Skin Cancer in Skin of Color

Porcia T. Bradford

Disclosures

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

In This Article

Melanoma

Melanoma is the third and most deadly form of skin cancer in all racial groups (see Table 3). During the 1970s, the incidence of cutaneous melanoma increased rapidly by 6% per year, but slowed to 3% per year from 1981 to 2000, and has remained stable since then (National Cancer Institute, 2009). Interestingly, rates of invasive melanoma have increased markedly among Hispanics in California since 1988, with a 1.8% per year increase in incidence of invasive melanomas among Hispanic males between 1988 and 2001, and a 7.3% annual increase in the period between 1996 and 2001 (Cockburn, Zadnick, & Deapen, 2006).

Major risk factors for melanoma include intermittent high exposure to sunlight (sunbathing) and chronic cumulative dosages of UVR (outdoor workers) (see Table 3). Host susceptibility factors include dysplastic nevi, increased number of nevi, freckling, family history of melanoma, fair complexion, light eyes, and blonde or red hair (Tucker & Goldstein, 2003).

Clinically, melanomas typically present as dark, rapidly spreading patches (see Table 3). Clues to the diagnosis of subungual (under the nail) melanoma include a pigmented band on the nail with width greater than 3 mm (Hutchinson's sign), variable pigment, rapid increase in size, and the presence of solitary lesions (Gloster & Neal, 2006).

In Caucasians and to a lesser extent, Hispanics, melanomas predominantly occur in sun-exposed skin, whereas in Asians and Blacks, UVR does not appear to be a significant risk factor, and the majority occur in non-sun-exposed skin (subungual, palmar and plantar surfaces, mucus membranes) (Bradford, Goldstein, McMaster, & Tucker, 2009) (see Table 3). Oral melanomas represent about 7.5% of all melanomas in Asians, and two-thirds of these tumors arise from oral melanosis (Collins, 1984). In non-Whites, the plantar portion of the foot is often the most common site, being involved in 30% to 40% of cases. People of color also have higher percentages of acral lentiginous melanoma (melanoma of the palms, soles, and nailbeds) than Caucasians (Bradford et al., 20 09), whereas superficial spreading melanoma is the most frequent subtype in Caucasians and Hispanics (Byrd-Miles et al., 2007).

Multiple studies have demonstrated 5-year melanoma survival rates of Blacks and Hispanics are consistently lower than those of Caucasians (Byrd, Wilson, Hoyler, & Peck, 2004; Rahman & Taylor, 2001; Reintgen, McCarty, Cox, & Seigler, 1982). Compared with Caucasians, Hispanics and Blacks tend to present with more advanced, thicker tumors and thus tend to have a poorer prognosis, with higher mortality. In a review of California melanoma cases, tumors thicker than 1.5 mm at presentation increased at 11.6% per year and 8.9% per year among Hispanic males and females, respectively (Cockburn et al., 2006). In a retrospective analysis of case reports to the Florida Cancer Data system, late stage (regional and distant) was more common among Hispanic (26%) and Black patients (52%) compared with Caucasians (16%) (Hu et al., 2006). Interestingly, in a review of California melanoma cases, it was shown that even after adjustments for age, sex, histology, stage, anatomic site, treatment, and socioeconomic status, a statistically significant increased risk of death was observed for Blacks compared with Caucasians (Zell et al., 2008). Hence, the poor survival for Black patients with melanoma is not fully explained by differences in treatment or socioeconomic status. All of these results indicated that more primary and secondary prevention efforts are warranted for the control of melanoma in all races/ethnicities, even for those persons who are at a lower risk of developing the disease (Friedman et al., 1994).

Treatment for melanoma includes wide local excision or, sometimes, amputations for melanoma involving the limb, such as acral lentiginous melanoma. Metastatic melanoma is very difficult to treat, but includes isolated limb perfusion with chemotherapy, radiation, IL-2, and experimental cancer vaccines (Markovic et al., 2007).

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