Melanoma misdiagnosis: Why patients with darker skin face deadlier outcomes
A recent literature review identifies strategies to improve ALM education materials for physicians, public (Issue #239, 1,700 words, 8 minutes)
Acral lentiginous melanoma (ALM) poses significant challenges, particularly in individuals with skin of colour. Delayed diagnosis and poorer outcomes remain prevalent in this cohort due to a combination of biological, socioeconomic, and healthcare-related factors, according to the authors of a recent review article.
In the review, published in Cancers (Jan. 30, 2025; 17(3):468), the authors note that addressing these disparities in outcomes and speed of diagnosis will require a comprehensive approach, including heightened awareness among both healthcare providers and patients, improved early detection strategies, and enhanced access to care.
The researchers conducted a comprehensive literature search in public databases using the search term “acral melanoma.” They reviewed studies focusing on epidemiology, clinical presentation, and treatment outcomes of ALM in various racial and ethnic groups.
Findings from the review show significant disparities in ALM outcomes exist across racial and ethnic groups, with African, Hispanic, and Asian individuals presenting with thicker, more advanced tumours at diagnosis. These populations encounter unique challenges, the authors write, including limited access to dermatologic care, under-recognition of melanoma presentation in darker skin types, and socioeconomic barriers leading to delayed diagnosis and treatment. Surgical management may require specialized approaches, such as partial amputation for subungual melanomas. Additionally, there is uncertainty regarding the tumour immune microenvironment (TME) in ALM, with some studies suggesting that it might be less favourable, resulting in a lower response to immunotherapy. ALM affects diverse populations, and the impact of ethnic and racial origin on ALM biology is largely unknown.
Researchers identified several steps that could be used to improve equity in patient experience and outcomes.
There is a need for more public-facing educational materials tailored to patients with skin of colour
Many educational materials for patients and physicians have historically highlighted the ABCDE rule as a tool for standard melanoma detection, which has limited utility in the acral subtype. Instead, the “CUBED” rule is a more sensitive indicator (Coloured lesion, Uncertain diagnosis, Bleeding lesion on the foot or under the nail, Enlargement of a lesion and Delay in healing). Promoting the CUBED system to a broad range of health professionals—such as podiatrists)—and non-physician businesses—such as nail salons)—could be valuable
Video instruction effectively delivers information on skin cancer recognition and protection compared to traditional text materials
Online materials, such as VisualDx, included a greater representation of individuals with darker skin compared to standard print materials, which may positively impact the receipt and implementation of skin cancer knowledge in communities of colour
Print materials with community input may serve as a method for addressing racially disparate outcomes in ALM
Recruiting more underrepresented groups in clinical trials
Deriving models of ALM from a spectrum of skin tones for preclinical research
Emphasizing transparency regarding the inclusion of patients with skin of colour in medical decision-making and scientific initiatives to ensure applicability to the general population
Bottom line: Patients with skin of colour continue to experience delayed diagnosis of ALM and poorer outcomes due to a combination of biological, socioeconomic, and healthcare-related factors. By promoting healthcare literacy and access to care and prioritizing equity in research and treatment, physicians can work toward personalizing care for ALM patients and narrowing the outcome gap for this aggressive melanoma subtype.
From the literature on skin cancer in skin of colour
Searching for equity: White normativity in online skin cancer images
Researchers examined the range of skin tones represented in publicly available online image search results through which non-medical audiences might seek information about skin cancer signs, symptoms, and risks.
The authors used the Fitzpatrick scale as a guide for analyzing the skin tones appearing in 1,600 Google image search results for search terms related to skin cancer.
Examining the images revealed that a significant majority—approximately 96%—of skin types depicted in Google image searches for information about skin cancer signs and prevention were Fitzpatrick types I, II, and III. Dark skin tones, Fitzpatrick types IV, V, and VI, appeared with significantly less frequency (roughly 4%) in the same search results.
The authors write that disparate representation of diverse skin tones—and, more specifically, omission of dark skin images—suggests that racial biases inflect the search results generated by seemingly race-neutral skin-cancer-related search terms. This embedded racial bias privileges white normativity to the disadvantage of dark-skinned patients, who are most likely to be racially classified as Black.
Melanoma in patients with skin of colour
In this review, the authors explore the epidemiology, clinical presentation, and healthcare disparities surrounding melanoma in skin-of-colour individuals to increase awareness of the intricacies and nuances of identifying these malignancies.
Topics include epidemiology or risk factors, primary locations, and health disparities.
The authors describe findings related to the higher melanoma morbidity and mortality rates for individuals with skin of colour. They note that while the most common sites for cutaneous melanoma in skin of colour patients are most often the hips and lower extremities, among American Indian/Alaskan Natives and Hispanic men, melanomas on the trunk are more common—similar to non-Hispanic White populations.
They write that their findings show that physicians should be familiar with the unique clinical and dermatoscopic presentations associated with these malignancies, including varying risk factors, primary locations, and healthcare disparities that may impede an early diagnosis.
