Over the past 25 years, we have made progress in melanoma treatment, screening, diagnosis
and prevention, however, addressing melanoma health disparities in some population
groups is an area in which progress has not kept up [1]. In general, poorer outcomes
for melanoma exist for ethnic minorities, people who are less educated, people of
lower socio-economic status, the elderly and the uninsured [2]. Ethnic minorities
are thought to be about two- to three-times as likely to die from melanoma as age-
and sex-matched individuals from nonminority groups [3]. Biological factors may account
for some of these differences but several of the underlying mechanisms of these disparities
are unclear and under-researched. Furthermore, while numerous epidemiological studies
have been carried out on melanoma and its prevention [4,5] we lack comprehensive research
on melanoma in ethnic minorities and other overlooked population groups in countries
around the world [2].
There is a need to address these disparities in melanoma in overlooked population
groups. In countries where there are typically few dermatologists serving the population,
the existing dermatology workforce may face additional pressure if melanoma incidence
increases and the patient load increases [1]. We may see more overlooked populations
seeking assistance with screening and detection of melanoma. In some countries, changing
demographics may also mean larger proportions of the population falling into ethnic
minority groups, therefore numbers of people seeking healthcare visits may increase.
In addition to these pressures, premature deaths [6], lost productivity due to years
of life lost [7] and impacts on communities and families are also costs associated
with melanoma disparities in overlooked groups.
In general, primary and secondary melanoma prevention has focused most of its attention
on specific populations and at-risk groups based on the known nonmodifiable and modifiable
risk factors for melanoma, among others, presence of naevi, sun exposure, sunbed use,
sunburns and phenotype [8,9]. Population-based melanoma prevention messages alerting
the public to these risk factors have been largely directed to the general population
as well as to high-risk outdoor occupations, high-risk recreation groups, patients
postskin cancer diagnosis and organ transplant recipients [10]. Overlooked groups
include ethnic minorities, the elderly, the military, the uninsured and people with
disabilities [11,12]. Among the elderly, the perceived risk for developing melanoma
and inclination to seek a skin examination tends to be low [1]. Health insurance status
also influences melanoma outcomes where people seeing their primary care physician
in the private sector are more likely to use skin cancer prevention screening, for
example, compared with patients using public healthcare [13].
Freeman and Chu's health disparities cancer model is based on the premise that social
setting, incorporating poverty, culture and social justice, plays a part in disease
outcome [14]. The model infers a relation between social determinants of health and
health inequities [15]. Many of the factors related to the successful implementation
of cancer prevention, control, and treatment are affected by socially determined factors.
One can consider poverty-related barriers that influence melanoma outcomes such as
income, education and health insurance, as well as barriers related to social injustice,
for example, incorrect assumptions and mistrust [2]. Some barriers influencing melanoma
outcomes pertain to culture including risk behaviors, acculturation, skin cancer awareness
and knowledge, language fluency and perceptions of skin cancer risk [2]. In general,
people with deeply pigmented skin usually perceive that skin cancer is a disease that
only affects people with fair skin [16] and while this is in part true since melanoma
incidence is higher in people with fair skin [17], melanoma does occur in people with
deeply pigmented skin. However, the risk factors associated with melanoma in people
with deeply pigmented skin are, in general, poorly understood.
Exploring melanoma disparities in people with deeply pigmented skin: a South African
perspective
South Africa has a dual economy with both formal and informal sectors and is a country
with one of the highest inequality rates in the world. In 2014, the Gini coefficient
measuring relative wealth for South Africa was 0.69 (1 is perfectly unequal) based
on income data including salaries, wages and social grants [18]. In addition to an
unequal economy, the South African population of 55.7 million comprises four population
groups: 80% Black African, 9% colored (of mixed ancestry), 8% White and 3% Indian/Asian
[19]. About 82 out of every 100 people of the country's population seek healthcare
in the public sector and only 18 in 100 people have private medical insurance [20].
Furthermore, South Africa is said to battle a quadruple burden of disease that includes
HIV/AIDS, high-material and child mortality, high levels of violence and injuries
and a growing burden from noncommunicable diseases [21].
