Skin Cancer in Skin of Color

Porcia T. Bradford

Disclosures

Dermatology Nursing. 2009;21(4):170-77; 206. 

In This Article

Squamous Cell Cancer

Overall, SCC accounts for about 20% of all skin cancers, and excluding melanoma, approximately 75% of all deaths attributed to skin cancers (Alam & Ratner, 2001). SCC is the most frequently diagnosed skin cancer in Blacks (Halder & Bridgeman-Shah, 1995) (see Table 2), and the second most common skin cancer in Caucasians, Asians, and Hispanics.

Predisposing factors for SCC in people of color include scars from thermal and chemical burns (Copcu, Aktas, Sisman, & Oztan, 2003), chronic leg ulcers (Kong, Jogia, Nayyar, Berrington, & Jackson, 2008), and previous sites of radiation. Immunosuppressed patients, such as those with organ transplants or the human papillomavirus, are also at increased risk for SCC (Harwood et al., 2000). Patients with chronic inflammation, such as osteomyelitis, hidradenitis suppurativa, or lupus vulgaris, are also at increased risk for SCC (Halder & Bridgeman-Shah, 1995) (see Table 2). In Blacks, the most important risk factors for the development of SCC are chronic scarring processes and areas of chronic inflammation. In fact, chronic scarring processes are noted in 20% to 40% of cases of SCC in Blacks (Gloster & Neal, 2006). Cases of SCC developing in Black and Chinese patients with chronic discoid lupus erythematosus have also been reported (Ee, Ng, Tan, & Goh, 2006; Sherman, Lee, & Flynn, 1993).

SCCs are often superficial, discrete, and hard lesions arising from an indurated, rounded, and elevated base (Alam & Ratner, 2001) (see Table 2). Nonhealing ulcers on skin of color, regardless of original etiology, should be biopsied if present for a significant amount of time (Halder & Bridgeman-Shah, 1995).

People of color develop SCC predominantly in areas infrequently exposed to the sun, such as the legs, in contrast to Caucasians, who develop them in chronically sun-exposed skin (Halder & Bang, 1988) (see Table 2). For example, in one Howard University series, 15% of SCCs occurred in the anus in Blacks (Halder & Bang, 1988) (see Table 2).

Invasive SCC has the potential to metastasize. The disparity in metastatic rates of SCC between people of color and Caucasians may reflect the tendency for people of color to present with more advanced disease, presumably as a result of delays in diagnosis, or it may be related to the presence of inherently more aggressive tumors (Gloster & Neal, 2006). Unfortunately, SCC that develops within a chronic scarring process tends to be more aggressive and is associated with a 20% to 40% risk of metastasis, compared with the 1% to 4% metastatic rate of sun-induced SCC in Caucasians (Gloster & Neal, 2006). In one series of patients with SCC, the greatest mortality was seen in patients with perianal tumors (Mora & Perniciaro, 1981). SCC that arises from lesions of chronic discoid lupus erythematosus also appears to metastasize at a greater rate than SCC that arises from other pre-existing lesions (Halder & Bridgeman-Shah, 1995), so hyperkeratotic or poorly healing lesions in areas of chronic discoid lupus erythematosus in people of color should be biopsied immediately. Most patients with primary SCC have an excellent prognosis. However, if metastatic disease is present, 10-year survival rates are less than 20% for patients with regional lymph node involvement and less than 10% for patients with distant metastases (Alam & Ratner, 2001). Treatment for SCC includes Mohs' micrographic surgery and electrodessication and curettage.

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