EXPERT ANALYSIS FROM AAD 17
ORLANDO (FRONTLINE MEDICAL NEWS) – Ignorance and exposure are teaming up to put Latinos in the bull’s-eye of skin cancer.
Many believe that they are not at risk for either melanoma or nonmelanoma skin cancers – and too often, their physicians believe the same, Maritza Perez, MD, said at the annual meeting of the American Academy of Dermatology. Because of such incorrect perceptions, Latino patients get little counseling about risky behaviors, and so their exposure to those dangers continues unabated.
“The behavior of many Hispanic patients is very risky,” said Dr. Perez , a clinical professor of dermatology, at Mount Sinai Medical Center, New York. “They don’t wear sunscreen. They don’t do skin self-exams. They use tanning beds. And because of these beliefs, they don’t educate their children about sun safety.”
Dr. Perez, who is also a certified Mohs surgeon, was one of six clinicians who spoke during the meeting at a special session focusing exclusively on Latin American skin issues. It’s the second time AAD has sponsored such a session at the annual meeting.
A research letter published in the Journal of the American Academy of Dermatology in 2011 broke down levels of skin cancer awareness by race and ethnicity among 165 whites, Hispanics, blacks, and Asians surveyed in New York City ( 64:198-200 ). Compared with whites, Hispanics were significantly less likely to have ever had a doctor perform a full body skin exam (21% vs. 61%) or to have performed a self-exam (37% vs. 54%). Significantly fewer believed that skin cancer could occur in darker skin (78% vs. 91%). Only 8% had heard of the ABCDs of early melanoma detection, compared with 27% of whites. And about half as many Hispanics said they wore sunscreen (55% vs. 96%).
Unfortunately, Dr. Perez said, doctors aren’t correcting these misperceptions. Many physicians display a similar lack of understanding. They may correctly believe that the risk for skin cancer is less among Hispanics than it is among whites overall, but fail to communicate individual risk.
What these physicians may not understand, Dr. Perez said, is that the Hispanic population comprises an incredible variety of ethnic backgrounds. The population’s centuries-long genetic mixing bowl means there is no “typical” Hispanic skin. Instead, it includes every Fitzpatrick skin type, from fair-skinned redheads to the darkest brown and black skins.
Inadequate healthcare access exerts yet another damaging force. Like other ethnic minorities, many Hispanic patients lack insurance or adequate access to medical care. Instead of seeking regular primary care that would include skin cancer screenings, they tend to rely on urgent care or emergency departments to address emergent health issues, Dr. Perez said. When primary and preventive care falls by the wayside, melanomas that could be diagnosed at a curable stage invariably progress.
“We know that the only way of curing melanoma is with a scalpel. And the only way to remove it is by treating early disease. We’re not doing that. Our melanoma patients are diagnosed at younger ages with more advanced disease with more lymph node involvement than Caucasians, so there is also more mortality. We achieve early-stage diagnosis in 91% of Caucasians, but only 74% of Hispanics.”
A 2011 paper on racial and ethnic variations in the incidence and survival of melanoma, based on national cancer registry data covering almost 70% of the U.S. population, from 1999-2006, provided more information on the differences between the white and Hispanic populations ( J Am Acad Dermatol. 2011 Nov;65[5 Suppl 1]:S26-37 ). Compared with non-Hispanic whites, Hispanics presented with thicker tumors (more than 1 mm, 35% vs. 25%), more regional involvement (12% vs. 8%), and more distant metastasis (7% vs. 4%).
Because adult Hispanic patients lack knowledge about their melanoma risk, they aren’t improving the outlook for their children, Dr. Perez said. The Hispanic demographic in the United States is already a young one. According on 2014 data cited by the Pew Research Center , 58% of Hispanics in the United States are aged 33 years or younger; 32% are younger than 18 years.
These young people are already endangering their health with unsafe sun behavior, Dr. Perez said. A 2007 study surveyed 369 white Hispanic and white non-Hispanic high school students in Miami about sun protection behaviors and skin cancer risk. The Hispanic teens were 2.5 times more likely to have used a tanning bed in the previous year; they were also less likely to wear sunscreen and protective clothing. The Hispanic students generally believed they were less likely to get skin cancer than the Caucasian students. They were 60% less likely to have heard of a skin self-exam and 70% less likely to have been told how to do one ( Arch Dermatol. 2007;143:983-8 ).
The oil to calm these troubled waters is education, Dr. Perez said. She takes this commitment very seriously, and said a simple conversation is the first step.
“I tell all my patients, no matter what ethnicity you are or what skin type you have, you can get skin cancer and you need regular, complete skin exams. And I teach them to do this for themselves.”
A senior vice-president for the Skin Cancer Foundation, Dr. Perez is coauthor of “ Understanding Melanoma: What You Need to Know ,” which is now in its fifth edition.
The book, originally published in 1996, is aimed at melanoma patients and their families. It covers the four types of melanoma and their causes and risk factors. Information on melanoma diagnosis, staging, treatment options, prognosis, and hereditary and genetic factors is also included, as well as guidelines for prevention.
The updated edition contains information on the latest immunotherapy and genetically targeted treatments, including ipilimumab (Yervoy), pembrolizumab (Keytruda), nivolumab (Opdivo), vemurafenib (Zelboraf), dabrafenib (Tafinlar) and trametinib (Mekinist). The book is available for download for a nominal fee.
She has also committed to educating physicians about the issue.
“If we want to decrease the incidence of melanoma in Latinos, decrease the tumor depth at diagnosis and bring down the higher mortality, we have to first educate the doctors who are taking care of these patients and correct the message delivered to Latinos by telling them that they are as prone to skin cancer as Caucasians. We simply have to get the message across that, just like everyone else, they need protection from the sun by applying sunblocks, using sunglasses, and covering their bodies with sun-protective clothing and large-rim hats. And we have to make medical care more accessible so that these people can be diagnosed and saved. This is what we need to do now. But I don’t know how many decades it will take to turn the tables.”
Dr. Perez had no disclosures relevant to her lecture.
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