Skin of Color

Melanoma in US Hispanics: Recommended Strategies to Reduce Disparities in Outcomes

In Collaboration with the Skin of Color Society

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Cutaneous melanoma is the most fatal form of skin cancer and presents a considerable public health concern in the United States. Although the age-adjusted incidence of melanoma among US Hispanics is lower than that of non-Hispanic whites (NHWs), Hispanics who are diagnosed with melanoma are more likely to present with thicker primary tumors, metastatic disease, and lower 5-year melanoma-specific survival rates than NHWs. Melanoma risk factors and reasons for late presentation among Hispanics are not completely understood. In this review, the epidemiology and clinical presentation of melanoma in Hispanics is summarized, and recommendations for a research agenda to advance understanding of this disease in the most rapidly growing segment of the US population is provided.

Practice Points

  • Although the age-adjusted incidence of melanoma among US Hispanics is lower than among non-Hispanic whites, Hispanics with melanoma are more likely to present with stage III disease and have distant metastases.
  • Late presentation of melanoma in Hispanics is not completely understood but may be attributed to socioeconomic factors, lack of skin cancer awareness and knowledge, lower rate of self- and physician-performed skin examinations, and differences in tumor biology, among other variables.
  • Research is needed to address gaps in knowledge about the risk of melanoma and comparatively poor outcomes among Hispanics so interventional efforts for prevention, early detection, and treatment can be implemented.


 

References

Cutaneous melanoma is a considerable public health concern. In the United States, an estimated 87,110 cases were diagnosed in 2017, and more than 9000 deaths are expected as result of this disease in 2018.1 Early diagnosis of melanoma is associated with favorable survival rates (5-year overall survival rates for melanoma in situ and stage IA melanoma, 99% and 97%, respectively).2 In contrast, the prognosis for advanced-stage melanoma is poor, with a 5-year survival rate of 16% for patients with stage IV disease. Therefore, early detection is critical to reducing mortality in melanoma patients.3

The term Hispanic refers to a panethnic category primarily encompassing Mexican-Americans, Cubans, and Puerto Ricans, as well as individuals from the Caribbean and Central and South America. These populations are diverse in birth origin, primary language, acculturation, distinct ethnic traditions, education level, and occupation. Hispanics in the United States are heterogeneous in many dimensions related to health risks, health care use, and health outcomes.4 Genetic predisposition, lifestyle risks, and access to and use of health care services can shape melanoma diagnosis, treatment, and progression across Hispanic populations differently than in other populations.

In this review, the epidemiology and clinical presentation of melanoma in US Hispanics is summarized, and recommendations for a research agenda to advance understanding of this disease in the most rapidly growing segment of the US population is provided.

Melanoma Incidence, Presentation, and Outcomes in US Hispanics

In the period from 2008 to 2012, the age-adjusted incidence of melanoma in US Hispanics (4.6 per 100,00 men and 4.2 per 100,00 women) was lower than in NHWs.5 Garnett et al5 reported a decline in melanoma incidence in US Hispanics between 2003 and 2012—an observation that stands in contrast to state-level studies in California and Florida, in which small but substantial increases in melanoma incidence among Hispanics were reported.6,7 The rising incidence of melanomas thicker than 1.5 mm at presentation among Hispanic men living in California is particularly worrisome.6 Discrepancies in incidence trends might reflect changes in incidence over time or differences in state-level registry reporting of melanoma.5

Despite a lower overall incidence of melanoma in US Hispanics, those who do develop the disease are 2.4 times more likely (age-adjusted odds ratio) to present with stage III disease (confidence interval, 1.89-3.05)8 and are 3.64 times more likely to develop distant metastases (confidence interval, 2.65-5.0) than NHWs.3,7,9-13 Disparities also exist in the diagnosis of childhood melanoma: Hispanic children and adolescents who have a diagnosis of melanoma are 3 times more likely to present with advanced disease than NHW counterparts.14 Survival analyses by age and stage show considerably lower survival among Hispanic patients compared to NHW patients with stage I and II disease. In part, worse survival outcomes among Hispanics are the result of the pattern of more advanced disease at presentation.8,14,15

Late presentation for evaluation of melanomas in Hispanics has been attributed to a number of variables, including a lack of skin cancer awareness and knowledge,9,16 a lower rate of self- and physician-performed skin examinations,10 differences in tumor biology,9 and socioeconomic forces.7,17

In a previous study investigating the relationship between neighborhood characteristics and tumor stage at melanoma diagnosis in Hispanic men in California, Texas, and Florida, several key findings emerged.17 First, residency in a census tract with a high density of immigrants (California, Texas) and a high composition of Hispanics (California, Florida) was an important predictor of a late-stage melanoma diagnosis in fully adjusted models. Additionally, the strength of association between measures of socioeconomic status (ie, poverty and education) and tumor stage at melanoma diagnosis was attenuated in multivariate models when enclaves and availability of primary care resources were taken into account. Hispanic melanoma cases in areas with a low density of primary care physicians had an increased likelihood of late-stage diagnosis in California and Texas. The probability of late-stage diagnosis was concentrated in specific regions along the United States–Mexico border, in south central California, and along the southeastern coast of Florida. Lastly, in Texas, Hispanic men aged 18 to 34 years and 35 to 49 years were at an increased risk of late-stage melanoma diagnosis compared to men 65 years and older.17

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