A response published online October 16, 2026, in the Journal of the American Academy of Dermatology pushes back on how De Giorgi et al. framed surgical delay in early-stage vulvar melanoma, arguing the authors overstepped when defining a causal threshold for time-to-surgery.

The letter, authored by Hue T.T. Tran, Raslina Shrestha, Duc V. Le, Luong T. Dang, Jamie N. Bakkum-Gamez, Julia S. Lehman, Clark C. Otley and Giang Huong Nguyen, takes aim at the language of causality rather than the observation itself. That distinction matters. Retrospective timing data can show association; it cannot, on its own, establish that a specific delay window causes worse outcomes.

Vulvar melanoma is rare, and rarity is exactly why this argument flares up. Small cohorts mean wide confidence intervals, confounding by tumor biology, and referral pathways that vary from center to center. When a study slices those cases by weeks-to-surgery, the cut-points often carry more statistical noise than signal.

What does this change for clinicians?

For dermatologists and gynecologic oncologists managing early-stage vulvar melanoma, the answer is: framing, not practice. The responding authors do not dispute that timely excision is appropriate. They dispute the leap from observational timing data to a published causal threshold — a number that payers, guidelines committees or malpractice arguments could later cite as a standard of care.

That risk is concrete. Once a threshold enters the literature, it tends to migrate. Quality metrics get built around it. Delay claims get litigated against it. If the underlying evidence is associational, the migration is premature.

Where the burden of proof sits

The exchange reflects a broader debate in cutaneous oncology: how confidently should retrospective data on time-to-treatment be translated into clinical guidance? Similar arguments have played out over melanoma of the skin, where Breslow thickness and tumor biology often explain survival differences that initially look like treatment-timing effects.

For rare vulvar tumors, the biology-first caution is stronger still. A tumor that grows fast enough to worsen prognosis may also be the tumor that presented early enough to be excised quickly — the classic confounding structure that timing studies must address before claiming causation.

Watch the ongoing correspondence in JAAD. If De Giorgi et al. reply, the back-and-forth will clarify whether a defensible delay threshold for early-stage vulvar melanoma can be drawn from current data, or whether the field needs prospective, biology-anchored work before any number is written into guidance.