Skin cancer awareness in suburban employees: a Hispanic perspective

Clinicopathologic comparison of basal cell carcinoma among a diverse patient population in Los Angeles County

Introduction

Basal cell carcinoma (BCC) is the most common malignancy in the United States. The majority of cases are identified in Non-Hispanic Whites (NHW) and are far less demonstrated in patients of colour (POC). However, the Hispanic population represents a large and growing proportion of the US population, and skin cancer diagnoses in Hispanics are rising. Thus, the goal of this study is to examine clinicopathologic differences between BCC in Hispanics versus NHW.

Methods

A retrospective chart review of Hispanic and NHW patients with BCC at Los Angeles County + USC Medical Center from January 2018 to March 2020 was performed. In total, 101 BCC samples from the first 100 patients identified of Hispanic ancestry, as well as 50 BCC samples identified from the first 50 patients identifying as NHW, were included for analysis. Patient characteristics (age, sex, medical history, and ethnicity), as well as tumour characteristics (location, subtype, tumour depth, and perineural invasion), were collected. We used between subjects t-tests for continuous variables, and chi-square tests for categorical variables.

Results

In total, 151 specimens were collected amongst 122 subjects (79 Hispanics and 43 NHW patients). Among NHW, the majority of patients (74.4%) were men, but among the Hispanic population, the majority (68.4%) were female (p < 0.001). Prior history of other skin cancer was more common among NHW (67.4%) than Hispanics (31.6%) (p=<0.001). The Hispanic population had a significantly higher proportion of head and neck tumours (p = 0.0004) but a lower proportion of extremity tumours (p = 0.001) compared to NHW. Pigmented BCC was significantly more common among Hispanic patients (p < 0.01). Finally, within the Hispanic group, there was a significant association between sex and histology (p = 0.004), with Hispanic men demonstrating more aggressive mix histology compared to Hispanic women.

Discussion

Our study supports the notion that BCC disparities occur among POC compared to NHW. This includes variations in epidemiologic factors such as sex and past medical history, primary tumour location, and pathologic characteristics. Further research should be conducted to identify additional differences in skin cancer presentation in POC to reduce the gaps in skin cancer knowledge and care.

The Impact of Acculturation on Skin Cancer Risk and Protective Behaviors in Hispanic Populations

The US Hispanic population faces rising skin cancer risks and poorer clinical outcomes, despite lower incidence rates. Acculturation, adopting elements of the dominant culture, may influence skin cancer attitudes and behaviors among Hispanics. We systematically reviewed PubMed articles from 2000 to 2023. Peer-reviewed English articles that assessed the relationship between acculturation and skin cancer in the Hispanic population were included. Andreeva et al. observed that lower acculturation levels correlated with increased use of shade and protective clothing (P < 0.05). More acculturated Latinos were more likely to use sunscreen, but this association weakened after adjusting for covariates (P > 0.48). Heckman et al. highlighted significant differences in skin cancer concern among Hispanic youth, with less acculturated individuals expressing greater worry (P < 0.05). Coups et al. found that higher acculturation was linked to less sun protective clothing usage and more frequent sunburns. Their subsequent online survey indicated that English-acculturated Hispanics engaged less in protective behaviors. Viola et al. reported that English-acculturated Hispanics perceived greater suntan benefits and had lower perceptions of skin cancer risk, severity, and concerns about photo-aging, along with higher melanoma risk factors, compared to Spanish-acculturated Hispanics. Acculturation influences skin cancer attitudes and behaviors in Hispanics. Tailored interventions based on acculturation levels are essential to reduce skin cancer risk. For example, educating English-acculturated Hispanics about skin cancer risks and prioritizing knowledge dissemination for Spanish-acculturated individuals may be effective approaches. These findings emphasize the need for targeted skin cancer prevention efforts to address disparities among US Hispanics.

Undereducation is afoot: Assessing the lack of acral lentiginous melanoma educational materials for skin of color

Acral lentiginous melanoma (ALM) is a subtype of cutaneous melanoma notorious for poor outcomes that disproportionately affect individuals with skin of color (e.g., African-, Hispanic-, Asian-descent) when compared to mortality rates among non-Hispanic White populations. There are several societal factors that contribute to racial disparities in ALM, including a lack of representative educational material in the context of patient education and medical instruction. This gap in representative information for the US population includes risk of disease, patterns of incidence, and differences in disease presentation in skin of color. The atypical presentation of ALM on acral volar skin sites makes early detection challenging and necessitates an increased index of suspicion on the part of physicians and patients alike. Studies underscoring the importance of early detection in reducing mortality risk make the availability of adequate representative educational materials indispensable.

Melanoma in skin of color: Part II. Racial disparities, role of UV, and interventions for earlier detection

Despite a higher incidence of melanoma among White individuals, melanoma-specific survival is worse among individuals with skin of color. Racial disparities in survival are multifactorial. Decreased skin cancer education focused on people with skin of color, lower rates of screening, increased socioeconomic barriers, higher proportions of more aggressive subtypes, and underrepresentation in research and professional education contribute to delays in diagnosis and treatment. Although high, intermittent UV exposure during childhood has been established as a significant modifiable risk factor for melanoma in individuals with lighter skin phototypes, there are limited data on UV exposure and melanoma risk in people with darker skin phototypes. The second article of this continuing medical education series will examine factors contributing to racial disparities in melanoma-specific survival, discuss the role of UV radiation, and address the need for further research and targeted educational interventions for melanoma in individuals with skin of color.

Recommendations From a Chinese-Language Survey of Knowledge and Prevention of Skin Cancer Among Chinese Populations Internationally: Cross-sectional Questionnaire Study

BACKGROUND

There is a paucity of studies assessing awareness and prevention of skin cancer among Chinese populations.

OBJECTIVE

The aim of the study is to compare attitudes and practices regarding skin cancer risks and prevention between Chinese Asian and North American Chinese populations and between Fitzpatrick scores.

