Advanced imaging techniques are increasingly being explored to improve early melanoma detection in high-risk patients. A recently published randomized clinical trial and cost-effectiveness analysis evaluated the impact of three-dimensional (3D) total-body photography (TBP) combined with sequential digital dermoscopy imaging (SDDI) without artificial intelligence (AI) for detecting melanoma in high-risk individuals, which found that while the approach led to significantly higher excision rates, it did not demonstrate a clear advantage in melanoma detection and was not cost-effective.
The randomized study, conducted by H. Peter Soyer, MD, of Clinical Research Facility, Princess Alexandra Hospital, Brisbane, Australia, and colleagues, published in JAMA Dermatology, analyzed the impact of in-person 3D TBP and SDDI via teledermatology without AI on melanoma detection rates, excision rates, and overall cost-effectiveness compared with standard skin examinations with dermoscopy in high-risk individuals.
The study results, along with the accompanying editorial by Laura K. Ferris, MD, PhD, and Adewole S. Adamson, MD, MPP, provided further insights into the strengths and limitations of the findings.
Increased Excision Rates, Lower Melanoma Detection
The study included 314 high-risk adults (mean age, 51.6 years; 62% women) in Brisbane, Australia, over a 3.5-year period from April 2018 to October 2021. High risk was categorized as either a previous diagnosis of melanoma in 302 participants (96%) or multiple, large, atypical nevi in 12 participants (4%) with a strong family history of melanoma. Participants were randomized to either usual care (standard skin examinations with dermoscopy) or usual care supplemented with 3D TBP-SDDI every 6 months for 2 years.
The study found that the intervention group underwent significantly more excisions: An average of 5.73 lesions per person compared with 3.99 in the control group (P = .02). However, fewer melanomas were detected in the intervention group than in the control group (24 vs 43 cases, respectively), leading to a lower melanoma incidence rate of 2.03 per 10,000 person-days compared with 3.62 in the control group (P = .02).
Despite the increased surveillance, the study found no statistically significant reduction in the risk for subsequent melanoma in the intervention group compared with the control group (hazard ratio, 0.63; P = .13). At 1-year follow-up, the intervention group exhibited higher rates of keratinocyte cancer (KC) excisions and benign lesion removals, with an average of 0.86 KC excisions per person compared with 0.42 KC excisions per person in the control group.
The authors suggested that heightened clinician attention to subtle skin changes detected through TBP-SDDI may have contributed to an increase in excisions and possible overdiagnosis. The relatively low number of melanomas identified in the intervention group could be attributed to random variation between the groups or increased sensitivity leading to the removal of precursor lesions before they progress into melanoma, they noted.
“These findings indicate that careful implementation is required to offset increased biopsies of benign lesions in patients at high risk,” the authors wrote, “and further trials are needed in which 3D total-body photography is integrated with teledermatology services or compared with usual care instead of being offered as an add-on service.”
Cost-Effectiveness Concerns
The parallel cost-effectiveness analysis conducted by Soyer along with Daniel Lindsay PhD and colleagues, also published in JAMA Dermatology, evaluated the financial impact of 3D TBP-SDDI compared with standard care using data from their study. Over a 24-month period, the analysis found that average per-person costs were $1708 in the intervention group vs $763 in the control group, resulting in an additional cost of $945. Notably, quality-adjusted life-years (QALYs) were identical between the groups (1.84 each), indicating no improvement in survival or quality of life.
From a health system perspective, the authors found the intervention increased government healthcare costs by 2.8-fold, though patient out-of-pocket expenses remained similar. Sensitivity analyses confirmed that even under different cost assumptions, the intervention was not cost-effective at the commonly accepted Australian willingness-to-pay threshold of $31,500 per QALY gained. The likelihood that 3D TBP-SDDI was both more expensive and less effective than usual care was estimated at 95.4%.
“The results of the cost-effectiveness analysis suggest that, under the specific conditions tested, a 3D TBP-SDDI by junior clinicians with teledermatologist review intervention over an initial 2-year surveillance window was not cost-effective,” the authors concluded. “There may be other benefits of 3D TBP-SDDI once AI clinician support systems have been integrated.”
