Welcome to this month's journal review — we're covering the July 2026 issue of the Journal of the American Academy of Dermatology, and I've got four pieces for you today: a nationwide medicolegal analysis of skin cancer litigation, a brief report on HIV-related exclusion criteria in cutaneous oncology trials, a National Cancer Database analysis of penile basaloid squamous cell carcinoma, and an ethics column on skin cancer screening in blind and visually impaired patients. Let's get into it.

First up is a nationwide analysis of skin cancer malpractice precedents in the United States, spanning 1930 through 2025. This is a retrospective legal-database review, essentially applying epidemiologic methods to case law rather than patient charts. The clinical problem here is familiar to all of us — skin cancer is common, litigation touches every specialty that manages it, and a 2018 study had already flagged dermatology as the most frequently implicated specialty in keratinocyte carcinoma suits. What hadn't been well characterized was the broader landscape across melanoma and keratinocyte carcinomas together, and specifically how melanoma's aggressive, potentially lethal behavior shapes medicolegal risk differently.

Methodologically, the authors mined LexisNexis using Boolean search terms tied to skin cancer, physician identifiers, and legal concepts, capturing any case where a physician was named as a defendant in a dispute over diagnosis or management of a cutaneous malignancy. This is really the only feasible design for this question — you can't prospectively study malpractice risk, and most claims never generate a public record anyway, so a legal-database review is the accepted methodology in this space, mirroring prior keratinocyte carcinoma and Canadian analyses cited in the paper.

They landed on 188 unique cases. Melanoma dominated, accounting for about half of all cases, with squamous cell carcinoma making up roughly one in five, and basal cell carcinoma around one in seven. This matters clinically — nearly three in ten cases involved a documented death, and close to four in ten involved metastatic disease, underscoring that melanoma's biology is driving the litigation burden here, not just its incidence. Geographically, New York and California led, together accounting for close to three in ten cases, which likely reflects population density and litigation patterns as much as anything clinical.

By setting, roughly six in ten cases arose from private practice, about one in four from prisons or correctional health systems, and the remainder from public hospitals. That correctional-health finding is worth sitting with — it's a distinct and recurring pattern of delayed diagnosis tied to limited access, with patients presenting with advanced melanoma or squamous cell carcinoma by the time care was rendered. On defendants, family physicians topped the list at about one in four, dermatologists including Mohs surgeons at about one in five, and pathologists or dermatopathologists close behind at roughly one in seven. General and plastic surgeons and internists made up smaller shares.

The leading allegation, at nearly four in ten cases, was failure or delay in diagnosis, followed by treatment or management errors at about one in four, then misdiagnosis, deliberate indifference, informed consent failures, and pathology errors each in the single digits to low double digits. There's a nice stratification here too — private practice claims skewed toward misdiagnosis, missed biopsies, informed consent, and pathology errors, while correctional cases skewed toward access-driven delay.

Now, outcomes — and this is where I'd urge some caution in how you interpret the numbers. Of the closed cases, just over half were resolved in favor of the defense, roughly four in ten were dismissed pretrial, and only about one in twenty resulted in a plaintiff-favorable verdict. The plaintiff wins clustered around delayed or missed diagnosis, failure to act on biopsy results, inadequate post-surgical follow-up, and failure to refer or escalate care — mostly in private practice. Damages in those cases ranged from about ten thousand dollars up to over four million, with the higher awards tied to permanent morbidity or pediatric patients.

The authors are appropriately careful in their discussion: a defense verdict doesn't mean care was flawless, and a plaintiff verdict doesn't always mean it was substandard — outcomes are shaped by procedural rules, evidentiary standards, statutes of limitation, and jurisdictional quirks that have nothing to do with clinical quality. The major limitation, which they state plainly, is that published court records dramatically underestimate the true burden of claims, since settlements and unreported cases never surface in a database like this.

So what's the practical takeaway? This isn't practice-changing in the sense of altering how you biopsy or manage anything — but it is a useful risk-awareness piece. The recurring failure points are the same ones we already counsel trainees on: timely biopsy of any lesion of concern, closing the loop on pathology results, and structured follow-up after surgical treatment, particularly in settings with access barriers. If you supervise trainees or work in any capacity with underserved or correctional populations, this is a good reminder that delayed-access litigation is a real and growing category, not a hypothetical one.