METHODS

A cross-sectional, internet-based, 74-question survey in Chinese was conducted focusing on Han Chinese participants internationally. The survey included Likert-type scales and multiple-choice questions. All participants were required to read Chinese and self-identify as being 18 years or older and Chinese by ethnicity, nationality, or descent. Participants were recruited on the internet over a 6-month period from July 2017 through January 2018 via advertisements in Chinese on popular social media platforms: WeChat, QQ, Weibo, Facebook, and Twitter.

RESULTS

Of the 113 completed responses collected (participation rate of 65.7%), 95 (84.1%) were ethnically Han Chinese, of which 93 (96.9%) were born in China and 59 (62.1%) were female. The mean age of these 95 participants was 35.8 (SD 13.3) years; 72 (75.8%) participants were born after 1975. Few but more North American Chinese reported that Chinese Asian populations received annual skin checks (4/30, 4.2% vs 0/65, 0%; P=.009) and believed that their clinician provided adequate sun safety education (13/30, 43.3% vs 15/65, 23.1%; P=.04). Participants with higher Fitzpatrick scores less frequently received sun safety education from a clinician (4/34, 11.8% vs 22/61, 36.1%; P=.02). More participants with lower Fitzpatrick scores used sunscreen (41/61, 67.2% vs 16/34, 47.1%; P=.05), but alternative sun protection use rates are similar across groups.

CONCLUSIONS

Cultural differences and Fitzpatrick scores can affect knowledge and practices with respect to sun protection and skin cancer among social media-using Chinese Asian and North American Chinese communities based on respondent demographics. Most participants in all groups understood that people of color have some risk of skin cancer, but >30% of all groups across regions and Fitzpatrick scores are unaware of current skin protection recommendations, receive insufficient sun safety education, and do not use sunscreen. Outreach efforts may begin broadly with concerted public and private efforts to train and fund dermatologists to perform annual total body skin exams and provide more patient education. They should spark community interest through mass media and empower Chinese people to perform self-examinations and recognize risks and risk mitigation methods.

Melanoma awareness and prevention among latinx and non-latinx white adults in urban and rural California: A qualitative exploration

BACKGROUND

Melanoma mortality rates in the US are highest among older men, individuals of lower socioeconomic status (SES), and people of color. To better understand these inequities, a qualitative exploratory study was conducted in Northern and Southern California to generate knowledge about barriers and facilitators of awareness, prevention, and early detection of melanoma in lower SES Latinx and non-Latinx White (NLW) individuals living in urban and semi-rural areas.

METHODS

Nineteen focus groups were conducted (N = 176 adult participants), stratified by race/ethnicity (Latinx, low-income NLW), geography (semi-rural, urban), and language (English and Spanish). Inductive and deductive thematic analysis was conducted, and the findings were organized using the socioecological model framework: individual, interpersonal, community, and health system/policy levels.

RESULTS

Four socioecological themes describe how key factors affect knowledge, perceived risk, preventive behaviors, and melanoma screening. Individual level findings revealed that many participants were not familiar with melanoma, yet were willing to learn through trusted sources. Having brown or darker skin tone was perceived as being associated with lower risk for skin cancer. Interpersonally, social relationships were important influences for skin cancer prevention practice. However, for several Latinx and semi-rural participants, conversations about melanoma prevention did not occur with family and peers. At the community level, semi-rural participants reported distance or lack of transportation to a clinic as challenges for accessing dermatology care. Healthcare systems barriers included burdens of additional healthcare costs for dermatology visits and obtaining referral.

CONCLUSIONS

Varying factors influence the awareness levels, beliefs, and behaviors associated with knowledge, prevention, and early detection of melanoma among low-income Latinx and NLW individuals and in semi-rural areas. Results have implications for health education interventions. Navigation strategies that target individuals, families, and health care settings can promote improved prevention and early detection of melanoma in these communities.

Skin Cancer Knowledge, Attitudes and Sun Protection Practices in the Hispanic Population: A Cross-Sectional Survey

Hispanics are more likely to be diagnosed with skin cancer at a later stage and experience worse overall survival than Whites. The objective of this cross-sectional study was to assess the skin cancer knowledge, attitudes, perceived risk, and sun protection practices among an underserved population in the Phoenix area. We recruited participants from the greater Phoenix area to undergo skin examination and complete a questionnaire. 208 participants were included. The majority were Hispanic (64.9%). Of this Hispanic group, most were from Mexico (87.9%). The Hispanic cohort had an overall mean skin cancer knowledge score of 3.68/6, the lowest of any other racial/ethnic group, but had the highest desire to learn more about skin cancer (64.6%, "strongly agree"). They were the most concerned about developing skin cancer (50.4%, "very concerned") but had relatively lower rates of sun protection practices (7.9% "always use" sunscreen, 22.0% "always use" sun-protective clothing). Limitations of this study include a small sample size, lack of validation for the skin cancer knowledge score, lack of season as a covariate in the multivariate analysis, lack of follow-up, and lack of robust skin cancer risk assessment. In conclusion, despite poorer skin cancer knowledge and sun protection practices, the Hispanic population had the highest concern for developing skin cancer and desire to learn more about skin cancer. Targeted and culturally relevant skin cancer and sun protection education for this group is needed.

Behavioral and Psychological Outcomes Associated with Skin Cancer Genetic Testing in Albuquerque Primary Care

Simple Summary

Genetic information is publicly available but research examining the best use of such information has not engaged diverse members of the public. We examined public reactions to melanoma genetic testing (using the melanocortin-1 receptor [MC1R] gene) in a study randomizing (like the flip of a coin) 600 diverse primary care patients to a MC1R test offer or usual care. We found that testing did not improve sun protection and skin cancer screening, nor did it lead worry to increase. However, groups less aware of their skin cancer risk, including those who thought their risk was “unlikely” at the start of the study, showed significant improvements in sun protection at three months. In conclusion, testing might be very helpful for certain people who have the most to learn about their risk, who may become motivated to protect themselves from the damaging effects of the sun as a result of skin cancer genetic testing.

