New CME courses on melanoma in skin of colour
Two accredited online programs will support front-line physicians (1,800 words, 9 minutes)
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Two accredited continuing medical education (CME) courses that support front-line medical professionals in screening for and diagnosing skin cancer in patients with darker skin types have been developed by Melanoma Canada, formerly The Melanoma Network of Canada.
“From what we understand, very little time is spent in medical school on dermatology and skin cancer, and even less on skin of colour,” said Falyn Katz, Executive Director of Melanoma Canada, in an interview with Skin Spectrum Weekly.
“We know from research that melanomas in darker skin, while not as common as in White skin, are often diagnosed at a later stage and often misdiagnosed,” said Katz. “So we thought it was important to educate GPs [general practitioners] and front-line health care practitioners on how to identify skin cancer and when to refer [to a dermatologist].”
Melanoma Canada advocates for and supports Canadians living with melanoma and skin cancer.
The two courses are available through the MD BriefCase website. The first, titled “Melanoma in people with skin of colour: Diagnosis and treatment,” reviews how melanoma presents in darker-skinned individuals, how to screen for the most common types of melanoma in this population, when to refer, and treatment options. It is 30 minutes long and is accredited for one-half of a MainPro credit.
Katz said a second course, “Subungual melanoma (SM): Screening and diagnosis within family practice,” covers an often-overlooked form of melanoma. That course is 15 minutes long and is accredited for one-quarter of a MainPro credit.
The new courses are a follow-up to an earlier, more general course Melanoma Canada launched two years ago, said Katz. That course, she added, “was very well received with nearly 1,500 clinicians taking it in the first year.”
Melanoma Canada has other projects in development that aim to improve screening for melanoma in underserviced communities, Katz said. Two projects she mentioned were:
An update to the Melanoma Canada website, to launch mid-November 2022. The new content will include an educational video on how patients and their loved ones can screen for signs of melanoma in skin of colour and information on common myths about the disease.
A website interface update that includes a slider will allow visitors to select imagery matching their skin tone. There are also plans to have the slider change the presented information to be content most relevant for the selected skin type.
A mobile skin cancer screening unit is set to begin travelling across Canada in May 2023. The mobile team will visit rural, Indigenous, and underserviced communities across the country over five years to facilitate early diagnosis and improve melanoma outcomes.
Bottom line: Late and missed diagnosis of melanoma continues to be a problem for patients with darker skin types. The patient advocacy group Melanoma Canada has sponsored two accredited educational sessions for front-line health professionals to help them more effectively identify potential melanoma and
to help them ensure better outcomes for their patients.
From the literature on melanoma in skin of colour
A cross-sectional study of acral melanoma awareness in a group of South African final phase medical students
The authors of this paper note there is a misconception that people with more highly pigmented skin types (Fitzpatrick 4-6) do not develop melanoma due to the protective effect of melanin.
They conducted this study to determine acral melanoma knowledge and awareness of a group of South African medical students.
The researchers surveyed 101 students using a questionnaire that included 20 clinical images of skin lesions requiring a diagnosis and management plan. For this study, the researchers analyzed responses to six images of melanomas. They also asked the participants questions to measure their knowledge of acral melanoma and related issues.
Only 7.9% of the participants diagnosed all six melanomas correctly; 61.4% correctly diagnosed at least half of the melanomas. While 77.2% of the participants identified all non-acral cutaneous melanoma correctly, only 8.9% identified all acral melanomas. However, of all participants making the correct diagnosis, more than 90% selected the appropriate management plan.
Primary cutaneous melanoma in Black patients: An analysis of 2,464 cases from the National Cancer Database 2004-2018
This retrospective cohort study examined 2,464 cases of Black patients with cutaneous melanoma from the U.S. National Cancer Database from 2004 to 2018.
Of the 2,464 cases, melanoma was more common among females than males (57.1% vs. 42.9%, p<0.001). The median Breslow depth was 1.8 mm. The findings showed the most common location for melanoma was the lower extremities (52.8%), followed by upper extremities (13.1%) along with otherwise specified/overlapping/other (13.1%), then by the trunk (11.8%), and head and neck (9.2%).
The recorded stage at diagnosis was I (30.7%), II (27.5%), III (24.1%), and IV (17.7%). Ulceration was observed in 41.4% of lesions. Acral lentiginous melanoma (ALM) was the most common specific histologic subtype (20.3%), followed by superficial spreading melanoma (9.4%).
After adjusting for confounders, the researchers found that higher stages and a primary site on the head and neck were the strongest independent predictors of worse overall survival.
Skin cancer risk factors among Black South Africans—The Johannesburg Cancer Study, 1995-2016
In this case-control study, researchers identified risk factors associated with keratinocyte cancers (KCs) and melanoma skin cancers (MSCs). Cardiovascular patients served as controls.
The investigators assessed sociodemographic exposures, environmental health variables, smoking, and HIV status.
