Reducing Health Inequities Among BIPOC Patients With Melanoma

Reducing Health Inequities Among BIPOC Patients With Melanoma

Cancer often strikes unexpectedly. It can be especially shocking for patients who are asymptomatic, as often is the case for many Black, Indigenous, and people of color (BIPOC) patients diagnosed with melanoma skin cancer. Melanoma skin cancer is highly treatable when caught in its early stages. Although BIPOC populations have a lower incidence rate of developing melanoma skin cancer compared with White non-Hispanic cohorts, they are often faced with a worse prognosis as a result of late-stage diagnosis and treatment.

Studies have shown that healthcare providers examining BIPOC patients generally have lower suspicion of possible skin cancers due to the decreased likelihood of occurrence. This approach may also result from the education, training, and level of confidence dermatologists employ when examining and recommending treatment plans for patients. These studies have further found that there is an overall lower public awareness of risk and a false sense of immunity due to increased melanin present in those with darker skin. These combined factors may help explain the probability that patients are being diagnosed at a later stage and experience higher rates of mortality.¹

This alarming trend of late-stage diagnosis negatively impacting patient outcomes is evident with regard to the average 5-year survival rate where Black patients average 71% compared to 94% in White patients.¹ One reason for this may be due to the disproportion of images of color included in the materials and resources used in the education of dermatology medical students, impacting what is looked for. A 2021 review discovered that only 15% of the educational materials and resources used in dermatology programs were of images of color and skin conditions that are commonly seen in people of color.² This lack of diversity in the curricula may be 1 factor Kreuger attributes to an overall decreased confidence and accuracy in diagnosing conditions in BIPOC patients.¹

Additional potential reasons for late-stage diagnosis may include:

• Populations of color are less likely to get full body scans annually.
• Melanomas tend to appear in BIPOC in areas that are least exposed to the sun, including the eyes, nail bed, lower legs, and soles of the feet.
• Several studies found BIPOC populations to use sunscreen less often than White non-Hispanic populations due to the irritation and/or residue it leaves on darker skin tones.³

Supporting Patients through Education to Reduce Risk

In order to spread awareness, patient education is key. General practitioners, nurse practitioners, and registered nurses meeting patients can share the benefits of receiving full body scans with a dermatologist when discussing recommended annual screenings. Informing patients that some over-the-counter and prescription medicines increase the skin's sensitivity to UV rays, making them susceptible to sunburn, may also be beneficial. Education around the benefits from daily use of sunscreen may go a long way in protecting patients from the risks of sun exposure. Explaining how routine sunscreen use can help improve hyperpigmentation and melasma in patients with darker skin tones may also motivate patient use. Lastly, providers can share additional ways to reduce risk by encouraging their patients to report any skin changes that develop during their check-ups. The American Academy of Dermatology (AAD) suggests BIPOC patients perform monthly skin self-exams and share the following tips to know what to look for²:

• Dark spot, growth, or darker patch of skin that is growing, bleeding, or changing in any way.
• Sore that won’t heal—or heals and returns.
• Sore that has a hard time healing, especially if the sore appears in a scar or on skin that was injured in the past.
• Patch of skin that feels rough and dry.
• Dark line underneath or around a fingernail or toenail.

Recommendations for Support after a Melanoma Diagnosis

When patients are diagnosed with melanoma, they may feel understandably shocked or overwhelmed as they try to understand what the future might hold for them. Providers can support patients in sharing information about the diagnosis, answering questions, explaining recommended treatment options, and clarifying next steps in care. These initial steps can prepare patients and help them understand while also allowing for opportunities to ask questions in order to make informed decisions regarding their care. Providers can also educate patients regarding opportunities for connecting to internal and external sources of support that are available. These may include individual counseling, support groups, and peer-to-peer matching programs.

Addressing Possible Barriers, Disparities, and Inequalities in Care

After a diagnosis of cancer and a treatment plan are discussed with patients, providers may be surprised to find that patients are experiencing challenges that impact their ability to adhere to the care plan. There are several barriers that patients with cancer might experience including:

• lack of sufficient financial resources,
• being uninsured or underinsured and the impact on treatment options,
• lack of access to transportation and/or physical barriers, and
• language barriers that may impact:
  • access to care,
  • understanding of the diagnosis and treatment options,
  • adherence to medication and appointment schedules, and
  • communication and comfort level of the patients and caregivers.

These barriers can make it challenging for patients to engage in shared decision making and may result in a very isolating experience.

It is also important to consider how a person’s environment impacts overall health and well- being and provide resources where gaps exist. Residential areas that are considered food deserts—where there is a lack of access to fresh food—coupled with a lack of local pharmacies to obtain medications can be especially challenging. Lastly, patients may often face cultural, social, and community barriers that can affect quality care. Establishing a good rapport and encouraging communication with patients as they undergo treatment can go a long way in helping them navigate their cancer experience.

Looking Toward a Brighter Future

On March 8, 2022, the AAD developed The Skin of Color Curriculum that provides inclusive training and a broader understanding in the approach to care for the BIPOC population.⁴ In addition to offering a more diverse curriculum, there is recognition of existing healthcare disparities in medicine and ways to identify implicit bias and microaggressions.

These adaptations in the education and training of medical professionals can provide much needed help and hope for optimal patient outcomes while reducing disparities and inequalities in healthcare. Increasing awareness in the general population and providing guidelines and information to patients, who may not know of their risks, can further reduce the chances of the unwanted effects of the sun including Melanoma skin cancer.² For BIPOC patients, it can be especially beneficial to use sunscreen daily and wear protective clothing. With summer and rising temperatures quickly approaching, patients—including those who are BIPOC—may want to stay informed of the possible risks and bear those in mind while enjoying the many benefits of being outdoors.

References

1. Why are so many Black patients dying of cancer? Association of American Medical Colleges. July 21, 2022. Accessed April 1, 2024. https://www.aamc.org/news/why-are-so-many-black-patients-dying-skin-cancer
2. Skin Cancer in People of Color. American Academy of Dermatology Association. 2024. Accessed April 4, 2024. https://www.aad.org/public/diseases/skin-cancer/types/common/melanoma/skin-color
3. Ask the Expert: Is There a Skin Cancer Crisis in People of Color? Skin Cancer Foundation. February 2, 2024. Accessed March 6, 2024. https://www.skincancer.org/blog/ask-the-expert-is-there-a-skin-cancer-crisis-in-people-of-color/
4. Skin of Color Curriculum. American Academy of Dermatology Association. March 8, 2022. Accessed April 4, 2024. https://learning.aad.org/Listing/Skin-of-Color-Curriculum-5719#:~:text=The%20Skin%20of%20Color%20Curriculum,practicing%20dermatologists%20and%20dermatology%20residents.
5. Vojvodic A, Vlaskovic-Jovicevic T, Vojvodic P, et al. Psychological Impact of Melanoma, How to Detect, Support and Help. Open Access Maced J Med Sci. 2019;7(18):3043-3045. Published 2019 Aug 30. doi:10.3889/oamjms.2019.770
6. Syder NC, Omar D, McKenzie S, Brown-Korsah JB, Taylor SC, Elbuluk N. Gaps in medical education curricula on skin of color in medical school, residency, and beyond: Part 1. J Am Acad Dermatol. 2023;89(5):885-892. doi:10.1016/j.jaad.2022.03.053
7. Twohig-Bennett C, Jones A. The health benefits of the great outdoors: A systematic review and meta-analysis of greenspace exposure and health outcomes. Environ Res. 2018;166:628-637. doi:10.1016/j.envres.2018.06.030