Abstract

Public availability of genetic information is increasing; thus, efforts to improve diversity in basic and translational research in genomics is a top priority. Given the increasing U.S. incidence and mortality of melanoma, and the prevalence of common melanocortin-1 receptor (MC1R) gene melanoma risk variants in the general population, we examined genomic testing of MC1R for skin cancer risk in a randomized controlled trial in Albuquerque, New Mexico primary care. Participants were 48% Hispanic and were randomized 5:1 to a MC1R test invitation or usual care. We assessed 3 month sun protection, skin cancer screening, and skin cancer worry outcomes associated with testing, and key effect moderators (e.g., cancer risk perceptions, and skin cancer risk factors). Our findings indicate that the primary outcomes were unchanged by the MC1R test offer, test acceptance, and level of risk feedback. Moderator analyses showed that those with lower risk perception, and those with skin that readily tans, significantly increased their sun protection in response to higher than average risk feedback. Risk feedback did not prompt cancer worry, and average risk feedback did not erode existing sun protection. This study paves the way for the development of tailored strategies to address low skin cancer risk awareness in this understudied context of public health genomics.

The impact of demographics, socioeconomics, and health care access on melanoma outcomes

Disparities in melanoma care exist in the United States. Disparities in provider type, patient demographics, place of residence, insurance status, socioeconomic status, race/ethnicity, and age impact melanoma outcomes. Melanomas detected by dermatologists are thinner, at an earlier stage, and have better survival outcomes compared with detection by primary care providers or patients. Lower socioeconomic status, race/ethnicity, and place of residence are associated with decreased access to or use of dermatologists, or both, and more advanced melanomas at diagnosis. Additionally, uninsured and publicly insured individuals are more likely to present with late-stage melanomas, resulting in worse outcomes. This review provides a comprehensive overview of how structural and patient-level characteristics influence melanoma outcomes in order to inform clinical care and health care policy as it relates to addressing gaps in melanoma care.

Interest and Uptake of MC1R Testing for Melanoma Risk in a Diverse Primary Care Population: A Randomized Clinical Trial

Importance

Germline variants in the MC1R gene are common and confer moderate melanoma risk in those with varied skin types. Approaches to precision skin cancer prevention that include genetic information may promote risk awareness and risk reduction in the general population, including Hispanics.

Objective

To examine prevalence of interest in and uptake of MC1R testing in the general population and examine patterns across demographic and skin cancer risk factors.

Design, Setting, and Participants

A randomized clinical trial examined interest in and uptake of MC1R testing among patients at University of New Mexico General Internal Medicine clinics. Study participants were randomized to either a usual-care condition (National Cancer Institute skin cancer pamphlet for diverse skin types) or an MC1R test offer. Participants were registered clinic patients (≥6 months) and English or Spanish fluent. Of the 600 participants recruited to the overall trial, the present study included those 499 participants randomized to the MC1R test offer.

Interventions

Participants were presented with the option to log onto the study website to read 3 educational modules presenting the rationale, benefits, and drawbacks of MC1R testing.

Main Outcomes and Measures

Main outcomes include website log on (yes vs no), saliva test kit request (yes vs no), and saliva test kit return for MC1R testing (yes vs no). Demographic and skin cancer risk factors were examined as potential predictors of test interest and uptake.

Results

Of the 499 participants (220 [44%] non-Hispanic white, 242 [48%] Hispanic, 396 [79%] female; mean [SD] age, 54 [14.3] years), 232 (46%) elected to learn about MC1R testing by logging onto the website; 204 (88%) of those who logged on decided to request testing; and 167 (82%) of those who requested testing returned the kit. The strongest predictors of website log on were race/ethnicity and education (non-Hispanic whites were more likely to log on [odds ratio for Hispanics vs non-Hispanic whites, 0.5; 95% CI, 0.3-0.7], as were more highly educated individuals [odds ratio for more than high school vs high school or less, 2.7; 95% CI, 1.7-4.3]). The strongest predictor of ordering the test was sunburn history (odds ratio, 5.4; 95% CI, 2.3-12.9 vs no sunburn history).

Conclusions and Relevance

There were moderately high levels of MC1R test interest and uptake in this diverse sample. Addressing potential barriers to testing may be warranted as genomic information becomes integrated into general population approaches to the precision prevention of skin cancer.

Trial Registration

ClinicalTrials.gov identifier: NCT03130569.

Psychosocial and Cultural Determinants of Interest and Uptake of Skin Cancer Genetic Testing in Diverse Primary Care

BACKGROUND

Translational research in genomics has limited reach and requires efforts to broaden access and utility in diverse populations. Skin cancer is common and rates are rising, including among Hispanics. Germline variants in the melanocortin-1 receptor (MC1R) gene are common in the population and confer moderate risk for melanoma and basal cell cancers across skin types. Feedback about MC1R risk status may promote skin cancer risk awareness and risk reduction.

AIMS

We examined the level of interest in pursuing MC1R testing, and patterns of interest across skin cancer perceived threat and control attitudes, cultural beliefs (family influence on health, health system distrust, cancer fatalism, skin cancer misconceptions), and health literacy.

METHODS

We used a study website to inform primary care patients in Albuquerque, NM about the benefits and drawbacks of MC1R testing. Website logon, request of a saliva test kit, and return of the test kit (yes vs. no) were primary assessments of study interest and uptake.

RESULTS

Of 499 participants provided with a test offer, 33% requested and returned the test. Lower family influence on participants' health was an important factor both overall and within ethnicity subgroups, and may indicate that primary care patients interested in skin cancer genetic testing see themselves as proactive health seekers, independent from family encouragement. Lower self-efficacy for skin cancer prevention was also an important characteristic of those who tested.

CONCLUSION

As evidence for common genetic markers for skin cancer accumulates, these findings suggest characteristics of those most likely to pursue genetic testing for skin cancer risk.

