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Screening alone can’t close skin cancer outcome gap
Routine screening identifies far fewer skin cancers in patients with skin of colour than in White patients, according to new research (1,600 words, 6 minutes)
New research suggests that increased skin cancer screening in individuals with skin of colour is not sufficient to address racial disparities in melanoma survival rates.
The study, published in JAMA Dermatology, analyzed data from 60,680 patients who self-reported as Hispanic, Alaska Native, American Indian, Asian, Black, or Pacific Islander. A total of 12,738 were screened for skin cancer, and 47,942 were not screened.
“In this study, we asked whether screening could address this disparity by helping detect melanoma early,” said senior author Laura Ferris, MD, PhD, in a press release “Our findings suggest that regular skin checks are not the answer, but that doesn’t mean that we should be offering less care or that our work is done. We need to investigate other approaches to improve outcomes for melanoma in patients with skin of colour.”
Dr. Ferris is a dermatologist at the University of Pittsburgh Medical Center and a professor of dermatology at the University’s School of Medicine.
During the five-year study period, only eight melanomas were detected in the tracked population, and just one of these was identified during a screening visit. Four were identified by health care professionals during other types of visits and three were detected by the patient or a family member.
The authors write that their results suggest that to detect one melanoma case in racial and ethnic minority populations, more than 12,000 screenings need to be performed. For comparison, the number needed to screen in White patients is 373, the researchers found in an earlier study.
“This is an almost unfathomable number of doctor’s visits to find one melanoma,” said Dr. Ferris. “Rather than screening everyone, educating physicians about the presentation of melanoma in skin of colour, educating the public about their risk of melanoma and making sure that people have access to a dermatologist when they have a suspicious lesion could be more effective in improving early detection.”
In the release, Dr. Ferris mentioned UV exposure is the largest modifiable risk factor for melanoma so sun protection is one vital precaution. However, she also emphasized the importance of patients watching their skin.
“If you have a suspicious lesion somewhere that is always covered by a shirt, it could still be melanoma. We encourage patients to seek care regardless of their perceived risk,” she said.
Bottom line: There is a large discrepancy in the number of patients needed to be screened for skin cancers to identify one cancer between White patients and patients with skin of colour. Increasing the rate of screening by physicians is unlikely to impact skin cancer outcomes among darker-skinned individuals so steps to improve patient education and access to dermatologists are needed.
From the literature on cancer in skin of colour
Onychocytic matricoma presenting as longitudinal melanonychia in a skin of colour patient
This paper presents the unique presentation of an onychocytic matricoma (OCM) in the toenail of a Black patient. The authors also review the clinical presentation, histologic features, and management of this rare, benign acanthoma of the nail matrix.
They note that there have only been 18 cases of OCM reported in the literature since it was first described in 2012. The previously described cases were in the fingernails and predominantly in White males. OCM presents with longitudinal melanonychia and nail thickening.
“OCM is a benign entity that may mimic a nail unit melanoma or squamous cell carcinoma especially when pachyonychia is present. Despite some clinical clues to suggest a diagnosis of OCM, a nail matrix biopsy is often required to rule out malignancy,” the authors write.
Asian American and Pacific Islander patients with melanoma have increased odds of treatment delays: A cross-sectional study
This retrospective review examined data on Asian American and Pacific Islander (AAPI) and Non-Hispanic White (NHW) melanoma patients from the U.S. National Cancer Database (NCD) from 2004 to 2020.
From a total of 354,943 AAPI and NHW melanoma patients the researchers identified, 1,155 (0.33%) were AAPI.
The AAPI patients had longer times from diagnosis to definitive surgery (TTDS) for stage I, II, and III melanoma (p<0.05 for all). When the researchers adjusted for sociodemographic factors, the AAPI patients had 1.5 times the odds of a TTDS between 61 and 90 days and twice the odds of a TTDS greater than 90 days. These racial differences in TTDS persisted in Medicare and private insurance types.
Investigators found uninsured AAPI patients had the longest TTDS (mean, 53.26 days), while those with private insurance had the shortest TTDS (mean, 34.92 days; p<0.001 for both).
Systemic therapy for Asian patients with advanced BRAF V600-mutant melanoma in a real-world setting: A multi-center retrospective study in Japan (B-CHECK-RWD study)
The authors of this paper note that while Anti-PD-1-based immunotherapy is considered a preferred first-line treatment for advanced BRAF V600-mutant melanoma, recent findings suggest that the efficacy of immunotherapy is lower in Asian patients with non-acral cutaneous melanomas.
To test the hypothesis that the optimal first-line treatment for Asian patients for this type of skin cancer may be different, researchers retrospectively examined data on Asian patients with advanced BRAF V600-mutant melanoma who had been treated with different medication classes. Data was collected from 28 institutions in Japan between 2016 and 2021. The patients were treated with first-line BRAF/MEK inhibitors (BRAF/MEKi group), anti-PD-1 monotherapy (Anti-PD-1 group), or a combination of nivolumab plus ipilimumab (PD-1/CTLA-4 group).
A total of 336 patients were treated with BRAF/MEKi (n=236), Anti-PD-1 (n=64) and PD-1/CTLA-4 (n=36). The median follow-up duration was 19.9 months for all patients and 28.6 months for the 184 patients who were alive at their last follow-up. For patients treated with BRAF/MEKi, anti-PD-1, PD-1/CTLA-4, the median ages at baseline were 62, 62, and 53 years (p=0.03).
