SAN FRANCISCO—Hispanic and Asian women have an increasing risk of developing non-melanoma skin cancer, according to a study presented here at the American Academy of Dermatology Annual Meeting.
“Previous perception has been that the skin cancer risk in Hispanics and Asians is lower than that of Caucasians, but despite their historically lower rates, in recent years the incidence of skin cancer in these groups has been increasing in the United States,” said Arisa Ortiz, MD, Assistant Clinical Professor of Dermatology and Director of Laser & Cosmetic Dermatology at the University of California, San Diego.
“Ethnic populations are not immune to skin cancer. We need to properly educate ethnic groups that skin cancer is not unique to Caucasians. In particular, clinicians need to target Hispanic and Asian women, who have an increased risk of developing skin cancer.”
Non-melanoma skin cancer (basal cell carcinoma and squamous cell carcinoma) is the most common type of malignancy in the United States, with more than 3.5 million non-melanoma skin cancers diagnosed each year. The incidence is rising at about 2.6 percent per year, and one in five Americans will be diagnosed in their lifetime.
“Non-melanoma skin cancers are more prevalent among Caucasians and have been well-studied in this group,” Ortiz said. “Most risk factors, characteristics, and recommendations for skin cancer prevention are based on studies of Caucasian patients. There are limited data on skin cancer in other ethnicities.”
Hispanics and Asians are the fastest-growing minorities in the United States and are projected to make up an even larger proportion of the population in the future, she noted. “It is important to evaluate the risk factors and clinical features of non-melanoma skin cancers in these ethic groups.”
She and her colleagues—first author Tiffany Loh, Alina Goldenberg, and Shang I. Brian Jiang—compared the incidence of non-melanoma skin cancers among Hispanic, Asian, and Caucasian patients presenting at the UCSD Mohs and Micrographic Surgery Unit between 2007 and 2012, comparing the risk factors and clinical characteristics of the lesions via a five-year retrospective chart review.
Electronic medical records contain documentation of patients' racial self-identification, and only patients who self-identified as Caucasian, Hispanic, or Asian were included. The records were reviewed for patient age, sex, lesion location, cancer subtype, pre- and post-operation size, and number of Mohs stages required for excision.
The researchers found more than 4,029 cases of non-melanoma skin cancers, the vast majority (96%) of which were in Caucasians. Hispanic patients were significantly younger (age 62) than Caucasians (age 67) and Asians (age 70).
“The majority of non-melanoma skin cancers in Caucasians occurred in men—64 percent male and 36 percent female,” Ortiz reported. “This is the reverse gender ratio in Hispanics, which was about 34 percent male and 66 percent female, and Asians, which was about 39 percent male and 61 percent female.”
Significantly more non-melanoma skin cancers occur in the “central face” area in Hispanics, she noted. Race was not a significant predictor for developing a specific non-melanoma skin cancer type, either basal cell carcinoma or squamous cell carcinoma.
“Surprisingly, we found an increased risk of non-melanoma skin cancer in Asian and Hispanic women. In Caucasians, it is more common for men to develop this disease,” Ortiz said, adding that the reason for the gender and cultural differences will require more research.
Asian cultures traditionally have favored fair skin as a beauty standard, she noted, but these attitudes may have shifted in second- and third-generation families that have adopted the U.S. preference for tanning. “In Asians from Asia, fair skin is thought to be attractive. When Asians migrate to the U.S., tan skin is thought to be more beautiful.”
The incidence of non-melanoma skin cancer in both Hispanic and Asian patients may be impacted by indoor tanning and excessive sun exposure, Ortiz continued. Members of these populations may not have access to sun protection information, or they may believe that their darker skin tone provides them with sufficient protection. It is important, however, for Hispanic and Asian individuals to take the same skin cancer prevention measures as Caucasians.
The study does have limitations in that it is a single-institution study with a small sample size and geographical location, and only patients with indications for Mohs and micrographic surgery were included.
In conclusion, Ortiz said: “The rise of non-melanoma skin cancers in Hispanics and Asians, especially among women, is concerning given that they are the fastest growing ethnic populations in the United States. It is important that proper counseling for photoprotection be stressed to those populations to prevent any further increase.
“Future large, multi-center studies focusing on non-melanoma skin cancer features and risk factors among minorities are necessary to further elucidate our findings.”
‘Skin Cancer in Skin of Color’
In a separate presentation titled “Why Skin Cancer is Important in Skin of Color,” Diane Jackson-Richards, MD, Director of the Multicultural Dermatology Center at Henry Ford Hospital in Detroit, noted that there is a need for clinics that specialize in treating skin of color. “By 2050, almost 50 percent of the U.S. population will be comprised of people with skin of color, according to the U.S. Census Bureau. Many common skin disorders present differently in skin of color, and skin of color responds differently to treatment. There is a higher frequency of some dermatologic disorders in certain ethnic groups.”