Correlates of sun protection behaviors in racially and ethnically diverse U.S. adults

Although skin cancer incidence is highest among non-Hispanic Whites, minority populations are often diagnosed with more advanced stage disease and are more likely to experience poor outcomes. Fewer people of color do not practice primary prevention of skin cancer according to recommendations, but public health education and interventions to promote sun protection behaviors have consistently targeted non-Hispanic Whites. This study examines performance of sun protection behaviors in a multiethnic sample and whether demographic, lifestyle and psychosocial predictors of these behaviors differ by race and ethnicity. In this study, a probability-based sample of 1742 adults completed an online survey in 2015. Main outcomes of interest included sunscreen use, wearing a sleeved shirt, and seeking shade. We stratified the sample into racial/ethnic groups (White, Black, Hispanic, Asian) and investigated demographic, lifestyle and psychosocial correlates of these behaviors in each group. Differences in adjusted estimates from each behavior-specific model were tested across strata. Racial/ethnic groups were significantly different in regards to sunscreen use and wearing a sleeved shirt, but similarly engaged in seeking shade. Results from multivariate ordered logistic regression models for each behavior revealed important demographic, lifestyle and psychosocial predictors and the importance of some demographic correlates varied between racial/ethnic groups. This study provides insight into the practice and correlates of skin cancer prevention among a multiethnic sample. Our findings suggest that targeting public health education efforts and interventions to promote sun protection in minority populations may be a beneficial approach to addressing heightened skin cancer morbidity and mortality in these groups.

A Qualitative Exploration of Latinos' Perceptions About Skin Cancer: the Role of Gender and Linguistic Acculturation

Latinos have the highest rate of skin cancers among U.S. minorities. Despite a rising incidence of melanoma-the deadliest form of skin cancer-and greater disease burden, Latinos tend to have poor awareness of skin cancer risk factors which may inhibit preventive action. We expanded on prior work by qualitatively examining potential moderators (i.e., gender, acculturation) of skin cancer perceptions among Latinos from El Barrio in Harlem, New York City. Four focus groups stratified by language (English/Spanish) and gender were conducted. Discussions were recorded, transcribed, and coded using thematic analysis. Thirty-eight self-identified Latinos (32 % male) participated. Across groups, median age was 35 years; 50 % completed <high school degree, 82 % had annual incomes ≤$29,999, and 55 % were born in Mexico. Mean acculturation level was 8.5 (SD = 3.9, range = 4-20). Major themes included (1) knowledge of common skin cancer risk factors, (2) acknowledgment of personal risk although lighter-skin individuals are at greater risk, and (3) awareness of effective risk reduction methods, despite the presence of fatalistic beliefs. Compared to males, females discussed tanning norms and appearance-based factors, identified children as vulnerable, highlighted the benefits of sun exposure, and wanted more information. Few linguistic acculturation patterns were noted; English speakers questioned the carcinogenic effect of sunscreen and reported more skin cancer-related physician discussions than Spanish speakers. Despite generally low acculturation, Latinos correctly identified skin cancer risk factors and agreed that it is preventable with engagement in risk-reducing behaviors. Future educational interventions must capitalize upon and reinforce such beliefs and address fatalistic perceptions which may hinder prevention efforts.

Recognizing Latinos' range of skin pigment and phototypes to enhance skin cancer prevention

Latinos in the United States may have the mistaken assumption that their natural pigmentation protects them from developing skin cancer that, effectively, serves as a barrier to Latinos receiving education in primary and secondary prevention of skin cancer. Latino adults of Mexican or Puerto Rican heritage attending community health fairs in the greater Chicago area responded to a culturally informed and sensitive measure for sunburn and tan, which was previously adapted to capture skin irritation with tenderness from the sun occurring in darker skin types (n = 350). By self-reported responses and spectrophotometry assessment of constitutive pigmentation, adapted Fitzpatrick skin types (FST) ranged from skin type I-IV in the Mexican American participants and from II to V in the Puerto Rican participants. The objectively measured proportion of adapted FST II skin type was greater than commonly perceived and demonstrated that many Latinos do indeed have sun-sensitive skin.

The Role of Neighborhood Characteristics in Late Stage Melanoma Diagnosis among Hispanic Men in California, Texas, and Florida, 1996-2012

Background

Hispanics diagnosed with cutaneous melanoma are more likely to present at advanced stages but the reasons for this are unknown. We identify census tracts at high risk for late stage melanoma diagnosis (LSMD) and examine the contextual predictors of LSMD in California, Texas, and Florida.

Methods

We conducted a cross-sectional study using geocoded state cancer registry data. Using hierarchical multilevel logistic regression models we estimated ORs and 95% confidence intervals for the impact of socioeconomic, Hispanic ethnic concentration, index of dissimilarity, and health resource availability measures on LSMD.

Results

We identified 12,493 cases. In California, late stage cases were significantly more likely to reside within census tracts composed mostly of Hispanics and immigrants. In Texas, LSMD was associated with residence in areas of socioeconomic deprivation and a higher proportion of immigrants. In Florida, living in areas of low education attainment, high levels of poverty, and a high percentage of Hispanic residents was significantly associated with LSMD. Residential segregation did not independently affect LSMD.

Conclusion

The influence of contextual predictors on LSMD varied in magnitude and strength by state, highlighting both the cosegregation of social adversity and poverty and the complexity of their interactions.

The role of spatially-derived access-to-care characteristics in melanoma prevention and control in Los Angeles county

Among 10,068 incident cases of invasive melanoma, we examined the effects of patient characteristics and access-to-care on the risk of advanced melanoma. Access-to-care was defined in terms of census tract-level sociodemographics, health insurance, cost of dermatological services and appointment wait-times, clinic density and travel distance. Public health insurance and education level were the strongest predictors of advanced melanomas but were modified by race/ethnicity and poverty: Hispanic whites and high-poverty neighborhoods were worse off than non-Hispanic whites and low-poverty neighborhoods. Targeting high-risk, underserved Hispanics and high-poverty neighborhoods (easily identified from existing data) for early melanoma detection may be a cost-efficient strategy to reduce melanoma mortality.

Skin Cancer Concerns in People of Color: Risk Factors and Prevention

Background: Though people of color (POC) are less likely to become afflicted with skin cancer, they are much more likely to die from it due to delay in detection or presentation. Very often, skin cancer is diagnosed at a more advanced stage in POC, making treatment difficult.The purpose of this research was to improve awareness regarding skin cancers in people of color by providing recommendations to clinicians and the general public for early detection and photo protection preventive measures. Methods: Data on different types of skin cancers were presented to POC. Due to limited research, there are few resources providing insights for evaluating darkly pigmented lesions in POC. Diagnostic features for different types of skin cancers were recorded and various possible risk factors were considered. Results: This study provided directions for the prevention and early detection of skin cancer in POC based on a comprehensive review of available data. Conclusions: The increased morbidity and mortality rate associated with skin cancer in POC is due to lack of awareness, diagnosis at a more advanced stage and socioeconomic barriers hindering access to care. Raising public health concerns for skin cancer prevention strategies for all people, regardless of ethnic background and socioeconomic status, is the key to timely diagnosis and treatment.