Researchers found objective response rates were 69%, 27%, and 28% for the three treatment approaches, respectively (p<0.001). The median progression-free survival (PFS) was 14.7, 5.4, and 5.8 months (p=0.003), and the median overall survival (OS) was 34.6, 37.0 months, and not reached, respectively (p=0.535).
They found the hazard ratios (HRs) for PFS of Anti-PD-1 and PD-1/CTLA-4 compared with BRAF/MEKi were 2.30 (p<0.001) and 1.38 (p=0.147), and for OS, the HRs were 1.37 (p=0.111) and 0.56 (p=0.075), respectively.
BRAF/MEKi showed a tendency for longer PFS and equivalent OS with PD-1/CTLA-4 (HRs for PD-1/CTLA-4 were 1.78 [p=0.149]) and 1.03 [p=0.953], respectively). For patients who received second-line treatment, BRAF/MEKi followed by PD-1/CTLA-4 showed poor survival outcomes.
Disparities between Asian groups in time to melanoma treatment: A cross-sectional study
The authors of this paper note that most studies examining racial disparities in dermatology outcomes aggregate Asian ethnicities into one group, despite differences between Asian ethnicities. With this paper, researchers assessed any differences in time to melanoma treatment between Asian subgroups.
For this retrospective review, researchers used data from the U.S. National Cancer Data Base (2004 to 2020) that included Asian patients with melanoma. They excluded those with excisional biopsy as definitive treatment.
The authors grouped Asian ethnicities by region.
Overall, the investigators found South and Southeast Asian patients had the longest treatment delays while presenting younger, with later-stage melanoma, and having Medicaid or no insurance. These groups' higher rates of Medicaid, no insurance, and living farther from the hospital may pose socio-geographic barriers to diagnosis and treatment, the authors write.
They hypothesize that as treatment for advanced stages takes longer to coordinate, Southeast Asian patients' higher TTDS may result from presenting with later-stage melanoma.
“Health behaviours may also contribute. Compared to other Asian groups, Filipino patients have the highest rates of indoor tanning, and Asian Indian patients apply sunscreen least often,” they write.
VIDEO: Anyone can get skin cancer, including people of colour
Dallas-based dermatologist Dr. Rajiv Nijhawan speaks on skin cancer prevention and early detection, with a focus on skin cancer in people of colour.
At the intersection of skin and society
Brock University in St. Catharines, Ont., is holding an event to highlight how Indigenous ways of knowing and understanding are being embedded into research at the university, and how this approach can be applied to other areas of work.
According to a press release from the University, “Healing Circles of Engagement, Weaving Relationships in Research,” a one-day interdisciplinary Canadian Institutes of Health Research Scientifique Café, will be held Wednesday, Aug. 23, from 9 a.m. to 3:30 p.m. in Brock’s Goodman School of Business Atrium. Advance registration is required for this free event.
The event is hosted by the Department of Nursing Research Committee and will focus on knowledge mobilization, highlighting Indigenous methodologies and protocols to ensure research is taking place in a culturally safe way intended to build respectful relations.
“Health and culture are central to one’s overall well-being,” Connie Schumacher, Assistant Professor of Nursing and Nursing Research Committee Co-chair says in the release. “We look forward to showcasing groundbreaking work taking place across Brock as we talk about ways of doing Indigenous research.”
The event will include panel presentations and two panel discussions with Indigenous and Indigenous-ally scholars.
Topics being discussed will include Indigenous language renewal and its impact on cultural identity, sociocultural contexts that influence health and wellness, culturally appropriate knowledge translation and mobilization, meaningful Indigenous engagement in remote communities and working with patient partners.
More details on the event, including the complete schedule, are available at ExperienceBU or by email through email@example.com
This event is funded by the Canadian Institutes of Health Research, Institute of Indigenous Peoples’ Health.
Aug. 22 is National Surgical Oncologist Day in the U.S.
Something to think about in the week ahead…
Winston Churchill, U.K. statesman, 1874 to 1965
New York-based dermatologist Dr. Michelle Henry discusses safe and effective uses of dermatologic laser treatments for women with skin of colour.
If you like Skin Spectrum Weekly, why not check out Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper print providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Drs. Lisa Kellett (Toronto), Michal Martinka (Calgary), and Jaggi Rao (Edmonton) discuss strategies for optimizing the management rosacea.
In a therapeutic update, Drs. Marcie Ulmer (Vancouver), Jen Lipson (Ottawa), and Sonya Cook (Toronto), detail current and upcoming advances in acne treatments.
An essay from Dr. Nickoo Merati (Montreal) submitted to the 2022 Dermatology Industry Taskforce on Inclusion, Diversity and Equity (DiTiDE) short essay contest. Dr. Merati wrote about the importance of people with skin of colour to “see” their community members represented at decision-making tables to rise to their full potentials. The essay also touches on efforts by Canadian medical students to improve the representation of skin of colour in dermatology education materials.
Plus regular features, including the popular column “Vender on Psoriasis” by Hamilton, Ont. dermatologist Dr. Ron Vender
Read a recent digital edition of The Chronicle of Skin & Allergy here. To apply for a complimentary* subscription or to receive a sample copy, please email firstname.lastname@example.org with your contact information.
The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
Season two of the Shear Listening Pleasure podcast with Dr. Neil Shear has launched. Listen to the eighth episode here, where Dr. Shear speaks with dermatologist Dr. Sonja Molin (Kingston, Ont.) about allergology, patch testing, and the growth of Queen’s University’s dermatology division.
And if you’re looking for a web destination for all things derm, visit derm.city, “Where Dermatology Lives.” Please like, rate, review, and share it with your colleagues.