Staff Writer: Andre McGowan
Skin cancers are more common among the White populace, but morbidity and mortality in skin cancer is higher among Blacks and Hispanics.
Skin cancers are among the most common types of cancer in the world. Most skin cancers, such as melanomas and non-melanomas, are more common in the White population, though it has been noted that in non-White populations, such as Hispanics and Blacks, skin cancer presents at a much later stage and with worse prognosis. This study aimed to uncover the factors that contribute to this disparity.
Epidemiologically, the incidence of newly diagnosed melanomas in the United States is higher in White patients (26 per 100,000 individuals) than in Blacks (1 per 100,000 individuals) and Hispanics (4.6 per 100,000 individuals). However, during the time of diagnosis, Blacks were noted to be diagnosed with late stage melanomas, which are deeper and have higher chances of regionally advanced or metastatic disease. Furthermore, data suggests that even if melanoma was diagnosed at the same stage, non-White patients have a higher risk of mortality than White patients.
There is also a noticeable difference in presentation of skin cancers in White patients compared to non-White patients. White patients tend to develop squamous cell carcinoma in sun-exposed areas, while multiple studies have concluded that, in the Black and Hispanic population, these cancers occur in non-sun-exposed areas such as the perianal area, groin, and the lower legs. The difference in presentation of skin cancer is also one of the reasons for the delay in diagnosis. For instance, the initial presentation of skin cancer is usually pigmentation, which becomes less likely noticeable in colored skin which does not alarm the patients. This masking of pigmented lesions that could point to cancer is one of the reasons why most people of color present with a more advanced stage of skin cancer compared to the White population, wherein such changes are easily noticeable.
Another factor that contributes to racial disparity in skin cancer care is the lack of educational resources that provide images of lesions on darker-pigmented skin, as well as the lack of educational programs that aim to train healthcare professionals on the recognition of lesions in pigmented skin. Thus, healthcare providers are less likely to recognize skin cancer in its early stages on darker-pigmented skin. As proof of this, more than 30% of chief residents and program directors of dermatology programs admit to not having had didactic sessions that focused on recognition of skin lesions on pigmented skin. This goes to show that there is a lack of education regarding the recognition of skin conditions on pigmented skin.
Cultural factors also play a role in the disparity in skin cancer incidence. Qualitative studies suggest that Hispanics and Blacks believe they are invulnerable to skin cancer. Thus, they practice fewer sun-safety habits such as putting on sunscreen and limiting sun exposure. Furthermore, a lot of Hispanics and Blacks have jobs that involve sun exposure, such as yard work, farm work, and construction. These factors, when taken together increase the risk of skin cancer by virtue of increased sun exposure. However, recent data suggests that in Black and Hispanic patients, sun exposure is not the only contributing factor to skin cancer development. Evidence suggests that since most skin cancers in this population occur in sun-protected areas, UV exposure may not be the prevailing risk factor. Other factors taken into consideration include HIV infection, which disproportionately affects the Black population; and genetics, which also play a role in skin cancer development. In Blacks, melanomas were found to have a high Ki-67 expression and a low level of p53 staining, which suggests a different biological basis and behavior of skin cancer in this population, which leads to differing presentations and outcomes.
Hopefully, by shedding light on the factors that cause this disparity in care, these factors will be addressed and more educational materials featuring diagnosis of skin conditions in pigmented skin will become more commonplace. Dermatology training programs should also actively promote learning modules addressing the diagnosis and management of skin conditions in pigmented skin in order to equip future dermatologists to manage skin diseases in patients of color. Prevention is better than cure, thus there must be active patient education that addresses beliefs that pigmented skin is immune to skin cancer. Sun protection must be advocated in order to reduce the risk of skin cancer across all populations regardless of skin color.
Source:
Shao, K., & Feng, H. (2022). Racial and Ethnic Healthcare Disparities in Skin Cancer in the United States: A Review of Existing Inequities, Contributing Factors, and Potential Solutions. Journal of Clinical and Aesthetic Dermatology, 15(7), 16-22. PMCID: PMC9345197