Melanoma Disparities among US Hispanics: Use of the Social Ecological Model to Contextualize Reasons for Inequitable Outcomes and Frame a Research Agenda

Cutaneous melanoma is a significant public health concern, accounting for thousands of deaths annually in the US. Early detection and diagnosis are critical given the poor prognosis and limited treatment options of advanced-stage disease. While non-Hispanic whites have higher incidence rates of melanoma, Hispanics are typically diagnosed at later disease stages and suffer higher morbidity and mortality. Currently, there is a paucity of literature investigating the root causes underlying these trends among Hispanics. Given that Hispanics are the most rapidly expanding demographic segment in the US, it is essential for cancer control efforts to elucidate the major determinants of their poor melanoma outcomes. Herein, we use the social ecological model as a framework to explore the multitude of influences on melanoma disparities among Hispanics and provide recommendations for planning future studies and interventions.

Health Disparities Influence Childhood Melanoma Stage at Diagnosis and Outcome

OBJECTIVE

To identify health disparities in pediatric patients with melanoma that affect disease presentation and outcome.

STUDY DESIGN

This was a retrospective cohort study of all persons aged ≤18 years diagnosed with melanoma and enrolled in the Texas Cancer Registry between 1995 and 2009. Socioeconomic status (SES) and driving distance to the nearest pediatric cancer treatment center were calculated for each patient. Logistic regression was used to determine factors associated with advanced-stage disease. Life table methods and Cox regression were used to estimate survival probability and hazard ratios.

RESULTS

A total of 185 adolescents (age >10 years) and 50 young children (age ≤10 years) were identified. Hispanics (n = 27; 12%) were 3 times more likely than non-Hispanic whites (n = 177; 75%) to present with advanced disease (OR, 3.8; 95% CI, 1.7-8.8). Young children were twice as likely as adolescents to present with advanced disease (OR, 2.2; 95% CI, 1.1-4.3). Distance to treatment center and SES did not affect stage of disease at presentation. Hispanics and those in the lowest SES quartile had a significantly higher mortality risk (hazard ratios, 3.0 [95% CI, 1.2-7.8] and 4.3 [95% CI, 1.4-13.9], respectively). In the adjusted survival model, only advanced disease was predictive of mortality (P < .001).

CONCLUSION

Hispanics and young children with melanoma are more likely to present with advanced disease, and advanced disease is the single most important predictor of survival. Heightened awareness among physicians is needed to facilitate early detection of melanoma within these groups.

Current Data on Risk Factor Estimates Does Not Explain the Difference in Rates of Melanoma between Hispanics and Non-Hispanic Whites

United States Hispanics have seven times lower melanoma incidence rates than non-Hispanic whites (NHW). It is unclear whether this difference can be explained solely by phenotypic risk factors, like darker skin, or whether modifiable risk factors, like sun exposure, also play a role. The purpose of this paper is to summarize what is currently known about melanoma risk factors among Hispanics and NHWs, and whether or not those differences could explain the difference in melanoma incidence. Through literature review, relative risks and prevalence of melanoma risk factors in Hispanics and NHWs were identified and used to calculate the expected rate in Hispanics and rate ratio compared to NHWs. We found that melanoma risk factors either have similar frequency in Hispanics and NHWs (e.g., many large nevi) or are less frequent in Hispanics but do not explain a high proportion of disease variation (e.g., red hair). Considering current knowledge of risk factor prevalence, we found that melanoma incidence rates in the two groups should actually be similar. Sun exposure behavior among Hispanics may contribute to the explanation for the 7-fold difference in melanoma rates. Currently, limited data exist on sun exposure behavior among Hispanics, but possibilities for improving primary prevention by further studying these practices are substantial.

Patterns of sun protective behaviors among Hispanic children in a skin cancer prevention intervention

BACKGROUND

Invasive melanoma is becoming more common in U.S. Hispanics, yet little is known about the sun protection behaviors in this population, particularly children and adolescents who incur high ultraviolet (UV) exposures.

METHODS

We used latent class analysis to examine patterns of sun protective behaviors in a cross-sectional survey of Hispanic elementary students participating in a sun safety intervention in Los Angeles from 2013- to 2014 (N=972). Five behavior indicators in two environments (school and home) representing multiple methods of sun protection were selected for the model.

RESULTS

Results suggested a four-class model best fit the data. Classes were labeled in order of increasing risk as multiple protective behaviors (28%), clothing and shade (32%), pants only (15%), and low/inconsistent protective behaviors (25%). Children who reported high parental engagement with sun protection were significantly more likely to be classified in high overall protective categories (odds ratio (OR)=4.77). Girls were more likely than boys to be classified in the highest protecting class (OR=3.46), but were also more likely to be in the "pants only" class (OR=2.65). Sensitivity to sunburn was associated with less likelihood of being in the "clothing and shade" class (OR=0.53).

CONCLUSION

The differences among these classes and their predictors reveal the heterogeneity and complexity of Hispanic children's sun protective behaviors. These findings have implications for the design and delivery of future sun protection interventions targeting Hispanic children, as strategies tailored to specific subgroups may be more effective in achieving meaningful behavioral changes.

Genetic Testing Awareness and Attitudes among Latinos: Exploring Shared Perceptions and Gender-Based Differences

BACKGROUND

Latinos, whose views are infrequently examined in genomic research, may be at risk of missing out on the benefits of genomic medicine.

AIMS

To explore this possibility, we conducted a qualitative study of awareness and attitudes about genetic testing among Latinos with lower acculturation in New York City.

METHODS

We conducted four focus groups (7 English-speaking men, 5 Spanish-speaking men, 13 English-speaking women and 13 Spanish-speaking women) to explore factors that influence the adoption of new innovations through the discussion of genetic testing in general, and a hypothetical vignette describing a genetic test for skin cancer risk, in particular.

