Skin cancer risks for skin of colour patients
In patients with skin of colour, most common skin cancers more frequently found on parts of the body shielded from the sun (1,500 words, 7 minutes)
Individuals with richly-pigmented skin are more likely to develop the most common skin cancers (melanoma, basal cell carcinoma, and squamous cell carcinoma) in regions of their bodies less exposed to the sun, according to dermatologist Dr. Andrew F. Alexis.
During an episode of the What’s Health Got To Do With It? podcast, Dr. Alexis, president of the Skin of Color Society, and Dr. Valerie Harvey, director of the Hampton Roads Center for Dermatology in Virginia and a former president of the Skin of Color Society, identified several factors that increase the risk of skin cancer or having poorer outcomes in people with darker skin tones.
Sites he listed include:
Melanoma
Soles of the feet
Palms of the hands
Nail beds
Mucous membranes
Squamous cell carcinoma
Areas of chronic ulcers
Areas with chronic wounds
Areas with chronic inflammatory processes
In the context of a human papillomavirus infection
Non-White individuals who develop cancer tend to be diagnosed at later stages, said Dr. Harvey. “They are three times more likely to present with disease after it has already spread to their lymph nodes. And they are four times more likely to present with distant metastases.”
There are many reasons why these populations are diagnosed later, she said.
“Part of it has to do with not being surrounded by anyone in your family who is focused on skin cancer, who knows about skin cancer, who has even had skin cancer,” she said.
As well she noted these patients’ primary care physicians are less likely to have conversations about sunscreen and sun protection with them. There is also an overall lack of awareness among healthcare providers about skin cancer risk and skin cancer in these patient populations, Dr. Harvey said, and a lack of access to dermatologic care.
The takeaway: For individuals with darker skin types, chronic skin injuries or inflammation can raise the risk of some skin cancers. Prognosis is also often worse when finally diagnosed due to cancer being identified later. These delays in diagnosis are partly driven by a lack of community and primary care knowledge of how skin cancer presents in darker skin.
From the literature on skin cancer in skin of colour
Poroma in a patient with Fitzpatrick type V skin
The authors of this paper note that diagnosing poroma—a rare, benign cancer of the hair follicles and sweat glands—can be challenging, and misdiagnoses can lead to poor outcomes. They say that a scarcity of published images of poroma in darker skin types likely contributes to the difficulty in achieving an accurate diagnosis.
In the reported case, an 82-year-old African American male (Fitzpatrick Type V) presented with a tender, bleeding exophytic growth on his foot that had been growing for three months.
The differential diagnosis included both inflamed benign lesions, such as poroma, pyogenic granuloma, and verruca, and malignancies (amelanotic melanoma, squamous cell carcinoma, and porocarcinoma).
Dermatopathology on a shave biopsy confirmed the diagnosis of eccrine poroma.
Validity of a self-assessment skin tone palette compared to a colourimeter for characterizing skin colour for skin cancer research
The authors of this paper developed a nine-point Self-Assessment Skin Tone Palette (SASTP) as an alternative to the Fitzpatrick skin type scale to incorporate skin tones with more variation than the Fitzpatrick scale while being compact and easy for the participant to use.
They also tested to see if the SASTP is correlated with a colourimeter's assessment of a melanin index to facilitate the inclusion of Hispanic and Black people in skin cancer research.
Some 188 participants were recruited who did not use artificial tanning. The subjects were asked to self-identify their skin tones using the SASTP. Researchers then assessed the criterion validity of the SASTP by measuring a range of skin colours compared to a melanin index reported from a colourimeter for the upper-inner arm (non-sun-exposed skin colour) and the outer forearm (sun-exposed).
Among the participants, 50% were White, 30% were Hispanic or White-Hispanic, and 20% were other racial categories.
Investigators found the mean melanin of the upper-inner arm decreased with lighter skin colour and a stronger tendency to burn. The SASTP, in comparison to melanin index values was correlated for both the upper-inner arm (r=0.81, p<0.001) and the outer forearm (r=0.77, p<0.001).
They conclude the SASTP can be considered as an alternative, less expensive method comparable to the objective colourimeter melanin index, which may be useful in studies on skin cancer among White, non-White, and Hispanic people.
Racial and ethnic differences in tumour characteristics and overall survival of women with melanoma: A national cancer database retrospective cohort study
This paper explores the racial and ethnic differences in women with melanoma.
The researchers conducted a retrospective cohort study, using data from the U.S. National Cancer Database 2004-2018 on 163,316 invasive primary cutaneous melanoma cases in women identified as non-Hispanic (NH) White, NH Black, NH Asian, NH American Indian/Alaska Native (AI/AN), or Hispanic.