Next, a brief report on HIV-related exclusion criteria in cutaneous cancer clinical trials. This is a cross-sectional review of ClinicalTrials.gov, looking at interventional trials for basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, cutaneous lymphoma, and melanoma between 2012 and 2025. The rationale for the design is straightforward and the authors state it directly — they wanted descriptive trends in exclusion language across policy eras, specifically before the 2016 ASCO guidance, a transitional period, and after 2020 FDA guidance, without trying to claim causation, which is the right level of inference for a trial-registry text-mining study like this.

Across 362 trials, immunotherapies were the most common intervention type, at roughly four in ten trials. The core finding: depending on tumor type, somewhere between four in ten and three in four trials excluded people with HIV under some combination of criteria — any immunodeficiency, chronic infection, prior or current immunosuppression, or HIV infection regardless of viral suppression or CD4 count. Squamous cell carcinoma trials excluded at about seven in ten, basal cell carcinoma at four in ten, Merkel cell at seven in ten, cutaneous lymphoma at three in four, and melanoma trials at roughly six in ten. And specifically among melanoma immune checkpoint inhibitor trials, more than seven in ten excluded people with HIV outright, despite FDA guidance supporting their inclusion.

Encouragingly, explicit allowances for well-controlled HIV — essentially, language permitting enrollment with stable CD4 counts and suppressed viral load — didn't exist before 2017 and became more common in the post-2020 era, tracking similar improvements seen in broader oncology pivotal trials. But here's the number that should stick with you: of all 362 trials reviewed, only eight adopted the ASCO-recommended threshold of a CD4 count above 350 with no recent AIDS-defining illness — the specific, actionable benchmark meant to safely broaden eligibility.

The authors are honest that this likely underestimates true exclusion, since they worked from registry-listed criteria rather than full protocols, and vague language like "any uncontrolled medical condition" may be hiding additional HIV-related exclusions that weren't captured. They also flag legitimate safety considerations that complicate a blanket inclusion push — rare immune-activation phenomena with PD-1 blockade, including Kaposi sarcoma herpesvirus-associated lymphoproliferation, risks of viral dissemination with oncolytic or live-vector therapies, and antiretroviral drug interactions — so eligibility really should be tailored to mechanism and immunologic intensity, not treated as all-or-nothing.

Practically, this is more of an awareness-and-advocacy piece than something that changes your Monday clinic. But if you're involved in trial design, protocol committees, or referring patients with HIV for enrollment in immunotherapy trials, this is directly actionable: know the ASCO-Friends threshold, and recognize that most cutaneous oncology trials still haven't caught up to it.

Third, a brief report using the National Cancer Database to characterize penile basaloid squamous cell carcinoma, comparing it against the more common keratinizing subtype, across patients treated from 2004 to 2023. Background here: basaloid squamous cell carcinoma is the prototypical HPV-associated histology of penile cancer, and while HPV-associated head and neck basaloid tumors are known to behave more favorably, survival data specific to the penile site have been limited. This is a retrospective registry cohort study — the obvious and really only practical design for a tumor this rare, since no single center would accrue enough basaloid cases to power a meaningful survival comparison.

Among 678 patients with basaloid histology, compared to the keratinizing group, they were older, less often Hispanic, more often on public insurance, carried a heavier comorbidity burden, and — interestingly — had smaller tumors but more advanced stage at diagnosis. On multivariable Cox regression, independent predictors of worse overall survival included age 60 or older, public insurance, tumor size of 30 millimeters or more, and advanced stage, each roughly doubling the risk of death in a clinically meaningful and statistically significant way. Surgery, and specifically surgery with negative margins, was associated with roughly a fifty percent reduction in risk — though the authors rightly caution this is likely confounded by indication, since healthier, earlier-stage patients are the ones who get to surgery in the first place.

