Sarah J. Hayek, BS, Hunter Hammett, BA, Anne C. Kane, MD, FACS
Understanding disparities in cutaneous malignancy is crucial for head and neck surgeons, as over 80% of nonmelanoma skin cancers occur in the head and neck region1. While skin cancer predominantly affects persons of European descent, recent studies reveal significant disparities in diagnosis and treatment outcomes in populations of color, including decreased access to early diagnosis, specialized care, and common treatment modalities. These disparities are even more relevant due to recent annual increase of 3-7% in skin neoplasm diagnoses overall, and an increase in incidence of melanoma in the United States by an average of 1.4% annually over the past decade1-2. Amongst diverse populations, there has been a 7.3% annual increase in melanoma in Hispanic men and a 3.4% annual increase in Hispanic women between 1990-20042.
Disparities in diagnosis, treatment, and outcomes of cutaneous malignancies occur across various demographic groups, including racial and ethnic minorities and patients with socioeconomic barriers such as transportation and insurance status2-4. Recognition of different presentations amongst diverse populations is essential, as delayed diagnosis contributes to increased morbidity and mortality rates among patients of color2-4. Screening rates vary dramatically across populations, with only 5% of minority patients receiving total body skin examinations compared to 49% of white patients2. This is especially important as melanoma in Black patients more commonly occurs in skin that is not sun-exposed compared to White patients2. Hispanic patients have also demonstrated lower ability to recognize suspicious melanoma features when surveyed4. Comprehensive understanding of cutaneous malignancy presentation amongst patients of color is pivotal for providing equitable care and optimal outcomes for all patients.
Disparities in treatment outcomes for cutaneous malignancies additionally exist in racial and ethnic minority groups. Hispanic and Black patients have been found to be more likely to present with advanced stages of melanoma compared to non-Hispanic Whites, with 26% of Hispanic and 52% of Black patients presenting with regional or distant metastases at diagnosis compared to only 16% of non-Hispanic Whites4. This has been attributed to a lower index of suspicion of disease amongst both patients and healthcare providers4. One study using the size of Mohs micrographic surgery defects to examine health disparities, found that Hispanic/Latino patients had 17% larger Mohs surgery defects compared to non-Hispanic White patients. When comparing squamous cell carcinoma to basal cell carcinoma defects, Hispanic patients were found to have 80% larger defects in squamous cell carcinoma cases compared to only 25% larger defects in non-Hispanic White patients3. Five-year survival rates for Hispanic and African American patients with melanoma are 77.2% and 70.6%, respectively, compared to 91.3% in Whites4. These disparities are exacerbated by historical underrepresentation of patients of color as most medical literature and research on cutaneous malignancy to date has been focused on lighter skin types, contributing to poorer prognosis and lower survival rates due to delayed diagnosis attributed to differing clinical presentations2. These disparities emphasize the need for targeted interventions and improved awareness among healthcare providers.
In addition to race, there are multiple social determinant factors impacting cutaneous malignancy outcomes. Non-Hispanic Black and Hispanic patients more frequently delay primary care visits due to cost and transportation barriers5. Insurance status significantly affects outcomes, with uninsured and publicly insured individuals presenting with more advanced melanomas compared to those with private insurance6. Medicaid patients had 52% larger Mohs defect sizes compared to Medicare patients, while patients with private insurance had 10% smaller defects3. Geographic disparities show higher prevalence of skin cancers in rural areas across all racial groups. However, this rural-urban disparity disappears in households earning over $100,000 annually, demonstrating the impact of multiple social determinants on patient outcomes7. Language and cultural barriers particularly affect Hispanic patients, with over 15% lacking medical coverage and facing limited culturally targeted screening efforts8. Additionally, both non-Hispanic Black and Hispanic patients report difficulty finding providers from similar cultural backgrounds, which they consider important for their care5. These factors contribute to delayed diagnoses and treatment disparities, such as Hispanic patients experiencing significantly longer wait times for surgery, radiation, and chemotherapy compared to non-Hispanic patients diagnosed with melanoma9.
Gender-specific behaviors significantly influence risk patterns. Women more frequently use sunscreen and seek shade, while men show higher rates of protective clothing use but experience more sunburns10-11. Despite higher skin cancer risks, men engage in fewer overall protective behaviors and less frequent daily sunscreen use11. This behavioral disparity, combined with the presentation and outcome differences, suggests the need for gender-specific prevention strategies and educational interventions.
Current initiatives aimed at addressing disparities in these at-risk populations emphasize education, awareness, and early detection practices. Community-based educational programs have proven instrumental in enhancing patient understanding of skin cancer diagnosis and prevention. These initiatives are particularly effective for high-risk populations, including individuals with significant sun exposure, smoking habits and family history of skin cancers12-16. Providing accessible resources—such as educational pamphlets, informative websites, and on-demand videos—helps promote a deeper patient understanding of skin cancer risk factors and/or their skin cancer diagnosis. Culturally adapted materials including visuals relevant to skin of color and videos specific for Hispanic populations for example were found to improve knowledge and self-screening practices in these populations13-14. These materials empower patients, giving them crucial information to navigate their skin cancer journey with confidence and clarity. Community-based programs have leveraged bilingual health workers to deliver localized education on risk factors and screening techniques to rural communities, with notable increases in participants’ knowledge and confidence with self-checks15. Broader efforts such as the Moffit Program for Outreach Wellness Education and Resources (M-POWER) have focused on empowering underserved communities through comprehensive health education and improved access to prevention and detection services16. These initiatives highlight the value of culturally and linguistically tailored approaches in fostering proactive health behaviors in vulnerable groups in order to reduce existing disparities. By integrating comprehensive clinical assessment, targeted educational programs, and patient-centered resources, healthcare providers can deliver holistic care that addresses both the medical and emotional aspects of skin cancer management across various population demographics, bridging the clear divide in skin cancer outcomes.
