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FEATURE ARTICLES

Skin Cancer in Skin of Color

The Importance of Expanding Education and Prevention Efforts to Include This Community

Thomley, Meredith E.; Roland, Damien L.; Noble, C. Alexis; Sharma, Manoj; Shipley, Sonya R.; Nahar, Vinayak K.

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Journal of the Dermatology Nurses’ Association: 3/4 2021 - Volume 13 - Issue 2 - p 106-109
doi: 10.1097/JDN.0000000000000609
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Abstract

SKIN CANCER RISK IN BLACK AMERICANS

In the United States, skin cancer is the most frequently diagnosed cancer, and most cases are preventable (U.S. Department of Health and Human Services, 2014). Together, malignant melanoma (MM) and nonmelanoma skin cancer (NMSC) account for at least 99% of all skin cancers (U.S. Department of Health and Human Services, 2014). The National Cancer Institute estimates 100,350 new cases of MM in the United States for the year 2020, with the incidence of NMSC estimated 18–20 times higher (Apalla et al., 2017; National Cancer Institute, 2020). In addition, epidemiological evidence suggests that the incidence of both MM and NMSC is increasing (Guy et al., 2015; U.S. Department of Health and Human Services, 2014). Because the risk of developing both MM and NMSC is more prominent in white Americans, these conditions are often regarded as diseases that largely spare skin of color (Singh et al., 1998). Although fewer Black Americans are diagnosed with skin cancer overall (close to two of every 100,0000 new cases), these patients often present in later stages with poorer outcomes and increased mortality (Ferrer, 2017; Halder & Bridgeman-Shah, 1995; National Cancer Institute, 2020). Particularly in cases of MM, where stage at diagnosis foretells prognosis, Black American patients present with more advanced lesions and have a longer time from diagnosis to surgery (Byrd et al., 2004; Tripathi et al., 2020). The authors suggest that this could be because in part of an unfamiliar presentation of lesions, lack of effective public education, and social barriers to care. Herein, we further explore the evidence for why this may be so.

In discussing the discrepancies of skin cancer prognosis across races, one must first acknowledge the anatomical and pathologic differences that predispose certain populations to delayed diagnosis (Singh et al., 1998). First, where melanoma occurs on sun-exposed skin 90% of the time in white populations, skin cancer appears in less exposed areas in the skin of color. In Black Americans, MM and NMSC may appear anywhere from mucosal to palmoplantar to subungual locations, making early diagnosis elusive (Byrd et al., 2004). In addition, squamous cell carcinomas found in skin of color have been noted to be frequently atypical in character. Whether papular or nodular, hyperkeratotic, or hyperpigmented, it is not uncommon for squamous cell carcinomas to be initially misdiagnosed in Black Americans (McCall & Chen, 2002). Therefore, a high clinical suspicion must accompany thorough physical examination techniques. These lesions may also be overlooked because of the assumption that skin of color is immune to sun damage. Although it is well described that the increased number of melanocytes in Black Americans yields more protection from cytotoxic damage by ultraviolet radiation, these cells do not confer complete resistance (Singh et al., 1998). In addition to sun exposure, cutaneous malignancies can develop under the influence of many other risk factors, such as genetic predisposition, chronic inflammation, and a large number of benign nevi, multiple atypical nevi, or the presence of actinic keratoses. These established risk factors may rarely apply to Black Americans, necessitating a high index of suspicion for clinicians (Byrd et al., 2004; Halder & Bridgeman-Shah, 1995). Given the growing burden of disease, providers must be more diligent in skin check screenings for their patients with skin of color. The need for diligence is particularly pressing among older adults, especially men, who experience the highest rates of melanoma in the Black American community (Culp & Lunsford, 2019).