Shades of evidence: A review of skin colour reporting in melanoma-related randomized controlled trials
Researchers examined the rate of skin colour reporting in randomized controlled trials (RCTs) involving melanoma in the top ten highest dermatology journals by impact factor over the past four decades.
Investigators included studies from the top 10 identified journals from inception to July 10, 2023. Included studies reviewed the diagnosis or treatment of melanoma, were RCTs, directly involved patients, and were written in English.
The authors characterized studies as positive for reporting skin of colour if their demographic data included race, ethnicity, skin of colour, Fitzpatrick scale, sunburn tendency, phototype, skin type, or skin tone.
Out of 76 studies researchers initially identified, only 49 articles met the inclusion criteria. Of these 49 articles, only 24 recorded skin colour data from their demographics (49%). Subgroup analysis showed no statistically significant difference in the reporting rate between studies grouped by decade (p=0.779) or by study location (p=0.763).
At the intersection of skin and society
Findings from a new KPMG survey in Canada show that nine in 10 Black Canadians want their employers to be vocal about anti-racism. Over the past five years, 86% feel their employer has made progress on promises to create a more equitable workplace for Black employees.
KPMG is a financial audit, tax, and advisory firm.
For this fourth annual survey, KPMG in Canada surveyed 1,000 Canadians who self-identified as Black on their employer's progress in addressing systemic racism in the workplace. The survey was conducted from Dec. 17, 2024, to Jan. 6, 2025, on Sago's AskingCanadians panel using its Methodify online research platform. Half of the respondents are women, and 48% are men. The respondents are between the ages 25 and 65, are employed (92%), self-employed (4%), and unemployed (3%).
In a press release, the firm notes that while 77% of Black Canadians still encounter microaggressions, discrimination and racism at work, more than 80% think Canadian companies will continue to support efforts to eliminate systemic racism/biases in the way they recruit, hire, and promote people.
“It's heartening that Black Canadians feel corporate Canada has made progress on its goals to be more inclusive and equitable,” says Rob Davis, Chief Inclusion, Diversity and Equity Officer at KPMG in Canada, in the release. “But while organizations have done much to ensure that all employees are treated fairly, our survey reveals that many Black Canadians continue to experience racism in the workplace and within society, which creates concerns about how their employer plans to keep improving in the future.”
Despite this, 75% of Black Canadians feel valued and respected in the same way as their non-Black colleagues. A further 78% express confidence in their company's ability to reduce systemic barriers in the workplace over the next five years. Mr. Davis says this optimism is crucial as it reflects that organizations understand the importance of creating workplaces free of bias to ensure the best people are hired and promoted and everyone is heard and valued.
“As employers, we need to maintain trust by continuing to take action to remove barriers and ensure inclusion and equity efforts are both meaningful, real and sustainable,” says Davis. “As we navigate the ongoing conversations around breaking down barriers, it's important to recognize the lived experiences of Black Canadians. It's simply good business to create an environment that enables everyone in our workforce to fully participate, be productive, and bring their best to work.”
Read more highlights from the poll here.
This week
March 25 is International Day of Remembrance of the Victims of Slavery and the Transatlantic Slave Trade
March 30 is National Doctor’s Day in the U.S.
Something to think about in the week ahead . . .
—Richard M. DeVos (1926-2018) U.S. businessman, co-founder of Amway.
Next week
In a presentation at the 10th annual Skin Spectrum Summit, Dr. Renée Beach (Toronto) provides an update on folliculitis barbae and its management.
Less than two weeks to the Indigenous Skin Spectrum Global Summit
There is still time to register for the first Indigenous Skin Spectrum Global Summit, which will be held in Montreal on April 5, 2025.
The summit will allow attendees to learn more about the unique dermatologic challenges facing Indigenous, rural, and circumpolar populations worldwide. Experts worldwide will provide insights on how physicians can support equitable health for these populations.
Summit chair Dr. Rachel Asiniwasis (Regina) leads a world-renowned faculty for this historic meeting.
Don’t miss an informative talk by Dr. Archana Kakadekar, an anatomical pathologist with subspecialties in dermatopathology and breast pathology, exploring the latest research on dermatopathology in skin of colour. Dr. Kakadekar is based in Saskatoon.
More details on the Global Summit are at this link.
If you enjoy Skin Spectrum Weekly, why not check out the Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Dr. Ruth Ann Vleugels (Boston) describes emerging treatments for dermatomyositis associated with lupus.
Drs. Charles Lynde (Markham, Ont.), Fiona Lovegrove (London, Ont.), Julien Ringuet (Quebec), and Kerri Purdy (Halifax) review new dermatologic therapies to watch in 2025.
Dr. Susan Poelman (Calgary) summarizes current research into hidradenitis suppurativa treatments and discusses why physicians should be optimistic about the future of managing this disease.
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Season three of the Vender on Psoriasis podcast with Dr. Ron Vender has begun. Listen to the new season here. In episode five, Dr. Vender discusses whether vitamin D influences psoriasis severity, sex differences in psoriatic inflammation itch, and the risk of psychiatric disorders associated with acitretin.
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