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Dermatopathology: Practical & Conceptual July - September 2003
What ever happened to BANS—and why?
A. Bernard Ackerman, M.D.
Naghmeh Yousefzadeh, M.D.
The history of BANS as conveyed through synopses of publications about it
Addendum 1 (The American Journal of Dermatopathology 1982 Oct;4(5):387–9.)
Although the validity of the notion of BANS was questioned soon after that acronym had been created, the fact that the concept lasted for four years prompts the query, legitimately, why ever was it published in the first place. Is it not curious that all of the authors of publications about BANS (as many as 21 for one of the articles), all of whom were members of the faculty of prestigious university medical centers, to wit, Harvard and New York University, and many of them reputed to be among the most expert in the world about melanoma, namely, Thomas B. Fitzpatrick, Alfred W. Kopf, Martin C. Mihm, Jr., Arthur J. Sober, and Darell S. Rigel, to mention but five of them, could publish such tripe, and so often and in as short a period of time, and is it not curious that only the group at New York University, not the one at Harvard, recanted?
Surely there must be an explanation for all this—and there is, as follows:
The overwhelming majority of the "authors" of the articles about BANS were not authors at all. In fact, most of the "authors" never even read the article attributed to them, let alone wrote a single syllable of it. One of us (ABA) "read out" virtually every melanoma that was included in the database of the Melanoma Cooperative Group at New York University between the years 1973 and 1993, and was privy to the way in which authorship came to be awarded. The leader of the group (AWK) sent each manuscript generated by a very few junior members of it (there were many scores of such articles during that 20 year period) to each member of the group (there were more than two score in it), asking whether that particular member would like to be an author. If the answer was "Yes," that person need only check the box that indicated affirmation.
During that 20 year period, never once did ABA agree to be an author of a single article that emanated from the Melanoma Corporative Group at NYU, notwithstanding the fact that he was responsible ultimately for every diagnosis histopathologically on which those articles were based. His revulsion at the manner in which authorship was determined was published in an editorial that appeared in
The American Journal of Dermatopathology (
Volume 4, Number 5, pages 387389) for 1982 under the title " The computer et al" (see addendum 1). Drs. Day, Kopf, and Rigel were invited to respond, but only the latter two did that (see addendum 2). The editorial and the response are published again here with permission of the current editor of
The American Journal of Dermatopathology,
Dr. Philip LeBoit.
Dr. Day, then a resident in dermatology at the Massachusetts General Hospital, was turning out articles in large numbers, among them ones pertinent to BANS (he was an author of 40 articles
during the three year span of his residency) and all of that work came to the same end as did BANS, that is, naught. It seemed in those days that Dr. Day was embarked fervently on an academic career. Since he left Harvard in 1983, his muse seems to have deserted him. In the ensuing 20 years he has published a total of 32 articles, most of which have been given to matters surgical, he having taken a fellowship in Mohs microsurgery in 1984 under Dr. Perry Robins at New York University. He now does Mohs micrographic surgery in San Antonio, Texas.
The review process for articles submitted to medical journals, particularly in fields like dermatology, pathology, and surgery, is flawed beyond description and seemingly beyond redemption, in part because it is predicated on the ill-advised concept of "peer review." The reviewers of the works about BANS were deemed by editors of journals to be peers of the "authors" of the works themselves and the result is that all of those articles were accepted for publication in so-called respectable peer-reviewed journals, ones given the household seal of approval by Index Medicus. And to compound the indecency of such a woefully flawed process, there is the clout exerted by Ivy League institutions like Harvard (the institution which not only bears chief responsibility for BANS, but for all the other detritus strewn about along with its partner in a tag team, the University of Pennsylvania, concerning issues like melanocytic dysplasia, the dysplastic nevus ("familial" and "sporadic"), the dysplastic nevus syndrome, the epidemic of melanoma, etc., etc., etc.). Had BANS been a mere dropping of the University of Mississippi or the University of South Dakota, rather than of Harvard and New York University, never would it have been published in a major medical journal and probably would have ended up in a throw-away, which, at best, it deserved. Instead, BANS became a household word in dermatology—at least for four years. But BANS was not the first myth to be propagated by self promoting dermatologists and pathologists who used "pigmented lesions" and clinics devoted to them as vehicles for their own advancement. One need only recall the nonsense served up in the past 50 years about subjects like junctional activity and activated junctional nevus, atypical melanocytic hyperplasia, mild, moderate, and severe dysplasia, wide and deep excision for primary cutaneous melanoma, elective lymph node dissection, the "histogenetic" classification of melanoma, lentigo maligna as a precursor of melanoma, radial vs. vertical growth phases of melanoma, melanocytic neoplasms with architectural disorder, melanocytic neoplasms of uncertain biologic potential, tumor infiltrating lymphocytes (TILs), minimal deviation melanoma, borderline melanoma, nevoid melanoma, pagetoid melanocytic proliferation—and more nonsense keeps coming. Sentinel node biopsy is now the rage, advocates of it, ignorant of rudimentary principles that guide behavior of metastasis, leading a stampede to make that procedure "standard of care," when, in actuality, it is nothing other than another fraud perpetrated on an unsuspecting and defenseless public, every member of which is a patient potentially.
BANS is all but forgotten, (although it continues to be mentioned in current textbooks of dermatology). For example, in the fifth, current edition of
Fitzpatrick's Dermatology in General Medicine,
page 1101, under the heading "Prognostic Factors for Stages I and II Melanoma," there is a paragraph about the anatomic sites of primary cutaneous melanoma and in it the authors refer to BANS as follows:
"Melanoma of intermediate thickness (0.69 to 1.69 mm) that are localized to the so-called BANS area (
calp) have been reported to have a worse prognosis than non-BANS melanomas. However, these findings have not been confirmed in other data bases."
BANS appears also in the second, current edition of the textbook
by Braun-Falco, Wolff, and Plewig, where on page 1542, among independent prognostic factors is written: "Malignant melanoma in the BANS region (back, upper aspect of arms, neck and scalp) may have a slightly worse prognosis than matches tumors elsewhere."
On September 24, 2002, in the circuit court of the county of St. Louis, State of Missouri, Louis P. Dehner, M.D. (an expert witness for the plaintiff in a suit against two pathologists that was won by the defense) referred in a deposition to BANS in his response to this question from an attorney for the defense:
Q. "Are you aware of the studies that also take into account whether the patient—in staging and prognostication, the patient's sex, age and location of tumor?"
A."I think those are all features. Generally in all of these kinds of studies, we want — want to take a look at the effect of these other variables, age, sex, and there's also the variable — there's also the variable of anatomic site of the tumor."
Q. "Right. Whether it's distal or whether it's on the axis or on the front?"
A. "That is correct. And there are some — the concept has been forwarded that patients who have malignant melanoma that arise in the so-called bans, the B-A-N-S, and this is the back of neck, the shoulder, scalp, that these sites — that these sites tend to have a worse prognosis that, for instance, than malignant melanomas that arise out in the extremities."
The lessons of BANS could be the basis for a course on ethics in medicine, one which should be a requirement for every medical student in every country in the world. And that is precisely why we are reminding of BANS here and now.
From the Ackerman Academy of Dermatopathology in New York City where Dr. Yousefzadeh did this work during an elective there. Dr. Ackerman is director of the Academy.
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