RESULTS

Through inductive thematic text analysis of focus group transcripts, our multidisciplinary team identified themes within knowledge and attitudes, communication and sources of information, anticipated responses, factors that may increase adoption, and barriers to adoption of genetic testing. Specifically, a majority of participants expressed some degree of uncertainty regarding the purpose of genetic tests and information these tests provide, rarely discussed genetic testing with others in their social networks, and expressed concerns about the misuse of and possible adverse emotional responses to genetic information. However, participants also expressed high levels of interest in receiving a skin cancer genetic test in response to the vignette and believed that receiving actionable health information was a primary reason to consider testing. Gender-based differences in perceived barriers to testing emerged.

CONCLUSIONS

The results highlight beliefs and barriers that future interventions could target to help ensure that Latinos have adequate understanding of and access to genomic medicine advances.

Occupational sunscreen use among US Hispanic outdoor workers

Background

Occupational ultraviolet radiation (UVR) exposure is a risk factor for skin cancer, and Hispanic individuals are over-represented in a number of outdoor occupations (e.g., farming, landscaping). This study examined predictors of occupational sunscreen use in a group of US Hispanic adults who work outdoors.

Results

A population-based sample of outdoor workers (n = 149, 85 % male) completed survey measures regarding their demographics, melanoma risk, perceived skin cancer risk, skin cancer knowledge, and their occupational sunscreen use. Sixty-nine percent of the sample reported never or rarely wearing sunscreen while working outdoors. Being female (p = .02), having a higher level of education (p = .03), and residing at a higher latitude (p = .04) were associated with more frequent sunscreen use.

Conclusions

This study highlights the importance of interventions to promote sun protection behaviors among US Hispanic outdoor workers, and identifies potential intervention targets.

Social determinants of racial and ethnic disparities in cutaneous melanoma outcomes

BACKGROUND

This article sought to elucidate how aspects of poverty and culture may contribute to race- and ethnicity-based disparities in cutaneous melanoma outcomes.

METHODS

We identified published studies addressing the social determinants of melanoma. Selected review articles included US-based studies comprised of patients representing adults, children, and adolescents.

RESULTS

African Americans and Hispanics diagnosed with cutaneous melanoma are more likely to present with more advanced stages of disease at diagnosis and have higher rates of mortality than their nonminority counterparts. These disparities may be a consequence of economic, social, and cultural barriers such as low income, public forms of health insurance, lower levels of education, lower levels of melanoma awareness and knowledge, and lower rates of participation in melanoma screening. No studies in the literature examined the potential impact of social injustice, English proficiency, immigrant status, and health literacy.

CONCLUSIONS

Substantial gaps exist in our knowledge of the pathways linking social determinants and race- and ethnicity-based disparities in melanoma. More studies are warranted to inform the development of effective interventions aimed at narrowing inequities and improving cutaneous melanoma outcomes among minority populations.

Efficacy of a sun protection workbook for kidney transplant recipients: a randomized controlled trial of a culturally sensitive educational intervention

A culturally sensitive educational intervention that encouraged sun protection behaviors among kidney transplant recipients (KTRs) was developed and the short-term efficacy was evaluated. Non-Hispanic White, Hispanic/Latino and non-Hispanic Black patients, who received a transplant 2-24 months prior to the study, were randomized into two study groups: intervention versus standard of care. Electronic reminders tailored to the weather conditions were sent every 2 weeks by text message or email. Self-reported surveys and biologic measurements were obtained prior to the intervention and 6 weeks later. Among the 101 study participants, there was a statistically significant increase in knowledge, recognition of personal risk of developing skin cancer, willingness to change sun protection behavior and self-reported performance of sun protection in participants receiving the intervention in comparison with those receiving standard of care (p < 0.05). The pigment darkening of the sun-exposed forearm and sun damage of the forearm and sunburns/skin irritation from the sun were significantly less in participants receiving the intervention (p < 0.05). Providing sun protection education at the beginning of summer with reminders tailored to weather conditions helped KTRs adopt sun protection practices. This sun protection program for KTRs may be incorporated into the care provided by the nephrologist or transplant surgeon.

Sun Protection Beliefs among Hispanics in the US

Purpose. We reviewed the literature on sun protection beliefs in Hispanics living in the United States to explore what challenges are faced by area of research. Method. A review of PubMED, PsycINFO, and CINAHL databases was performed. Studies were published in peer-reviewed journals (in all years available) and written in English. The search terms used were [“skin cancer” OR “sun protection”] AND [“Latino” OR “Hispanic”] AND “beliefs.” Eligible papers were included in the final analysis after meeting the following inclusion criteria: (1) the records had to quantitatively examine and report sun protection beliefs in Hispanics, (2) the number of Hispanic participants in the sample had to be clearly specified, and (3) studies reporting differences in sun protection beliefs between Hispanics and other racial and ethnic groups were included in the review. Results. Of the 92 articles identified, 11 met inclusion criteria and addressed sun protection beliefs regarding skin cancer seriousness and susceptibility, and benefits and barriers of sun protection and skin cancer risk behaviors. Characteristics of studies and results were examined. Conclusion. There is insufficient evidence to determine a pattern of sun protection beliefs among Hispanics in the United States. More quality studies are needed which focus on sun protection beliefs in Hispanics.

Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public

Skin cancer is less prevalent in people of color than in the white population. However, when skin cancer occurs in non-whites, it often presents at a more advanced stage, and thus the prognosis is worse compared with white patients. The increased morbidity and mortality associated with skin cancer in patients of color compared with white patients may be because of the lack of awareness, diagnoses at a more advanced stage, and socioeconomic factors such as access to care barriers. Physician promotion of skin cancer prevention strategies for all patients, regardless of ethnic background and socioeconomic status, can lead to timely diagnosis and treatment. Public education campaigns should be expanded to target communities of color to promote self-skin examination and stress importance of photoprotection, avoidance of tanning bed use, and early skin cancer detection and treatment. These measures should result in reduction or earlier detection of cutaneous malignancies in all communities. Furthermore, promotion of photoprotection practices may reduce other adverse effects of ultraviolet exposure including photoaging and ultraviolet-related disorders of pigmentation.