Finding studies and data on melanoma morbidity and mortality for overlooked groups
in South Africans is challenging. National Cancer Registry data show that melanoma
incidence is lower among Black Africans in South Africa compared with White South
Africans [17]. The type of melanoma and the anatomic site of melanoma occurrence also
differs between population groups, where this information is available. Melanoma in
Black Africans is usually acral lentigenous melanoma and commonly occurs on the upper
limb/shoulder and lower limb/hip compared with the occurrence on the head and trunk
anatomic sites of White South Africans [17]. The 5-year melanoma survival for people
with deeply pigmented skin is typically lower compared with that for White populations
[2]. The few published studies show later stage of cutaneous melanoma at diagnosis
and lower 5-year survival rates among Black South Africans compared with White South
Africans [22]. The risk factors for melanoma in people with dark skin are complex
and not well understood. It is unlikely that sun exposure plays an important role
in the epidemiology of acral lentigenous melanoma, however, trauma, such as insect
bites, wounds and scar tissue, may be an important risk factor warranting further
research for this population group [22]. Other risk factors such as sex, age and genetics
are also important [22].
Contributing factors related to delayed diagnosis seen among Black South Africans
are likely to include low-perceived melanoma risk, low index of suspicion of melanoma
among healthcare providers and in some cases, suboptimal access to healthcare [22].
If efforts were made to increase secondary melanoma prevention in South Africa and
improve early detection of thin melanomas, there may be some pressure placed on the
180 dermatologists practicing in the public and private sectors in the country [23].
If we are to try and address melanoma in Black South Africans, a comprehensive, holistic
approach will be needed.
What can be done to reduce health disparities in melanoma in overlooked populations?
The complexities of preventing melanoma in overlooked population groups, such as Black
South Africans and in countries with wide disparities in inequality are challenging
[24]. Three board areas, namely research, skills development and treatment, and education
and raising awareness need to be addressed if we are to reduce the health disparities
that are seen in overlooked populations and minority groups in relation to melanoma.
Reliable data and research are needed on the epidemiology of melanoma in overlooked
population groups in different countries around the world. For example, we need to
explore how socially determined factors influence the inequities that exist in stage
of melanoma and survival rates among individuals with dark versus fair skin. There
is work to be done to better understand emerging issues, such as the implications
of skin bleaching among individuals with dark skin and the subsequent risk, if any,
of skin cancer [25]. It would also be helpful if cancer registry records include data
about personal ancestry, population group and skin color. This information would be
valuable for developing effective interventions and developing melanoma prevention
measures and strategies that target vulnerable groups.
We need to improve knowledge and awareness of melanoma among medical professionals
[12] as well as familiarize clinicians with important features that characterize melanoma
and the different forms of melanoma in patients across all Fitzpatrick phototypes
with different skin colors [12]. It is also important that we aim to raise awareness
about dermatologic health disparities in melanoma among overlooked populations themselves
and ensure high-quality treatment and healthcare services for all groups.
Many primary and secondary population-based melanoma prevention campaigns have focused
on targeting the general population and provided specific messages, such as to check
moles, to avoid sunburn and to use sun protection. Messages about sunburn, for example,
might not be relevant in terms of melanoma prevention among some overlooked groups,
especially for individuals with deeply pigmented skin. Sunburn as a term is not commonly
understood among individuals with deeply pigmented skin [26] therefore, messages about
sun protection related to sunburn are not helpful to all individuals in a population
in relation to melanoma prevention. We need to enhance and expand our efforts to raise
awareness about melanoma among ethnic minorities and overlooked groups and include
information on early signs of melanoma in pigmented skin [12]. This information needs
to be in appropriate formats for different cultures and languages too [16].
Conclusion
The complexities of preventing skin cancers in countries with multiethnic populations
and wide disparities in inequality, wealth, health status and access to health services
are challenging. Several factors contribute to these disparities in melanoma outcomes
including social determinants of health and various barriers such as the lack of training
for diagnosis and treatment of melanoma among healthcare professionals in public healthcare
settings. Next generation melanoma prevention research should include, among others,
efforts to identify risk factors for melanoma in overlooked population and populations
with disparities in melanoma outcomes. Several of the barriers, while undoubtedly
complex, are potentially modifiable and additional research will help to better understand
how to tackle these complexities with the end goal of reducing the burden of melanoma
morbidity and mortality in overlooked populations and ethnic minorities.