Analysis of Melanoma in African American Patients in the United States

Discussion

Cutaneous melanoma is an aggressive cancer that can be deadly if not diagnosed and treated early. It has a higher incidence amongst the Caucasian population, however, in rare instances, it also occurs in AA patients (1). Due to the low incidence of melanoma in AAs diagnosis and treatment is often delayed. Moreover, most public health educational campaigns target causation patients (9). Educating patients and physicians is a critical component to increasing awareness of total skin evaluations especially amongst AAs where they maybe underutilized; these have been shown to be an effective tool at detecting melanoma earlier (10).

Understanding the diversity of presentation amongst different ethnicities for melanoma is fundamental to achieving an early diagnosis and effective treatment. The significance of this study is that it contributes to understanding the demographic and socioeconomical characteristics of this disease and sheds light on treatment disparities between AAs and Caucasian patients.

Our study demonstrated that the age distribution of melanoma among AA and Caucasian patients is similar. However, there is a higher proportion of AA females compared to males; while the contrary is true for Caucasians.

Patients with a lower socioeconomic status are more likely to be diagnosed at advanced stages of melanoma and therefore have a higher mortality (11). Linos et al. studied 29,792 patients with melanoma from California and reported that patients with a lower socioeconomic status were more likely to present with a Breslow depth greater than 4 mm (11). A similar study by Chang et al. showed that a lower socioeconomic status was associated with a lower 5 year mortality even when stratifying for stage at diagnosis (12).

Our results showed that AAs have melanoma that is more likely to be located in the extremities compared to Caucasians that have higher distribution in the trunk, head and neck. The location of cutaneous melanoma can be significant when it comes to the initial identification and earlier diagnosis. While moles on the face and trunk may be more easily identified, acral locations can make diagnosis more challenging for physicians and patients. The location of melanoma in AAs could be a contributing factor to the delay in diagnosis. In a study conducted by Cormier et al. (13), AAs were found to have the worst prognosis when compared to white patients and other minorities (13). They also found that AAs had a 4-fold higher risk of being diagnosed at stage IV disease and were 1.5x more likely to die due to melanoma than white patients (13). This is congruent with our results that show that AA patients were more likely to present at advanced stages of disease when compared to white patients, even when adjusting for cofounders.

The most common and effective treatment for patients diagnosed with cutaneous melanoma is surgical resection of the lesion (14). Our results showed that AAs are less likely to receive treatment with an increased number of days to surgery. This is in concordance with the results found by Mahendraraj et al. (1), in which they found that AAs were less likely to receive surgical resection when compared to white patients (1). Moreover, a previous study that enrolled 151,154 patients diagnosed with cutaneous melanoma showed that white patients were more likely to receive appropriate surgical treatment compared to AAs (94.5% vs. 86.6%, p<0.05) (5).

The authors recognize several limitations to this analysis. Due to incomplete data of the NCDB we were unable to include histologic subtype and tumor mitotic index. The accuracy of the data found on the database is subject to the accuracy of centers reporting. Wrong input of data can potentially confound significant associations identified. Future directions for research in melanoma are warranted to fully explore which demographic factors are associated with late-stage diagnosis, considering education level, socioeconomic status, and insurance coverage as potential contributing factors.

In conclusion, AAs have significantly higher odds of being diagnosed at a later stage of disease, ulceration, treatment delay and have melanoma located in the extremities. We hope these findings can help guide future multi-institutional studies to design diagnostic and treatment algorithms for patient-specific melanoma care and shed light on the discrepancies that exist.