There were 160 KCs cases, and 53% (n=85) were females. The males with KCs were older than females: 51 (IQR: 41–59) years on average versus 46 (IQR: 36–56) years. Most cases were recorded in individuals 51 to 60 (28%, 44/160). There were 101 MSC cases, and 60% (n=61) were females
Investigators found that among KCs subtypes, there were more squamous cell carcinomas (SCCs) (78/160 in females and 72/160 in males) than basal cell carcinomas (BCCs). The SCC lesions were primarily found on the h’ head and neck skin (51%, 38/72) and the trunk in females (46%, 36/78).
MSC was shown to affect the skin of the lower limbs in both males (68%, 27/40) and females (59%, 36/61).
After adjusting for age, current place of residency, type of cooking fuel used, smoking, and HIV status, males had an odds ratio (OR) of 2.04 for developing KCs (confidence interval [CI]: 1.08-3.84, p=0.028) compared to females. Similarly, when age, current place of residence, and location of cooking (indoors or outdoors) were adjusted, males had an OR of 2.26 for developing MSC (CI: 1.19-4.29, p=0.012).
The authors conclude that the observed differences in the anatomical distribution of KCs by sex suggest different risk factors between sexes. Also, they mention the association they found between patients living in rural areas and skin cancer warrants further investigation.
Features of skin cancer in Black individuals: A single-institution retrospective cohort study
To describe clinical features and risk factors of skin cancers in Black individuals, researchers evaluated records of 165 Black individuals diagnosed with skin cancer between Jan. 2000 and Jan. 2020 at a single institution.
Of those, 113 were diagnosed with melanoma, 35 with squamous cell carcinoma (SCC), and 17 with basal cell carcinoma (BCC). Most (80%) of the melanomas were acral. Of eight cases with dermoscopic images, six (75%) displayed a parallel ridge pattern (PRP). The surrounding uninvolved background skin was visible in seven cases, and all demonstrated a PRP. Four (57.1%) melanoma lesions had a peripheral hypopigmented “halo.”
The non-melanoma skin cancers were pigmented and had similar dermoscopic features as those reported in predominantly White populations. Most of the SCCs (n=5, 71.4%) had a hypopigmented “halo,” and most of the BCCs (n=10, 55.6%) had an accentuated reticular network next to the lesions.
VIDEO: Skin cancer and black skin—Saint Lucia Cancer Society May 2021 Webinar
At the intersection of skin and society
The Canadian Medical Association Journal (CMAJ) is releasing two issues that focus on the health of Black people in Canada and discuss anti-Black racism in Canadian healthcare.
In an editorial in the first of the two issues, Kirsten Patrick, MBBCh, Editor-in-chief of CMAJ, said the idea for the issues emerged from a late-2020 meeting with two co-leads of the Black Health Education Collaborative (BHEC)—Drs. Onye Nnorom and OmiSoore Dryden.
“Drs. Nnorom and Dryden proposed that CMAJ show solidarity with Black communities in Canada by having a special edition on anti-Black racism and its effects on health in Canada,” wrote Dr. Patrick in the editorial. “We said no. Special issues are a lot of work, and our staff was overwhelmed by more-than-doubled submissions in the first year of the pandemic. We offered to create a CMAJ collection for articles on Black health instead. Drs. Nnorom and Dryden explained why that would be an almost meaningless gesture that would do nothing to highlight how anti-Black racism affects people’s health in Canada. And so began a course of learning for me, and the start of a journey for the CMAJ Group.”
Originally intended to be a single special issue, a call for papers resulted in more than 20 submitted manuscripts by the deadline, Dr. Patrick wrote. As the papers were being reviewed, a decision was made that there were enough high-quality papers for CMAJ to publish two back-to-back issues.
“Moreover, one article not selected for the special issue has been published in a regular issue of CMAJ, one has been published in CMAJ Open, and one was posted on CMAJ Blogs.”
Topics covered in the special issues include:
The experiences of Black medical students, resident physicians, and nurses in Canada
Efforts to address historical anti-Black racism in healthcare professions
The effects of anti-Black racism on health and patient care
An innovative model of embedding Afrocentric principles in healthcare delivery
“Our initial ‘no’ to publishing a special issue could perhaps be categorized under ‘how white people often react when asked to act to combat racism,” wrote Dr. Patrick. “That is, we are happy to say nice things and make gestures of minimal inconvenience, but we seldom want to disrupt our systems in a major way or take action that may diminish our power and white privilege.”
Dr. Patrick writes that she is inspired to build on the groundwork laid by the articles published in the two special issues. She notes that while the articles are vital, more work needs to be done by the CMAJ Group and other academic journals to address racism in systems and processes.
Oct. 31 is World Cities Day
November is National Native American Heritage Month in the U.S.
Something to think about in the week ahead…
Samuel Johnson, English writer, 1709-1784
Dr. Andrew F. Alexis reported during his talk at the 2022 Skin Spectrum Summit several skin conditions can lead to pigment loss in dark skin, which can have a significant quality-of-life impact on patients. The next edition of SSWeekly will cover Dr. Alexis’ views on managing these conditions and how to help patients recover pigment.
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