She noted that a recent online survey sent to dermatology chief residents and program directors asked about faculty or didactic lectures focusing on skin of color. The results showed that only 14.5 percent of programs have an expert in skin of color, less than one-quarter have experts that lecture on skin of color, and only slightly more than half have didactic lectures focusing on skin of color.
“Although skin cancer is much less prevalent in people of color, it is often associated with increased morbidity and mortality due to presenting at a more advanced stage. Increased education and awareness is needed.”
Non-melanoma skin cancer and melanoma account for 40 percent of neoplasms in Caucasians and, by contrast, in five percent of Hispanics, four percent of Asians, and two percent of blacks. But there are racial and ethnic variations in the incidence and survival rates for cutaneous melanoma in the U.S.
The melanoma five-year survival rate among Caucasians is 92 percent compared with 86 percent among Hispanics and 78 percent among blacks.
What will improve the outcome of skin cancer in patients with skin of color? Jackson-Richards asked. “Improving outcomes through early detection, improving patient awareness of their skin cancer risk, and education on appropriate sun protection.”
For early detection, clinicians need to “educate ourselves as well as those we are training to know the subtle differences in the presentation of skin cancer in various ethnic groups,” she said.
Adoption of Western culture by Asian Americans appears to have had an effect on skin cancer rates. An online and paper survey given to Asian Americans in northern California found that 60 percent of second-generation Westernized Asian Americans reported deliberate sunbathing compared with 47 percent of first-generation Asian Americans. The rate was only 34 percent of those raised mainly in Asia.
A recent survey of nearly 800 Hispanic adults examined the psychosocial correlates of sun protection behaviors. The participants resided in Arizona, California, Florida, New Mexico, or Texas and had no prior history of skin cancer. The survey included questions about suntan benefits and skin color preference, sun protection benefits and barriers, and sun protection behaviors and the perceived risk of skin cancer.
About three-quarters of the respondents said they were happy with their skin color; only 11 percent said they wanted darker skin. One-quarter felt their skin color protected them, and two-thirds disagreed with the feeling that there is nothing that can be done to lower the risk of skin cancer, she reported.
These results are similar to a study of Caucasians that found that three-quarters reported that the benefit of using sunscreen was to prevent sunburn, she continued. One-third of the respondents did not have some type of sun protection as part of their daily routine. Barriers to sunscreen use included the perceived unpleasant feeling, the cost, not knowing what to use, and the feeling that it interfered with work or leisure, she said.
The lack of sun-protection behaviors among African Americans may also be a problem. A study of more than 2000 African American adults in California assessed three types of sun protection behaviors: use of sunscreen, sunglasses, and broad-brimmed hats. Respondents rated their skin type similar to a Fitzpatrick rating.
The results showed that about two-thirds of respondents never used sunscreen and about one-third engaged in at least one sun-protective behavior. The odds of sunscreen use increased with income and education, and women were three to six times more likely to use sunscreen than men were.
There are also health disparities among different ethnic and racial middle and high school students in sun exposure beliefs and knowledge. A survey with a pre- and post-test given to approximately 800 adolescents in grades 6 to 12 found that about two-thirds felt that tans were “more attractive.”
Caucasians had the highest pre-test scores, Asians the second highest, and blacks the lowest scores. The survey also showed that parents of darker-skinned children did not encourage sun protection.
Jackson-Richards also provided information on how sunscreens are advertised. An assessment of 24 magazines for sun care products advertised from May through September 1997 to 2002 found that these products were advertised primarily in women's magazines. Advertising in men's, recreation, and parenting magazines were far fewer, she said.
The availability of sunscreen in Hispanic neighborhoods may also be an issue. A study of 65 Spanish-speaking adults participating in community-based focus groups asked the participants about their perceived risk of skin cancer and use of sunscreens. The researchers canvassed three communities: one primarily Hispanic, one primarily Caucasian, and one with an equal number of Caucasians and Hispanics. More than 100 merchants, including markets, pharmacies, and convenience stores, were assessed for sunscreen availability.
Only nine of the 65 participants (14%) considered themselves to be at risk for skin cancer. None had been taught skin self-exams. “Most did not use sunscreen because, they said, it was ‘too costly,’ ‘they don't need to,’ or ‘my skin has adapted to the sun,’” Jackson-Richards said.
Stores carrying sunscreen were twice as common in Caucasian neighborhoods as compared with Hispanic ones, and Hispanic neighborhoods had fewer sunscreens to choose from.
Specifically Ask about Sunscreen Use
Clinicians can improve early detection of skin cancer by asking their patients specific questions about sunscreen use: “Is it in a makeup or only applied to the face? Is it only worn on vacation or for all sun-exposed activities? What is your occupation? How often do you re-apply sunscreen? What SPF is your sunscreen?”
Jackson-Richards said that to improve awareness, she suggests instructing patients about the advantages of self-exams. A study in Chicago that included various ethnic groups instructed patients on how to identify abnormal moles. More than three-quarters of the nearly 100 participants returned for follow-up three months later with improved knowledge of skin cancer and self-skin checks.