SKIN CANCER PREVENTION PRACTICES IN BLACK AMERICANS

Whereas some of the listed risk factors like preexisting pigmented lesions or genetic conditions are fixed, others can be influenced by one's lifestyle and daily practices (Halder & Bridgeman-Shah, 1995). Behaviors such as increased sun exposure and infrequent sun protection make one more susceptible to developing a concerning lesion. Studies show that one's perceived risk of acquiring skin cancer impacts the likelihood that they would participate in healthy habits surrounding sun exposure (Pichon, Corral, Landrine, Mayer, & Adams-Simms, 2010). However, there lies a growing gap between the actual and perceived risk of developing a malignant lesion. This discrepancy is further underlined by differences in demographics, particularly race. About 13%–25% of sun-sensitive individuals perceive themselves to be at a high risk for skin cancer, with factors such as personal or family history increasing that risk (Pichon, Corral, Landrine, Mayer, & Norman, 2010). Black patients perceive themselves to be at an even lower to no risk of skin cancer, citing heart conditions and diabetes to be their prevailing concerns. One study illuminates why this perception is low, touting a lack of known family or friend history of skin cancer history in Black American communities (Lunsford et al., 2018). Primarily Black households also seem to have fewer skin-cancer-related conversations, with the assumption that having a darker skin tone and a rare history of sunburn are completely protective (Lunsford et al., 2018). These beliefs are perpetuated in society, resulting in less diligence surrounding skincare for patients of color regarding their skin.

Accepting these norms is certainly understandable, as most of the public education surrounding skin cancer is aimed toward red- or blonde-haired individuals with light eyes and freckles (McCall & Chen, 2002; Meh et al., 2013). Although current educational programs are both available and prevalent in our community, they are typically designed for a white population in mind (Rigel, 2008). Neither print nor digital media sources frequently publicize sun protection for patients of color (Lunsford et al., 2018). We posit that patient education efforts for skin cancer prevention should specifically target the Black population as well. Meh et al. agree, stating, “There is, therefore, a need for educational information tailored for African Americans to influence knowledge, attitude, and sun protection behaviors towards skin cancer” (Meh et al., 2013). A key component of skin cancer prevention for Black patients is being cognizant of the fact that darker skin does not bestow immunity from cancer of the skin. Although these patients may have more protective melanocytes in their skin, Black Americans are still prone to deadly skin cancers such as melanoma. We hope that, by increasing effective education about protective barriers and skin cancer prevention, Black Americans may be diagnosed earlier with fairer prognoses.

HEALTH EDUCATION IMPLICATIONS TO IMPROVE SKIN CANCER PREVENTION PRACTICES IN BLACK AMERICANS

The behavioral educational interventions targeting skin cancer have underutilized technology and environmental constructs (Taber et al., 2018). A review of 86 such behavioral interventions found that only 65.8% had used behavioral theories, of which social cognitive theory (Bandura, 1986), the theory of planned behavior (Ajzen, 1991), and health belief model (Rosenstock, 1974) were the most common ones (Taber et al., 2018). Most of these theoretical models are now old and getting replaced with fourth-generation multitheory models (MTMs) that utilize the constructs of environment and technology more pragmatically (Sharma, 2017). One such model is the MTM of health behavior change (Sharma, 2015, 2017), which can be used to design efficacious and effective behavioral interventions for skin cancer prevention in Black Americans. The MTM breaks down behavior change into initiation and maintenance phases. The initiation requires getting persuaded of behavior change, having the sureness to make the behavior change, and having resources from the physical environment, whereas the maintenance phase of the behavior change requires one to transmute one's emotions into actions, making changes with the help of technology, and having backings from the social environment such as from family and friends. Interventions based on this approach with other health behaviors are showing more efficacious results (Bashirian et al., 2019; Brown et al., 2020; Hayes et al., 2019). Such an approach needs to be applied to skin cancer prevention interventions especially for Black populations.

Providers must additionally play a role in skin cancer prevention and seek out, educate, and encourage sun-safe behaviors for Black patients (Meh et al., 2013). When addressing this subject matter, it has been shown that detailing procedural recommendations, like teaching known risk factors and practicing sun protection, are more effective than declarative counseling, or stating the exact science of skin cancer formation (Meh et al., 2013). Perhaps, if healthcare providers were to counsel their skin of color patients on sun exposure avoidance like they would their lighter-skinned patients in the clinic, disparities because of delayed diagnosis and poor prognosis in Black Americans with skin cancer can be improved (Gupta et al., 2016). In addition to clinical care, spreading a sun-safe message in the community is also important to reiterate good sun practices outside the medical environment. For example, religious entities, community centers, and local schools could be places where skin cancer prevention is taught in predominately Black areas. As a result of such efforts, clinicians can establish rapport with the community, thus augmenting the impact of medical advice on patients. Community leaders, partnered with dermatologists and other skincare providers, could engage in public health awareness efforts as well. Such efforts could ultimately lead to a paradigm shift in the Black community through skin protective education, which could ultimately reduce the number of patients with delayed presentations of cutaneous malignancies.

