Survival for Patients With Invasive Cutaneous Melanoma Among Ethnic Groups: The Effects of Socioeconomic Status and Treatment

Stanford University, Palo Alto, California, United States
Journal of Clinical Oncology (Impact Factor: 18.43). 01/2008; 26(1):66-75. DOI: 10.1200/JCO.2007.12.3604
Source: PubMed


Although uncommon, melanoma is associated with poor survival characteristics among African Americans and Hispanics compared with non-Hispanic whites (NHWs). Low socioeconomic status (SES) is also associated with poor survival among patients with melanoma, but it is not known whether this is because of SES itself or because of treatment disparities. We set out to determine this by using the large, population-based California Cancer Registry (CCR) database as a model.
We conducted a case-only analysis of CCR data (1993 to 2003), including a descriptive analysis of relevant clinical variables and SES. The SES variable used has been derived from principle component analysis of census block-level CCR data that was linked to census data to address seven indicators of SES. Univariate analyses of overall survival (OS) were conducted using the Kaplan-Meier method. Multivariate survival analyses were performed using Cox proportional hazard ratios (HRs).
A total of 39,049 incident patient cases of cutaneous melanoma, including 36,694 in NHWs; 127 in African Americans; 1,996 in Hispanics; and 262 in Asian-Americans, were analyzed. Higher SES was associated with an early stage at presentation (P < .0001), with treatment with surgery (P = .0005), and with prolonged survival (P < .0001). After adjustments for age, sex, histology, American Joint Committee on Cancer stage, anatomic site, treatment, and SES, a statistically significant increased risk of death was observed for African Americans compared with NHWs (HR, 1.60; 95% CI, 1.17 to 2.18); no survival differences were noted for Asians or Hispanics compared with NHWs in the adjusted analysis.
Low SES independently predicts poor outcome among patients with cutaneous melanoma. However, the poor OS observed for African American patients with melanoma is not explained by differences in treatment or SES.

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Available from: Frank L Meyskens
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    • "Disparities in melanoma incidence can be attributed to disparities in socioeconomic status (SES). Although melanoma incidence is generally associated with higher SES (Hemminki et al., 2003), low SES has been correlated with advanced stage of melanoma at diagnosis and worse survival (Roetzheim et al., 2000; Ortiz et al., 2005; Zell et al., 2008). The relationship between SES and melanoma epidemiology is complex, mitigated by genetic risk, environmental exposure, and prevention practices among populations of varying SES strata and racial/ethnic backgrounds. "
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    ABSTRACT: 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.Journal of Investigative Dermatology advance online publication, 12 December 2013; doi:10.1038/jid.2013.465.
    Full-text · Article · Nov 2013 · Journal of Investigative Dermatology
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    • "In the United States, the incidence of skin cancer is higher among non-Hispanic white individuals compared to Hispanics (28.7 versus 4.1 per 100,000 annually) [1], but there are considerable disparities in terms of its morbidity and mortality among racial/ethnic minority groups such as Hispanics [2] (i.e., individuals of Central or South American, Cuban, Mexican, Puerto Rican, or other Spanish culture or origin [3]). Compared to non-Hispanic whites, when diagnosed with melanoma, Hispanics are more likely to be diagnosed at a younger age and with more advanced disease and have lower melanoma-specific survival rates [4-9]. The melanoma incidence among Hispanics increased by 19% from 1992 to 2008 [10]. "
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    ABSTRACT: Background Skin cancer prevention interventions that target the growing number of U.S. Hispanics are lacking. The current study examined the prevalence and correlates of sun protection and exposure behaviors (i.e., sunscreen use, shade seeking, use of sun protective clothing, and sunburns) among U.S. Hispanics with sun sensitive skin, with a focus on potential differences according to acculturation and Hispanic origin. Methods The sample consisted of 1676 Hispanic adults who reported having sun sensitive skin (i.e., they would experience a sunburn if they went out in the sun for one hour without protection after several months of not being in the sun). Participants completed survey questions as part of the nationally representative 2010 National Health Interview Survey. Analyses were conducted in August 2012. Results Greater acculturation was linked with both risky (i.e., not wearing sun protective clothing) and protective (i.e., using sunscreen) sun-related practices and with an increased risk of sunburns. Sun protection and exposure behaviors also varied according to individuals’ Hispanic origin, with for example individuals of Mexican heritage having a higher rate of using sun protective clothing and experiencing sunburns than several other subgroups. Conclusions Several Hispanic subpopulations (e.g., those who are more acculturated or from certain origins) represent important groups to target in skin cancer prevention interventions. Future research is needed to test culturally relevant, tailored interventions to promote sun protection behaviors among U.S. Hispanics. Such initiatives should focus on public health education and increasing healthcare provider awareness of the importance of skin cancer prevention among Hispanics.
    Full-text · Article · Nov 2012 · BMC Public Health
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    • "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. "
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    ABSTRACT: In general, skin cancer is uncommon in people of color when compared to Caucasians. When it does occur, it is often associated with increased morbidity and mortality. Differences in survival rates may be attributed to skin cancers being diagnosed at a more advanced stage, and socioeconomic factors such as lack of adequate insurance coverage and lack of transportation can function as barriers to timely diagnosis and early treatment. In addition to advanced stage at presentation, malignant skin lesions in skin of color often present in an atypical fashion. Because skin cancer prevention and screening practices historically have been lower among Hispanics, Blacks, and Asians, and given the changing demographics in the United States, interventions that are tailored to each of these groups will be needed. Public educational campaigns should be expanded to educate people of all skin types with emphasis on skin cancers occurring in areas not exposed to the sun (Byrd-Miles et al., 2007), since sunlight is not as important an etiologic factor in the pathogenesis of skin cancer in people of color. Dermatologists and primary care physicians should instruct their darker-skinned patients on how to perform routine skin self-examinations. Physicians should also encourage patients to ask their specialists such as their gynecologist, dentist, and ophthalmologist to look for abnormal pigmentation during routine exams. To reduce the burden of skin cancer, several prevention methods for all people have been strongly encouraged, including monthly self-examinations, daily use of SPF 30 or greater sunscreen, sunglasses with UV-absorbing lenses, and avoiding tanning booths (American Cancer Society, 2008) (see Table 7). In addition, recommendations for clinicians to promote the prevention of skin cancer in skin of color have also been made, including closely monitoring changing pigmented lesions on the palms and soles and hyperkeratotic or poorly healing ulcers in immunosuppressed patients (Halder & Bridgeman-Shah, 1995) (see Table 7).
    Preview · Article · Jul 2009 · Dermatology nursing / Dermatology Nurses' Association
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