Melanoma in skin of color in Connecticut: an analysis of melanoma incidence and stage at diagnosis in non-Hispanic blacks, non-Hispanic whites, and Hispanics

BACKGROUND

The incidence of melanoma is increasing in Caucasians and in Hispanic subgroups in California and Florida. There is a paucity of information regarding melanoma incidence, stage at diagnosis, and other patient and tumor factors among minority subgroups in the northeast USA. This report examines melanoma in non-Hispanic white, non-Hispanic black, and Hispanic residents of Connecticut.

METHODS

Trends in age-adjusted melanoma incidence rates (1992-2007) and the corresponding annual percentage changes in rates were calculated for Connecticut residents by race and Hispanic ethnicity. The racial/ethnic variation was evaluated for a number of patient and tumor characteristics: gender, age at diagnosis, marital status, anatomic site, histology, ulceration, Breslow thickness, and stage at diagnosis. Statistical significance at the 95% level was assessed using confidence intervals (95% CIs) and Pearson's chi-squared tests.

RESULTS

Between 1992 and 2007, melanoma incidence increased by 4.1% per year in non-Hispanic whites in Connecticut (95% CI 3.1-5.1%; P<0.05). Melanoma incidence remained relatively stable for Hispanics and non-Hispanic blacks over the same period. A significantly higher proportion of advanced (regional and distant) melanomas were diagnosed in non-Hispanic blacks (19.1%) and Hispanics (17.1%) than in non-Hispanic whites (8.7%) (P<0.001).

CONCLUSIONS

A significantly higher proportion of advanced melanomas were diagnosed in non-Hispanic blacks and Hispanics than in non-Hispanic whites. There is a growing need to educate patients and healthcare providers of the necessity for skin cancer surveillance regardless of the race of the patient.

Psychosocial correlates of sun protection behaviors among U.S. Hispanic adults

The incidence of skin cancer among U.S. Hispanics increased 1.3% annually from 1992 to 2008. However, little research has focused on skin cancer prevention among the rapidly growing Hispanic population. In this study, we examined theory-driven, psychosocial correlates of sun protection behaviors in a population-based sample of 787 Hispanic adults (49.6% female, mean age = 41.0 years) residing in five southern or western U.S. states. Participants completed an English- or Spanish-language online survey in September 2011. The outcomes of focus were sunscreen use, shade seeking, and use of sun protective clothing. The correlates included suntan benefits, sun protection benefits and barriers, skin color preference, perceived natural skin protection, photo-aging concerns, perceived skin cancer risk, skin cancer worry, skin cancer fatalism, and sun protection descriptive norms. Results of multiple linear regression analyses revealed the following: sun protection barriers were negatively associated with each outcome; descriptive norms were positively associated with each outcome; perceived natural skin protection was inversely associated with sunscreen use; skin cancer worry was positively associated with shade seeking and use of sun protective clothing; skin cancer fatalism was negatively associated with shade seeking; and skin color preference was negatively associated with use of sun protective clothing. A number of additional statistically significant associations were identified in bivariate correlation analyses. This study informs the potential content of interventions to promote engagement in sun protection behaviors among U.S. Hispanics.

Predictors of neighborhood risk for late-stage melanoma: addressing disparities through spatial analysis and area-based measures

Minority populations have disproportionately more advanced stage melanoma and worse survival. To clarify the impact of race and ethnicity on late-stage melanoma diagnosis, we performed spatial analysis of geocoded melanoma cases diagnosed in Florida, 1999-2008, to identify geographic clusters of higher-than-expected incidence of late-stage melanoma and developed predictive models for melanoma cases in high-risk neighborhoods accounting for area-based poverty, race/ethnicity, patient insurance status, age, and gender. In the adjusted model, Hispanic ethnicity and census tract-level poverty are the strongest predictors for clustering of late-stage melanoma. Hispanic whites were 43% more likely to live in neighborhoods with excessive late-stage melanoma (P<0.001) compared with non-Hispanic whites (NHW). For every 1% increase in population living in poverty, there is a 2% increase in late-stage melanoma clustering (P<0.001). Census tract-level poverty predicted late-stage melanoma similarly among NHW and Hispanic whites. The impact of insurance coverage varied among populations; the most consistent trend was that Medicaid coverage is associated with higher odds for late-stage melanoma. The finding that Hispanics are most likely to reside in high-risk neighborhoods, independent of poverty and insurance status, underscores the importance of addressing, and overcoming community-level barriers to melanoma care.

Skin cancer surveillance behaviors among US Hispanic adults

BACKGROUND

Little skin cancer prevention research has focused on the US Hispanic population.

OBJECTIVE

This study examined the prevalence and correlates of skin cancer surveillance behaviors among Hispanic adults.

METHODS

A population-based sample of 788 Hispanic adults residing in 5 southern and western states completed an online survey in English or Spanish in September 2011. The outcomes were ever having conducted a skin self-examination (SSE) and having received a total cutaneous examination (TCE) from a health professional. The correlates included sociodemographic, skin cancer-related, and psychosocial factors.

RESULTS

The rates of ever conducting a SSE or having a TCE were 17.6% and 9.2%, respectively. Based on the results of multivariable logistic regressions, factors associated with ever conducting a SSE included older age, English linguistic acculturation, a greater number of melanoma risk factors, more frequent sunscreen use, sunbathing, job-related sun exposure, higher perceived skin cancer risk, physician recommendation, more SSE benefits, and fewer SSE barriers. Factors associated with ever having a TCE were older age, English linguistic acculturation, a greater number of melanoma risk factors, ever having tanned indoors, greater skin cancer knowledge, higher perceived skin cancer severity, lower skin cancer worry, physician recommendation, more TCE benefits, and fewer SSE barriers.

LIMITATIONS

The cross-sectional design limits conclusions regarding the causal nature of observed associations.

CONCLUSIONS

Few Hispanic adults engage in skin cancer surveillance behaviors. The study highlights Hispanic subpopulations that are least likely to engage in skin cancer surveillance behaviors and informs the development of culturally appropriate interventions to promote these behaviors.