FUTURE RECOMMENDATIONS TO IMPROVE EQUITABLE CARE

Finally, we must address the root of why members of the Black community experience skin cancer more so than their white counterparts. As aforementioned, Black Americans have a low survival rate for skin cancer as a result of the healthcare disparity that exists in our society (American Cancer Society, 2009). The historical basis of such disparity is long standing and deeply entrenched in the Black community, leaving scars that linger to this very day. For example, unsanctioned experiments in Black patients such as the Tuskegee Study of Untreated Syphilis have led to deep-seated mistrust of the healthcare system (Alsan & Wanamaker, 2018). In fact, patients of color are less likely to report trust of their physicians and hospitals and are less likely to seek treatment or follow recommendations for this reason (Armstrong et al., 2007). Because we can attribute this increased skin cancer mortality to presenting with advanced disease when going to see a physician, we then must ascertain what additional barriers to care would cause this delay (Cress & Holly, 1997). Distrust in the healthcare system may prevent patients from raising concerns about new or changing lesions to their provider. This distrust is a common barrier among Black patients in addition to experiencing difficulty acquiring primary care providers and health insurance as well as receiving appropriate preventative care. Significant predictors of diligent sunscreen use rely heavily on education and income; likewise, Black patients may be less educated on sun exposure and may be less able to obtain sunscreen and other resources (Meh et al., 2013; Pichon, Corral, Landrine, Mayer, & Norman, 2010). Shave and punch biopsies can be costly but can save lives if done early in a disease process. Because Black Americans may come from lower socioeconomic backgrounds, diagnostic studies may serve as a financial barrier in getting patients appropriate care. Besides cost, patients may avoid seeking perceived invasive interventions if their healthcare provider is not of a concordant race according to a National Bureau of Economic Research study (Alsan et al., 2018). In fact, outcomes for Black patients tended to be better when they were treated by Black providers. We feel that employing Black dermatology providers could offset several of these barriers to care and provide an avenue to treatment for these patients. Additional ideas to consider would include free skin checks at dermatology clinics for patients without insurance. We advocate to not only increase skin cancer prevention education but also place more skincare specialists in Black communities. Finally, patients of color may have difficulties surrounding and apprehensions about acquiring a provider in a scarce market of Black dermatologists. If there were more Black dermatologists in the field and representation in the community from physicians who resembled the same demographic as the community, patients may feel more comfortable seeking treatment. Access to care would also likely improve as physicians of color are more likely to treat minority patients and practice in underserved areas (Komaromy et al., 1996). Task forces like the American Academy of Dermatology's Minority Task Force and the Skin of Color Society work to address these issues, and future research may address the shortage of Black dermatologists. In addition to increasing the number of minority providers, medical education programs must also seek to address the implicit biases of healthcare providers. Bias impacts clinical decision making, and its presence has been shown to prevent the administration of potentially lifesaving treatments (Green et al., 2007). Therefore, failing to address biases during the course of medical training likely is a large contributor to healthcare disparity. Finally, training programs must seek to include copious images of skin diseases in patients of color to further facilitate early recognition and treatment. Although a detailed discussion is beyond the scope of this commentary, future work must continually seek to dismantle systemic racism as well as address the social determinants of health that contribute to health inequity as well as poor health outcomes of minority populations.

To influence the culture around skin cancer prevention in Black Americans, we must tackle the barriers to equitable treatment. First, we recognize that anatomic and pathophysiologic differences must be studied by all and given careful attention, imploring clinicians to maintain a high index of suspicion in the skin of color. Second, we assert that, to form proper sun-sparing behaviors, public education must be paramount. Finally, we acknowledge the impact of barriers to care in Black populations. Future research efforts should focus on strategic education interventions and effective public policy changes that make receiving healthcare from a dermatologist accessible, equitable, and reliable.

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Keywords:

Skin Cancer; Prevention; Skin of Color; Health Education

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