Of the included cases, 96.9% were NH White, 1.7% Hispanic, 0.9% NH Black, 0.4% NH Asian, and 0.1% NH AI/AN women.
The investigators found the most common primary site was the lower extremities for all groups. Acral lentiginous melanoma (ALM) was the most common specific histologic subtype in NH Black women, while superficial spreading melanoma was most common for all other groups.
ALM accounted for 33.4% of lower extremity tumours in NH Black, 23.7% of NH Asian, 19.9% of Hispanic, 16.7% of NH AI/AN, and 3.7% in NH White women (p<0.001).
NH Asian women with ALM and NH Black women for all other histologic subtypes had the highest median Breslow thickness.
Other findings:
The stage at diagnosis was significantly associated with race/ethnicity (p<0.001)
Melanoma was diagnosed at stage I for 69.0% of NH White, 58.7% of NH AI/AN, 50.7% of Hispanic, 49.6% of NH Asian, and 35.4% of NH Black women
NH Black women had the highest rates of ulceration (37.2%) and regional lymph node positivity (20.6%)
Five-year overall survival rates were 84.7% for NH White, 81.1% for NH AI/AN, 78.8% for Hispanic, 75.2% for NH Asian, and 65.0% for NH Black women (p<0.001)
NH Black race independently increased mortality when compared to NH White women
Undereducation is afoot: Assessing the lack of acral lentiginous melanoma educational materials for skin of colour
In this paper, the authors discuss factors contributing to racial disparities in outcomes in acral lentiginous melanoma (ALM).
They note that a lack of representative educational material for both patient education and medical instruction contributes to these disparities.
Gaps they identify in the available information include risk of disease, patterns of incidence, and differences in disease presentation in skin of colour.
The authors write that the atypical presentation of ALM on acral volar skin sites makes early detection challenging. Physicians and patients should both have an increased index of suspicion, they say.
VIDEO: Skin cancer in skin of colour
Dermatologist Dr. Paul Yesudian (Chester, U.K.) reviews the latest literature on the risk factors, clinical features, and management of skin cancers in skin of colour. From a virtual talk for the Skin of Colour meeting organized by the British Association of Dermatologists.
At the intersection of skin and society
Dr. Sheryl Lightfoot, professor of Political Science and First Nations and Indigenous Studies at the University of British Columbia, has been named the chair of the United Nations Expert Mechanism on the Rights of Indigenous Peoples.
This is the first time an Indigenous woman from Canada has been appointed to the position. The last time a Canadian held the position was in 2012 when Grand Chief Wilton Littlechild was appointed chair.
“I’m excited but it’s also very daunting,” says Dr. Lightfoot in a press release. “As the world has emerged out of the pandemic lockdowns, Indigenous issues have really emerged at the forefront around the world. These issues have existed for a long time, but the impacts of the pandemic were often harder on Indigenous people and Indigenous rights. We have a lot of work to do to address this.”
Dr. Lightfoot added that the appointment is especially important for Canada as it is a “recognition of the country’s leadership role in the declaration and implementation of the rights of Indigenous peoples.”
The Expert Mechanism, which is composed of seven independent experts appointed by the Human Rights Council, is charged with providing expertise to the Human Rights Council. The mechanism also advises states in achieving the aims of the UN Declaration on the Rights of the Indigenous Peoples, which affirms Indigenous peoples’ rights to self-determination, equality, and non-discrimination.
Dr. Lightfoot said one of her goals as chair is to work toward enhanced representation and participation for Indigenous governing bodies from around the world at the UN Human Rights Council in a way that is “fair, just, and appropriate.”
This week
July 24 is International Self-Care Day
July 26 is National Disability Independence Day in the U.S.
July 30 is World Day Against Trafficking in Persons
Something to think about in the week ahead…
—Paulo Coelho, Brazilian author
Next week
Skin Spectrum Weekly reports on research investigating disparities in the incidence of cutaneous T-cell lymphoma arising from race and ethnicity, as well as socioeconomic status.
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:
A review of advances in cosmetic dermatology with Drs. Monica Li (Vancouver), Jessica Asgarpour (Toronto), Jason Rivers (Vancouver), and Andrei Metelitsa (Calgary).
Drs. Andrei Metelitsa (Calgary), Charles Lynde (Markham, Ont.) and Irina Turchin (Halifax) discuss new treatments for plaque psoriasis.
An essay from Dr. Shakira Brathwaite (Toronto) submitted to the 2022 Dermatology Industry Taskforce on Inclusion, Diversity and Equity (DiTiDE) short essay contest. Dr. Brathwaite wrote on the need for health systems to “see colour” and recognize the differences in needs and challenges dermatology patients with different skin types experience.
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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.
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