Knowledge, perceptions and behaviours about skin cancer and sun protection among secondary school students from Central Italy

BACKGROUND

Although sun exposure is a strong risk factor for skin cancer, tanning is very popular among adolescents. Awareness of skin cancer and sun exposure might influence sun protective behaviours in this population.

OBJECTIVES

To investigate the awareness of skin cancer and sun-safe practices among Italian adolescents.

METHODS

A questionnaire about knowledge of skin cancer, perceived severity of sun rays/skin cancer and behaviour toward sun protection was administered to 1204 secondary school students. Predictors of these three components were assessed by case-control analyses considering different combinations of answers. Multiple logistic regression models were used to this scope.

RESULTS

The majority of participants had heard of skin cancer in the past (97.0%), correctly identified possible causes (58.6%) and names (64.2%) of skin cancers and judged appropriately the perceived danger of sunrays (70.2%) and skin cancer (80.6%). Nonetheless, students' behaviour was poor: only 13.5% stated to always use sun-safe practices and 39.1% never used any. Independent predictors of proper knowledge were: Lyceum school, and family or TV/media as information source; of appropriate perceived severity: Lyceum school, a darker skin type, and dermatologists as information source; of acceptable behaviour: female sex, a darker skin type, and dermatologists or general practitioners (GPs) as information source.

CONCLUSIONS

Despite a fairly good knowledge about skin cancer and sun exposure, students' behaviour was unsatisfactory. Knowledge is not sufficient to produce a positive behaviour, as determinants of these two aspects are different. Dermatologists and GPs should be considered as key-figures for future multicomponent intervention strategies in this field.

Skin cancer risk perceptions: a comparison across ethnicity, age, education, gender, and income

BACKGROUND

Studies of noncutaneous and cutaneous malignancies support the hypothesis that poor risk-perception status contributes to health disparity.

OBJECTIVE

We evaluated skin cancer (SC) risk perceptions across race and other demographic markers using the Health Information National Trends Survey (HINTS) and compared them to discover differences in perception that may contribute to the disparities in SC diagnosis and treatment.

METHODS

Respondents with no history of SC were randomly selected to answer questions assessing perceived risk and knowledge of preventive strategies of SC. Logistic regression was performed to identify associations between perceptions of SC and demographic variables including self-described race, age, sex, education, income, and health insurance status.

RESULTS

Blacks, the elderly, and people with less education perceived themselves as at lower risk of developing SC. They, along with Hispanics, were also more likely to believe that one cannot lower their SC risk and that there are so many different recommendations on how to prevent SC that it makes it difficult to know which ones to follow. Lower education also correlated with greater reluctance to have a skin examination.

LIMITATIONS

HINTS is a cross-sectional instrument, thus it only provides a snapshot of SC perceptions.

CONCLUSION

Uncertainty and altered perceptions are more common in the SC risk perceptions of ethnic minorities, the elderly, and those with less education. These are the same groups that are subject to disparities in SC outcomes. Educational programs directed at these demographic groups may help to reduce the SC-related health disparities.

Melanoma knowledge, perception, and awareness in ethnic minorities in Chicago: recommendations regarding education

OBJECTIVES

To assess the level of melanoma awareness and risk perception among ethnic minorities and to identify ways to enhance the relevance of melanoma educational materials for ethnic minorities.  

METHODS

Twelve focus groups composed of participants from a single ethnicity [African-American (n=40), Hispanic (n=40), and Asian (n=40)], participated in a 2 h discussion on melanoma and skin cancer and commented on an educational brochure by the American Cancer Society and reacted to photographs of melanoma on ethnic skin. Participants also evaluated the ability to sunburn and tan and the skin cancer risk of images of celebrities before and after the discussion. Additionally, participants assessed the skin tone of celebrities as very fair, fair, olive, light brown, dark brown, and very dark. The audiotape recordings of the 12 focus groups were transcribed and analyzed with the Non-numerical Unstructured Data Indexing Searching and Theorizing software for common themes.

RESULTS

The common themes were (1) lack of relevance of skin cancer to ethnic people, (2) understanding of skin cancer risk terminology is based on personal experience and what is acquired from the media, and (3) sources of health information for ethnic minorities are fragmented and physicians are not the primary source of information. Celebrity images representing the six skin tones were selected.

CONCLUSIONS

Relevance of melanoma education to ethnic people may be improved by using 'melanoma skin cancer', photographs of early melanoma in people with dark skin, and providing guidance on how to inspect hands and feet for suspicious moles.

Health care inequities: an introduction for dermatology providers

When differences in health and health care are avoidable and unfair, they are labeled health inequities. In large part health inequities reflect social determinants of health, lack of access to care, and a health care system that does not allow sufficient time and resources so high-quality care may be provided to all patients. Programs aiming at reducing health disparities must include the provision of services as well as address access to care and socioeconomic barriers. This article focuses on health care disparities in dermatology, and invites providers to become agents of change.

Acculturation and sun-safe behaviors among US Latinos: findings from the 2005 Health Information National Trends Survey

OBJECTIVES

We examined the relationship between acculturation and sun safety among US Latinos.

METHODS

We used linear regression models to analyze data from 496 Latino respondents to the 2005 Health Information National Trends Survey. Using sunscreen, seeking shade, and wearing protective clothing were the primary outcomes and were assessed by frequency scales. Acculturation was assessed with a composite index.

RESULTS

In bivariate models, acculturation was negatively associated with use of shade and protective clothing and positively associated with sunscreen use (all, P < .004). In adjusted models, acculturation was negatively associated with seeking shade and wearing protective clothing across gender and region of residence (all, P < .05).

CONCLUSIONS

Our results demonstrated both adverse and beneficial effects of acculturation on Latinos' risk behaviors relating to skin cancer. Education about sun safety is needed for all Latinos and should be tailored to different levels of acculturation. Initiatives for Latinos who are not yet acculturated could focus on reinforcing existing sun-safe behaviors and presenting new ones, such as use of sunscreen; initiatives for highly acculturated Latinos might require more resources because the objective is behavior modification.