Social Determinants of Racial and Ethnic Disparities in Cutaneous Melanoma Outcomes
the ONA take:
Poor prognosis and limited treatment options for advanced-stage cutaneous melanoma make early detection and diagnosis critical. Although its incidence is greatest in whites, most studies have shown that racial and ethnic minorities with a diagnosis of cutaneous melanoma are more likely to experience worse outcomes. In general, patients’ perception of their risk of cancer is a significant barrier to risk reduction. The medical literature has shown that blacks and Hispanics perceive their risk for developing skin cancer as very low. Therefore, these patient populations are not likely to practice skin self-examinations. As a result, they are more likely to present with advanced disease at diagnosis than are whites.
Socioeconomic status measures (eg, highest level of education, occupation, income, health insurance status, and place of residence) are key factors in preventive medicine practices, cutaneous melanoma incidence, stage at diagnosis, and melanoma mortality rates. Furthermore, acculturation, the process by which immigrants adopt the lifestyle norms of their host country, among Hispanics has contributed to behavioral changes that increase their risk of skin cancer.
With this information, the medical community will be able to develop more effective programs targeted to these populations. However, more information is needed about this disease in regard to other US minority groups, such as Asians, Pacific Islanders, Native Americans, and Native Alaskans.
Background: This article sought to elucidate how aspects of poverty and culture may contribute to race- and ethnicity-based disparities in cutaneous melanoma outcomes.
Methods: We identified published studies addressing the social determinants of melanoma. Selected review articles included US-based studies comprised of patients representing adults, children, and adolescents.
Results: African Americans and Hispanics diagnosed with cutaneous melanoma are more likely to present with more advanced stages of disease at diagnosis and have higher rates of mortality than their nonminority counterparts. These disparities may be a consequence of economic, social, and cultural barriers such as low income, public forms of health insurance, lower levels of education, lower levels of melanoma awareness and knowledge, and lower rates of participation in melanoma screening. No studies in the literature examined the potential impact of social injustice, English proficiency, immigrant status, and health literacy.
Conclusions: Substantial gaps exist in our knowledge of the pathways linking social determinants and race- and ethnicity-based disparities in melanoma. More studies are warranted to inform the development of effective interventions aimed at narrowing inequities and improving cutaneous melanoma outcomes among minority populations.
Cutaneous melanoma is a significant public health concern. In 2013, 76,690 incident cases and 9,480 deaths occurred from cutaneous melanoma in the United States alone.1 The poor prognosis and limited treatment options of advanced-stage disease make early detection and diagnosis critical. Although the incidence of cutaneous melanoma is greatest in Caucasians,2 most studies have shown that racial and ethnic minorities diagnosed with cutaneous melanoma are more likely to experience worse cutaneous melanoma outcomes.2-7
Surveillance, Epidemiology, and End Results data reveal that Hispanics, African Americans, American Indians, and Asians diagnosed with cutaneous melanoma are more likely to present with advanced (regional and metastatic) cutaneous melanoma than Caucasians.3,4,8-12 Moreover, while the proportions of local stage or in situ cutaneous melanomas have increased among Caucasians, an opposing trend has been observed among Hispanic men living in California who present with thicker primary tumors at diagnosis.4 Evidence also suggests variability in the quality of care received by minority patients with cutaneous melanoma. A Surveillance, Epidemiology, and End Results–based study found that blacks were less likely than Caucasians to receive surgical treatment for melanoma,13 and those who underwent surgery experienced shorter survival time than other races.13
After accounting for demographical and clinical characteristics, minorities have an approximate two- to three-fold greater risk of melanoma-specific mortality than their nonminority counterparts.14 In African Americans, differences in mortality rates persist even after stage at diagnosis is considered.2 Although biological factors may account for some of these differences (cutaneous melanomas in minorities tend to occur at unusual anatomical sites and may be of more aggressive histological subtypes), the underlying mechanisms of these disparities remain unclear.2