Addressing Skin Cancer Disparities: Unique Challenges and Solutions for Patients with Skin of Color

Dr. Valerie M. Harvey’s insightful presentation at the 2024 Skin of Color Update focused on the unique clinical and pathological features of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma in patients with skin of color. As the founder and clinical director of the Hampton Roads Center for Dermatology and a past president of the Skin of Color Society, Dr. Harvey brought her extensive experience to emphasize the importance of understanding skin cancer presentations and disparities in care among racially and ethnically diverse populations. The presentation also offered a pathway forward to reduce these healthcare inequities.

Dr. Harvey detailed how BCC, SCC, and melanoma present differently in patients with skin of color compared to lighter-skinned populations. BCC, which accounts for roughly 80% of all skin cancers, is the most common skin cancer in Hispanic individuals and the second most common in Black individuals.¹ It often appears as a solitary papule with rolled borders in sun-exposed areas, though the pigmented variant, more prevalent in skin of color, can make diagnosis more challenging. Squamous cell carcinoma (SCC), representing about 20% of skin cancers, is more common in Black patients, particularly in areas that are less exposed to the sun, such as protected or partially exposed regions.¹ Clinically, SCC may manifest as hyperpigmented plaques or nodules that are often mistaken for benign lesions, such as warts. Melanoma, while rarer in individuals with skin of color, tends to occur in acral locations, such as the hands, feet, and nails, and is often diagnosed at more advanced stages due to its subtler presentation and lower clinical suspicion.¹

Disparities in Diagnosis and Treatment

In her presentation, Dr. Harvey provided extensive data on the disparities in skin cancer outcomes between individuals with skin of color and non-Hispanic White populations. She noted that racial and ethnic minority patients are often diagnosed at later stages, with more advanced disease. For example, non-Hispanic Black patients are more likely to present with thicker, more invasive melanomas. Socioeconomic status, insurance coverage, and healthcare access were significant factors contributing to these delays in diagnosis.^2,3 Black patients are also more likely to experience longer wait times for treatment, sometimes facing delays of 30 to 90 days for surgeries or immunotherapy, compared to their White counterparts.⁴ These delays can severely affect prognosis, particularly for aggressive cancers like melanoma.

Additionally, melanoma in skin of color presents specific challenges. Dr. Harvey discussed how melanoma incidence rates are significantly lower in Black, Hispanic, and Asian populations compared to non-Hispanic White individuals, yet the survival rates for melanoma in non-whites are disproportionately lower .⁵ Another key study showed that while survival outcomes for localized melanoma worsened for all minoritized groups compared to non-Hispanic Whites, the disparities for regional and distant melanoma stages were especially pronounced for Hispanic patients.⁶ The study indicated that Hispanic patients saw the greatest worsening of survival disparities for regional and distant disease compared to other groups.⁶ Melanoma is often found in areas not typically associated with sun exposure, such as the lower limbs or mucosal surfaces, contributing to delayed diagnoses.⁷

Acral lentiginous melanoma (ALM) is particularly problematic, as it commonly occurs on the hands and feet and has poorer survival rates compared to other melanoma subtypes. Dr. Harvey discussed alarming survival disparities associated with ALM, particularly in Black, Hispanic, and Asian patients. She referenced a study that compared 5-year and 10-year survival rates for ALM and found that they were significantly lower across racial and ethnic minorities compared to White patients.⁸ For instance, the 10-year survival rate for ALM in Black patients was 71%, compared to 82.6% for White patients, with Hispanic and Asian populations falling in between. This disparity persists even when controlling for tumor thickness, a critical factor in melanoma prognosis, suggesting that other factors such as delayed diagnosis and access to care may be at play.⁸

Another significant finding Dr. Harvey presented was from a large study analyzing 1,439 cases of melanoma in Black patients between 1998 and 2007. The study found that 78.3% of ALM cases in Black patients were located on the lower limbs, primarily the feet.⁵ The unique location and difficulty in recognizing the lesions contributed to the poorer outcomes, as Black patients with ALM were more likely to present with later-stage, thicker melanomas. She also highlighted that, while White patients tend to present with thinner melanomas, Black patients, in particular, present with thicker, more advanced tumors, further complicating treatment and prognosis.

Dr. Harvey also explored the unique genetic and immunological profiles of ALM compared to other types of melanomas.⁹ She noted that ALM has a distinct mutation profile, including a lower frequency of BRAF and NRAS mutations, which are common in cutaneous melanomas (CMM). Instead, ALM is more likely to involve mutations in genes such as TYRP1, PTEN, and c-KIT, which suggests a different biological pathway of development. Additionally, ALM has a lower mutational burden than cutaneous melanomas, meaning that it has fewer genetic changes overall, which may partly explain why it behaves differently from other types of melanomas.