While the majority of medical literature on cutaneous malignancy focuses on lighter skin types, there is growing interest in disparities in skin cancer including in those with skin of color and those impacted by social determinants of health. It is crucial that we recognize the variability in presentation amongst patients with skin of color and acknowledge disparities in diagnosis and treatment in this population. There is a need for greater research regarding health disparities amongst cutaneous malignancy patients in order to effectively construct targeted interventions for these affected populations. While most cutaneous malignancies are diagnosed by dermatologists, head and neck surgeons often become involved in treatment of these cancers in the head and neck area due to the intricate anatomy and importance of cosmetic outcomes in this area. Due to their significant involvement in treatment of these cancers, head and neck surgeons should be engaged in research and prevention of these disparities including working with their dermatologist partners on prevention strategies, ultimately leading to improvement in patient treatment outcomes.
References:
- Kolk A, Wolff KD, Smeets R, Kesting M, Hein R, Eckert AW. Melanotic and non-melanotic malignancies of the face and external ear – A review of current treatment concepts and future options. Cancer Treat Rev. 2014;40(7):819-837. doi:10.1016/j.ctrv.2014.04.002
- Munjal A, Ferguson N. Skin Cancer in Skin of Color. Dermatol Clin. 2023;41(3):481-489. doi:10.1016/j.det.2023.02.013
- Blumenthal LY, Arzeno J, Syder N, et al. Disparities in nonmelanoma skin cancer in Hispanic/Latino patients based on Mohs micrographic surgery defect size: A multicenter retrospective study. J Am Acad Dermatol. 2022;86(2):353-358. doi:10.1016/j.jaad.2021.08.052
- Higgins S, Nazemi A, Chow M, Wysong A. Review of Nonmelanoma Skin Cancer in African Americans, Hispanics, and Asians. Dermatol Surg. 2018;44(7):903-910. doi:10.1097/DSS.0000000000001547
- Juarez MC, Shah JT, Lee N, Stevenson ML, Carucci JA, Criscito MC. Racial and ethnic differences in healthcare access and utilization among U.S. adults with melanoma and keratinocyte carcinomas in the NIH All of Us Research Program. Arch Dermatol Res. 2024;316(10):686. Published 2024 Oct 14. doi:10.1007/s00403-024-03383-5
- Cortez JL, Vasquez J, Wei ML. The impact of demographics, socioeconomics, and health care access on melanoma outcomes. J Am Acad Dermatol. 2021;84(6):1677-1683. doi:10.1016/j.jaad.2020.07.125
- Lin RR, Lee J, Maderal AD, Elman SA. Rural Health Disparities in Skin Cancer Amplified Among Skin of Color. J Drugs Dermatol. 2024;23(6):480-484. doi:10.36849/JDD.8094
- Perez MI. Skin Cancer in Hispanics in the United States. J Drugs Dermatol. 2019;18(3):s117-s120.
- Popp K, Popp R, Bansal S, et al. Disparities in Time-to-treatment for Patients With Melanoma. Anticancer Res. 2024;44(2):631-637. doi:10.21873/anticanres.16852
- Reuter NP, Bower M, Scoggins CR, Martin RC, McMasters KM, Chagpar AB. The lower incidence of melanoma in women may be related to increased preventative behaviors. Am J Surg. 2010;200(6):765-769. doi:10.1016/j.amjsurg.2010.06.007
- Haluza D, Simic S, Höltge J, Cervinka R, Moshammer H. Gender aspects of recreational sun-protective behavior: results of a representative, population-based survey among Austrian residents. Photodermatol Photoimmunol Photomed. 2016;32(1):11-21. doi:10.1111/phpp.12213
- Wu YP, Aspinwall LG, Conn BM, Stump T, Grahmann B, Leachman SA. A systematic review of interventions to improve adherence to melanoma preventive behaviors for individuals at elevated risk. Prev Med. 2016;88:153-167. doi:10.1016/j.ypmed.2016.04.010
- Chao LX, Patterson SSL, Rademaker AW, Liu D, Kundu RV. Melanoma Perception in People of Color: A Targeted Educational Intervention. Am J Clin Dermatol. 2017;18(3):419-427. doi:10.1007/s40257-016-0244-y
- Roman CJ, Guan X, Barnholtz-Sloan JS, Xu J, Bordeaux JS. A Trial Online Educational Melanoma Program Aimed at the Hispanic Population Improves Knowledge and Behaviors. Dermatol Surg. 2016;42(5):672-676. doi:10.1097/DSS.0000000000000689
- Chung GY, Brown G, Gibson D. Increasing Melanoma Screening Among Hispanic/Latino Americans: A Community-Based Educational Intervention. Health Educ Behav. 2015;42(5):627-632. doi:10.1177/1090198115578748
- Rivera-Colón V, Ramos R, Davis JL, et al. Empowering underserved populations through cancer prevention and early detection. J Community Health. 2013;38(6):1067-1073. doi:10.1007/s10900-013-9715-8