Editorial Perspective: Balancing Promise and Pitfalls
In an accompanying editorial, Ferris, of the Department of Dermatology, The University of North Carolina at Chapel Hill, and Adamson, of the Division of Dermatology, Dell Medical School, The University of Texas at Austin, contextualized these findings, acknowledging the long-standing role of TBP in dermatology but cautioning against overdiagnosis and unnecessary excisions. They highlighted the difficulty in designing randomized controlled trials for skin cancer diagnostics, noting that the inability to blind participants and physicians, as well as subjective biopsy decisions, complicates study interpretation.
One major limitation cited was the fact that the clinicians performing the biopsies did not have direct access to longitudinal 3D TBP images, which may have reduced the potential benefits of the technology.
Their editorial also emphasized the importance of tracking lesion changes over time to better distinguish between benign and malignant growths. “Quantifying change over time may both reduce removal of stable, innocuous lesions, as has been shown in other studies of TBP, and facilitate more rapid and objective identification of growing lesions that are most likely to cause harm and warrant a biopsy,” the authors noted.
Asked to comment on the results, Jennifer A. Stein, MD, PhD, a melanoma specialist, and professor of dermatology, New York University, New York City, echoed similar concerns about the challenges of distinguishing early melanomas from benign atypical moles, particularly in high-risk patients. “It can be difficult to distinguish an early melanoma from a benign, but atypical mole in patients who have lots of moles,” she told Medscape Medical News.
“One technique we commonly use is dermoscopy, which allows us to look deeper into the skin to detect features of melanoma that distinguish them from harmless moles. We can also take dermoscopic photos to follow moles over time for change.” She added that while dermoscopy requires specialized training, it is a quick and painless tool that can aid in reducing unnecessary biopsies.
Implications for Clinical Practice, Future Directions
The study by Soyer and colleagues contributes to growing research examining the role of advanced imaging technologies in skin cancer surveillance. A recent retrospective study conducted by Jordan Phillipps, MD, and colleagues at Mayo Clinic in Jacksonville, Florida, and presented at the American Academy of Dermatology (AAD) 2025 Annual Meeting, suggested that 3D TBP may actually improve biopsy decision-making by enhancing malignancy detection.
Notably, Phillipps and his team found that 3D TBP led to a 35% reduction in biopsies per patient encounter, particularly by decreasing unnecessary removal of benign and premalignant lesions such as actinic keratoses. However, the study also highlighted key limitations, including questions about cost-effectiveness, generalizability, and the need for direct comparisons with clinician-performed skin screenings, which remain the current gold standard.
While these findings reinforce the potential benefits of tracking lesion changes over time, further research is needed to determine how best to integrate automated imaging into routine dermatologic practice. According to Soyer and his colleagues, while 3D TBP has the potential to enhance early detection, its increased excision rates without a clear reduction in melanoma incidence — combined with high costs — suggest that its widespread implementation may not yet be justified.
This study was supported by grants from the Australia National Health and Medical Research Council, Queensland Genomics, Queensland Government, Princess Alexandra Research Foundation, and the Medical Research Future Fund Rapid Applied Research Translational Program. Soyer reported equity in e-derm-consult GmbH and MoleMap; receiving consulting fees from Canfield Scientific Medical; and a patent licensed to Trajan Medical and Scientific via Uniquest, all outside the submitted work. Another author reported receiving travel support to attend the European Association of Dermato-Oncology meetings, and consulting fees from the Melanoma Network of New Zealand, outside the submitted study; and another author reported new employment by Canfield after the work was submitted. No other disclosures were reported. Ferris disclosed receiving personal fees from DermTech and nonfinancial support from DermaSensor, outside the submitted work. Adamson reported receiving support from the Robert Wood Johnson Foundation, the American Cancer Society, and Meredith’s Mission for Melanoma during the conduct of this work. Stein reported no relevant financial relationships.
Jennifer Fisher, MMSc, PA-C is a Connecticut-based dermatology PA and freelance medical writer.