The headline finding, though, is the survival curve itself: despite presenting with more advanced stage, basaloid tumors showed a clear survival advantage over keratinizing squamous cell carcinoma through the first five years, translating to about a one-quarter reduction in mortality risk on multivariable analysis in that window — statistically significant and clinically substantial. Beyond five years, the curves crossed, with basaloid survival appearing to fall behind — but the authors are appropriately skeptical of over-interpreting that tail, since numbers at risk decline sharply, and given this cohort's older age and heavier comorbidity burden, late mortality is probably being driven by competing causes of death rather than the cancer itself.

This fits a broader pattern the authors note from other HPV-associated basaloid tumors, including head and neck primaries, where a similar paradox appears — more nodal involvement or advanced stage at presentation, but better outcomes overall, possibly reflecting greater radio- and chemo-responsiveness of HPV-driven tumors. It's also why some pathologists have argued against applying conventional high-grade histologic labeling to these HPV-associated variants, since the "high-grade" appearance doesn't track with aggressive behavior the way it does in HPV-negative disease.

Limitations are the standard registry caveats: no individual-level HPV testing, so the HPV association is inferred from histology alone; no recurrence data; no cause-specific mortality; and the usual missingness inherent to the National Cancer Database. Practically, this isn't going to change your surgical margin planning tomorrow, but it is useful prognostic counseling information — if you're involved in multidisciplinary discussions on penile cancer, knowing that basaloid histology carries a more favorable early survival trajectory despite higher stage at presentation is a genuinely useful nuance to bring to that conversation, even as the long-term picture remains unsettled.

Last is an Ethics Journal Club piece — a "Dear Dr Dermatoethicist" letter, not a study, so no methods or data here, just a case-based ethical framework. The scenario: a physician who counsels all patients on self skin exams and the ABCDE mnemonic for melanoma is now facing a blind patient who cannot perform a visual self-exam, and is asking how to maintain adequate surveillance without compromising the patient's privacy or autonomy.

The column opens by grounding the scale of the issue — roughly seven million people in the US live with visual impairment, about one million of whom are blind — and makes the point that dermatology carries a unique access barrier beyond the usual transportation, cost, and scheduling issues that affect all visually impaired patients: the ABCDE framework is fundamentally a visual tool, so it simply doesn't transfer to a patient who can't see their own skin.

The ethical scaffolding here is beneficence and nonmaleficence — the obligation to close this surveillance gap rather than let suspicious lesions go undetected — balanced against autonomy and privacy. Dr Dermatoethicist walks through several practical options rather than a single mandated answer. One is involving a caregiver in skin checks between visits, with the caveat that this requires the caregiver to be present and briefed at office visits too, and that it raises real privacy concerns given that thorough skin checks involve private anatomic areas — plus not every patient has a caregiver available. A second option is simply increasing the frequency of in-office screening, say every three to six months rather than annually depending on individual risk, which the column frames through the lens of justice — equitable, if not identical, care — while acknowledging this adds burden if transportation or cost barriers are already limiting factors, and recommends that front desk and triage staff be alerted to prioritize timely visits for this population. The third option is teaching structured tactile self-exam technique, which the column is careful to frame as a supplement rather than a replacement for in-office screening, but one that can aid earlier detection and preserve a meaningful degree of patient independence.

The teaching point to take from this one is less about a specific protocol and more about the mindset: standardized counseling tools like ABCDE aren't universally accessible, and equitable care sometimes means adjusting the modality of surveillance, not just its frequency. If you have blind or low-vision patients in your practice, this is a prompt to explicitly document a tailored surveillance plan — caregiver involvement, shortened recall intervals, tactile exam instruction, or some combination — rather than defaulting to standard annual visual self-exam counseling that this patient population simply cannot execute.

That wraps our four articles for July. Big picture across this issue: a sobering but useful look at where skin cancer litigation actually concentrates, a call to modernize HIV eligibility criteria that most cutaneous oncology trials still haven't implemented, a reassuring prognostic nuance for penile basaloid squamous cell carcinoma, and a practical ethics framework for an access gap that's easy to overlook. Thanks for listening, and I'll see you next month.