07] They won't even be significant. Everybody will be like, of course. Of course, Ade. This is apparent. Why did anyone think it was controversial at all? That's what my hope is. It just becomes part of the conversation. Even so much so detached from my name, it's just the idea is just pervasive. That's what I'm hopeful for in the future.
[00:15:25] Christine Ko: That's awesome. I love that. Thank you for spending the time with me. I really appreciate it.
[00:15:31] Ade Adamson: Appreciate it, too.