Mortality rates among minority patients highlight need for skin cancer education

Denver - Although skin cancers occur less commonly in skin of color (SOC), an expert says, their poorer prognosis reveals a need for increased education among patients and providers.

Diane Jackson-Richards, M.D., says it’s a misconception that skin cancer is not a major issue in skin of color. Although skin cancer occurs much less commonly in darker-skinned patients than those with lighter skin, she says, it’s associated with increased morbidity and mortality because skin cancer in SOC presents at a more advanced stage. Dr. Jackson-Richards is senior staff dermatologist at Henry Ford Hospital, Detroit. She spoke at the 72^nd annual meeting of the American Academy of Dermatology.

Nonmelanoma skin cancer (NMSC) and melanoma account for 5 percent of cancers in Hispanics, 4 percent in Asians, and 2 percent in blacks - versus approximately 40 percent of skin neoplasms in Caucasians, Dr. Jackson-Richards says. While basal cell carcinoma (BCC) represents the most common skin cancer in Caucasians, Hispanics and Asians, it’s less common in blacks than squamous cell carcinoma (SCC).

As in other races, BCC in SOC typically presents as a solitary nodule with central ulceration.

“It’s more common in the head and neck area, and with advancing age,” she says. “Not everyone with SOC has skin type V or VI,” and those whose skin falls on the fairer end the SOC spectrum have less melanin to protect against UV exposure. Because around 50 percent of BCCs in SOC is pigmented, she adds, “We can’t just say that a hyperpigmented lesion is just irritated seborrheic keratoses if it does not resolve.”

Cancer risk factors

Dr. Jackson-Richards says SCC the most common skin cancer in blacks and Asian Indians, and the second most common skin cancer in Hispanics, East Asians and whites. Along with the standard risk factors for whites, such as chronic sun exposure, she says, “In people of color, there seem to be other risk factors.” These include chronic inflammatory processes such as lupus, hidradenitis suppurativa and chemical and thermal burns. SCCs in black skin also are more likely to appear in different locations - such as the lower leg and anogenital region - than in whites, she says.

Acral lentiginous melanoma (ALM) is the major subtype of melanoma seen in African-American, Asian and Hispanic skin. Dr. Jackson-Richards points out, however, that ALM in itself does not carry a worse prognosis than melanoma in other locations. In a 56-patient series, she says, researchers found a survival rate similar to those of superficial spreading or nodular melanoma, once adjustments had been made for tumor thickness (Ridgeway CA, Hieken TJ, Ronan SG, et al. Arch Surg. 1995;130(1):88-92).

As for predictors of survival, “It’s not that the tumor is an ALM necessarily. It’s tumor thickness and presence of ulceration that determine survival,” Dr. Jackson-Richards says.

In another case series, 50 percent of ALMs in SOC showed loss of p16 expression and high Ki67 expression, which she says is associated with hyperproliferative activity (Vuhahula E, Straume O, Akslen LA. Anticancer Res. 2000;20(6C):4857-4862). “These markers are usually associated with tumor aggressiveness,” she says.

Overall, “The median age at diagnosis is usually later - 50 to 65 years - in darker skin groups. African Americans and Hispanics usually present with more advanced disease and have lower survival rates,” Dr. Jackson-Richards says.

Survival rates

One study analyzed data from the National Cancer Institute’s Surveillance, Epidemiology and End Results database, along with the Centers for Disease Control and Prevention cancer registry program, for racial differences in incidence and survival rates of melanoma.

“These investigators found that the incidence of melanoma was higher in females for whites and Hispanics under age 50, and for Asian-Pacific Islanders under age 40. In the United States, 70 percent of white females ages 16 to 49 years reported using tanning beds (Wu XC, Eide MJ, King J, et al. J Am Acad Dermatol. 2011;65(5 Suppl 1):S26-S37),” Dr. Jackson-Richards says.

Additionally, “Whites and blacks were older at diagnosis than Hispanics and other racial groups. The trunk was the most common site for whites, Asians and Native Americans. The lower limb was more common in blacks and Asian-Pacific Islanders. In Hispanics, the trunk area and the lower limb-hip were roughly equal as presentation sites,” she says.

As for ALM, Dr. Jackson-Richards says, Hispanics had the highest incidence among all ethnic groups.

No less importantly, five-year survival rates in this study were as follows: 92 percent in whites, 86 percent in Hispanics, 85 percent in Native Americans; 81 percent in Asian-Pacific Islanders, and 78 percent in blacks.

Another study that analyzed 649 melanoma cases retrospectively showed that in African-Americans, 32.1 percent of melanomas present at stage 3 or 4, versus 12.7 percent in whites (Byrd KM, Wilson DC, Hoyler SS, Peck GL. J Am Acad Dermatol. 2004;50(1):21-24).

“The five-year survival rate in this study was 58 percent for blacks, compared to 84.8 percent for whites,” Dr. Jackson-Richards says.

Boosting awareness

Raising awareness about skin cancer in patients of color begins with education, she says. In a recent survey, “Blacks and Hispanics felt their risk of skin cancer was low; they were less likely to believe that skin exams are important, and more likely to feel there’s little that they could do to reduce their risk of skin cancer (Buster KJ, You Z, Fouad M, Elmets C. J Am Acad Dermatol. 2012;66(5):771-779).”

Another study showed that shoppers in Hispanic neighborhoods had significantly fewer sunscreens available in local stores (Hernandez C, Calero D, Robinson G, et al. Photodermatol Photoimmunol Photomed. 2012;28(5):244-249).

“We must question all our patients about their sunscreen use,” Dr. Jackson-Richards says. “I make it part of my history whenever I do a skin exam. I ask them, ‘Are you applying it just to your face, or to all areas? Do you use it only on vacation, or for daily outdoor activities?’ We must educate our patients on the proper use of sunscreen and skin exams.”

By the same token, she says, “We must educate our healthcare professionals that when we do a complete skin exam, we must include the palms, soles, perianal area and oral cavity,” which are sometimes overlooked.

Disclosures: Dr. Jackson-Richards reports no relevant financial interests.