Dermatologist Shani Francis begins every patient examination in her Gurnee, Illinois, practice by looking for signs of sun damage or exposure, followed by a discussion about the risks for skin cancer. If the patient has dark skin, she makes sure to caution them about something many are unaware of: Dark skin doesn’t make you immune to skin cancer.
Darker skin contains more of the skin pigment melanin, which is believed to protect skin somewhat from UV rays and make skin more likely to tan than burn. (A history of sunburns is a risk factor for skin cancer.) But melanin is not an insurance policy, says Dr. Francis.
“I make sure to tell my patients that just because you can tan doesn’t mean you should,” says Francis. “Melanin is a good protection, but the blackest person on Earth probably has an SPF of about 13, which provides some protection, but it's not enough. No one is immune. You can get skin cancer anywhere you have skin.”
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Skin Cancer: More Deadly When Diagnosed Later in Nonwhite People
Skin cancer is the most common of all human cancers. Each year, 1 million people in the United States are diagnosed with one of the three main types of the disease: basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma.
BCC and SCC are both classified as nonmelanoma skin cancer and account for the overwhelming majority of cases. Melanoma accounts for just 1 percent of all skin cancers, but it is the most deadly.
In 2020, it is estimated that there will be 100,350 new cases of melanoma in the United States and 6,850 deaths from the disease. The good news is that when diagnosed and treated early, almost all skin cancers are curable. The bad news: Because of a lack of awareness, skin cancer tends to be diagnosed at a later stage in nonwhite people.
“We know that 52 percent of black patients and 26 percent of Hispanics present with advanced-stage melanoma, compared to only 16 percent of white people, just because of lack of awareness and perceived risk,” says Francis.
Because skin cancer is most treatable and curable when caught at early stages, delayed diagnosis results in a disparity in survival. The average five-year melanoma survival rate is 65 percent in Black Americans, for instance, versus 91 percent in white Americans, according to the The Skin Cancer Foundation.
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Skin Cancer in People of Color: A Different Presentation
Most images of skin cancer online tend to skew toward how they look on people with a light skin tone. An image of basal cell carcinoma is most likely to appear pink or pearly on white skin; on dark skin, however, BCC is equally likely to be brown or slightly translucent, according to the Skin Cancer Foundation.
Squamous cell carcinoma is the most common skin cancer diagnosed in Black Americans. SCC tends to appear as a sore that will not heal. In white people, these lesions tend to develop in areas exposed to the sun. In nonwhite people, however, SCC tends to appear in areas that are not frequently exposed to the sun.
In white people, melanoma tends to be largely a result of sun exposure and appears as brown, tan, or black lesions that are large, irregularly shaped, and in areas exposed to the sun. However, in nonwhite people a type of melanoma known as acral lentiginous melanoma (ALM), which accounts for only 2 to 3 percent of all melanomas in the overall population, is the leading type of melanoma.
ALM typically appears as a small patch of darkened skin that resembles a stain or bruise. It may also appear as a new streak in a nail not caused by an accident or bruise, a streak that has damaged the fingernail, or an elevated, thickened patch on the sole of the foot or palm of the hand, according to the AIM at Melanoma Foundation. Some spots may be reddish or orange in color.
“There’s a misconception that UV is the only thing that causes skin cancer. UV is some of the equation but not all of it,” explains Francis. “Genetics also plays a role, but scientists haven't fully delineated the biology for why ALM shows up on the extreme in people of color.”
Perhaps the most famous person to have had ALM melanoma is reggae superstar Bob Marley, who died due to melanoma that started in his big toe.
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Skin Cancer: More Deadly in People of Color
One disturbing new trend is the apparent increase in skin cancer mortality in people of color.
The increase in skin cancer is attributed to lower public awareness of the risk of the disease among individuals of color. Because of this, this group of people is also less likely to practice sun-safe behaviors like using sunscreen, to go to the doctor for skin exams, or to do skin self-exams.
In addition, healthcare providers may be less diligent about looking for skin cancer in patients of color because they dismiss the risk, too.
The notion that they are immune to skin cancer is particularly strong in some cultures. “The belief that Hispanic people don’t have to worry about skin cancer has existed among Latinos for generations,” says Maritza Perez, MD, a dermatologist at the Icahn School of Medicine at Mount Sinai in New York.
“They hear it from their parents and grandparents, and then they pass this belief on to their children,” says Dr. Perez. Perez cites a study of high school students in which 43 percent of Latinos never or rarely used sunscreen. This same group of students was also 2.5 times more likely to have used tanning beds in the last year.
In a study published in March 2019 in the Journal of Drugs in Dermatology, Perez found a 20 percent increase in the number of Hispanics diagnosed with melanoma in the past 20 years.
Lower rates of health insurance coverage also play a role. Specifically, more than 15 percent of Latinos are uninsured and lack a regular healthcare provider, which may cause delays in treatment.
Educating Healthcare Providers and People of Color About Risk, Prevention, and Signs
There is growing awareness of the dangers of skin cancer among people of color, but advocates say there is still a long way to go on the prevention front.
Healthcare professionals and cancer awareness organizations must make a more concerted effort to dispel the myth that dark skin renders one immune to skin cancer, say advocates, and improve the rate of early diagnosis.
“While sun avoidance is part of the program, I also emphasize wearing protective clothes, hats, sunglasses, and SPF 15 or above,” says Francis. “We've got to educate people about where to look and what to look for.”