Immunologically, Dr. Harvey explained that ALM tumors often have a suppressed tumor microenvironment, characterized by lower levels of immune cells such as NK cells, CD8+ T cells, and gamma delta T cells, which are typically responsible for attacking cancer cells. This immune suppression can make ALM more resistant to immunotherapies that are otherwise effective in treating other melanoma subtypes.⁹ The lack of robust clinical models for ALM further complicates research efforts and limits treatment options.

Addressing the Disparities 

To tackle the significant disparities in skin cancer diagnosis and treatment, Dr. Harvey emphasized the importance of raising awareness among both the public and healthcare professionals. Public health campaigns tailored to reach minority populations can improve knowledge and encourage earlier dermatologic consultations. Additionally, she underscored the need to improve the quality of epidemiological data collection to better capture diverse populations and skin types. In this vein, she highlighted the need for AI-driven diagnostic tools trained on a wide variety of skin tones to reduce misdiagnoses.

Another key solution presented was the implementation of patient navigators—trained professionals who can assist patients in navigating the complex healthcare system, ensuring timely diagnoses, treatment, and follow-up care. Dr. Harvey advocated for increasing representation of patients with skin of color in clinical trials and research studies to better understand the biological pathways that contribute to more aggressive cancers in these populations.

The Path Forward 

In her closing remarks, Dr. Harvey laid out a comprehensive plan to bridge the gap in skin cancer care for patients with skin of color. She called for improvements in medical education, particularly around recognizing the manifestations of skin cancers in darker skin tones. She advocated for dermatology curricula and clinical imagery to be more inclusive of diverse skin types. Dr. Harvey also proposed increased research funding to support studies on skin cancer disparities, leveraging organizations like the National Institutes of Health (NIH) and the American Academy of Dermatology (AAD).

Overall, Dr. Harvey’s presentation was a call to action for dermatologists to be at the forefront of tackling healthcare disparities. By focusing on education, research, and inclusive patient care, the dermatology community can play a critical role in improving outcomes for patients with skin of color.

References:

1. 1. Hogue L, Harvey VM. Basal Cell Carcinoma, Squamous Cell Carcinoma, and Cutaneous Melanoma in Skin of Color Patients. Dermatol Clin. 2019;37(4):519-526. doi:10.1016/j.det.2019.05.009
   2. Kooistra L, Chiang K, Dawes S, Gittleman H, Barnholtz-Sloan J, Bordeaux J. Racial disparities and insurance status: An epidemiological analysis of Ohio melanoma patients. J Am Acad Dermatol. 2018;78(5):998-1000. doi:10.1016/j.jaad.2017.11.019
   3. Yan BY, Barilla S, Strunk A, Garg A. Survival differences in acral lentiginous melanoma according to socioeconomic status and race. J Am Acad Dermatol. 2022;86(2):379-386. doi:10.1016/j.jaad.2021.07.049
   4. Tripathi R, Archibald LK, Mazmudar RS, et al. Racial differences in time to treatment for melanoma. J Am Acad Dermatol. 2020;83(3):854-859. doi:10.1016/j.jaad.2020.03.094
   5. Brady J, Kashlan R, Ruterbusch J, Farshchian M, Moossavi M. Racial Disparities in Patients with Melanoma: A Multivariate Survival Analysis. Clin Cosmet Investig Dermatol. 2021;14:547-550. Published 2021 May 24. doi:10.2147/CCID.S311694
   6. Qian Y, Johannet P, Sawyers A, Yu J, Osman I, Zhong J. The ongoing racial disparities in melanoma: An analysis of the Surveillance, Epidemiology, and End Results database (1975-2016). J Am Acad Dermatol. 2021;84(6):1585-1593. doi:10.1016/j.jaad.2020.08.097
   7. Myles ZM, Buchanan N, King JB, et al. Anatomic distribution of malignant melanoma on the non-Hispanic black patient, 1998-2007. Arch Dermatol. 2012;148(7):797-801. doi:10.1001/archdermatol.2011.3227
   8. Bradford PT, Goldstein AM, McMaster ML, Tucker MA. Acral lentiginous melanoma: incidence and survival patterns in the United States, 1986-2005. Arch Dermatol. 2009;145(4):427-434. doi:10.1001/archdermatol.2008.609
   9. Carvalho LAD, Aguiar FC, Smalley KSM, Possik PA. Acral melanoma: new insights into the immune and genomic landscape. Neoplasia. 2023;46:100947. doi:10.1016/j.neo.2023.100947

This information was presented by Dr. Valerie Harvey during the 2024 Skin of Color Update conference. The above session highlights were written and compiled by Dr. Nidhi Shah.

Did you enjoy this article? You can find more here.