Washington Post - Betty Jordan always regarded melanoma, the deadliest form of skin cancer, as a white person's disease. “Whenever I heard the word, my mind would automatically think: 'Caucasian,' '' she says. “It was something I never worried about.''
So she was shocked five years ago to learn that the quarter-size dark spot on her left foot was acral lentiginous melanoma (ALM), an aggressive cancer that disproportionately afflicts African Americans and other dark-skinned people. “I never paid any attention to it until a friend urged me to see a doctor,'' she says. “The area was hard to see, and it never occurred to me to get serious about it.''
Fortunately, it was caught early and removed. The prognosis is excellent for Jordan, 69, a retired computer network engineer who lives in Temple Hills, Maryland.
But this is not typically the case for dark-skinned people who develop ALM or other skin cancers. Because they often assume they are not at risk, their cancers tend to be diagnosed at a more advanced stage, and patients are likely to face a bleaker outcome.
“It's true that the vast majority of melanomas occur in fair-skinned people, but it's important to know that dark-skinned people can get skin cancer, too,'' says Maral Skelsey, a surgeon and skin cancer specialist who heads the Georgetown University Medical Center's dermatologic surgery centre. “They often are dismissed by their general physicians in terms of risk. I hear it so often: 'No one told me I could get skin cancer.' ''
Melanoma rates among all Americans have been increasing for the past 30 years, probably due to failure to take sufficient protective measures against ultraviolet ray exposure and to increasing use of tanning booths. Melanoma accounts for fewer than 2 percent of skin cancer cases, but it kills more frequently than the others. In 2014, an estimated 76 100 new cases of melanoma will be diagnosed, with about 9 710 deaths, according to the American Cancer Society.
To be sure, melanoma is many times more common in whites (1 in 50) than in African Americans (1 in 1,000) or Hispanics (1 in 200). But the danger for affected people of colour is greater: The five-year survival rate for African Americans is 73 percent, compared with 91 percent for Caucasians, according to the American Academy of Dermatology.
That difference is probably due to later diagnosis and treatment: The initial melanoma diagnosis is not made until the disease is at an advanced stage for an estimated 52 percent of non-Hispanic blacks and 26 percent of Hispanics, compared with six percent of non-Hispanic white patients, according to the Skin Cancer Foundation, a public education and research organisation.
ALM, while rare overall, primarily strikes people of colour - African Americans, Asians, Pacific Islanders and Hispanics - and it can be lethal. The disease is most often found on the palms, nail beds and soles of the feet. These are areas of the body that have less pigment and receive less exposure to the sun; they also are locations people are most likely to ignore.
Reggae musician Bob Marley died in 1981 at age 36 from ALM, initially thought to have been a soccer bruise under his toenail.
“This is a deadly form of skin cancer which disproportionately afflicts blacks and can behave more aggressively,'' says Suraj Venna, director of the Melanoma and Cutaneous Oncology Centre in the Washington Cancer Institute at MedStar Washington Hospital Centre. “The way to combat this is to educate people from these communities, as well as their health-care providers.''
ALM can arise in skin that appears to be normal, and it can develop within a mole. It often starts as a slowly enlarging flat patch of discoloured skin and is sometimes mistaken for a stain. At first, the malignant cells are found within the outermost layers of the skin, but the cancer later can become invasive. The thicker the melanoma, the more likely it is to metastasise and become life-threatening.
Experts don't know why ALM overwhelmingly affects people of colour or why it usually shows up in less-pigmented areas of their bodies.
“There likely is some interplay in biology, ethnicity and the environment,” Venna says. “Maybe there is some protein or gene we are not seeing in the white population. Pigment does protect them, which probably explains why they don't have the same incidence of melanoma on their backs or legs... The field definitely needs more studies on genetics and ethnic variation, especially to explain the poorer outcomes in African Americans.”
Dermatology experts stress that dark-skinned people should never be complacent about their risk of skin cancer. These experts recommend regular full-body examinations for them, just as for fair-skinned individuals, and urge them to be especially vigilant about routinely checking locations where ALM typically develops.
“Your physician shouldn't dismiss you just because you are black if you have any new or changing skin lesions on your body, especially nail changes,'' Skelsey says. “If somebody has a wide, dark streak under a nail or on the edge of the skin where it meets the nail, it is very important to have it evaluated, especially if it is something that persists and is wide and solitary. The only way to know for sure is to biopsy the area.''
Washington podiatrist Sheldon Laps recalls the African American patient who came to him 10 years ago with a mass on the end of one of her big toes that had started as a coffee-coloured stain. Doctors had been treating her with antibiotics for 18 months, mistakenly assuming she had an infection.
But it wouldn't go away, so they sent her to Laps for further evaluation. He thought it was a bone tumour and immediately took an X-ray. But the bone was normal. He then performed a biopsy. “It was acral lentiginous melanoma,'' he says. “I was flabbergasted when I got the report. I had never seen a case of that before.''
An orthopedic oncologist amputated the toe, and initial scans of the patient's liver, spleen, bones and lungs were clear. But the tumour had spread, and she died several years later. “I have to wonder what might have happened if she had not been misdiagnosed for a year and a half,'' Laps says. “She might not only still have her toe, but still have her life.''
The only effective treatment for ALM is surgical removal of the cancer, which makes early detection especially important. A special surgical technique known as Mohs, named after Frederic E. Mohs, the physician who developed it, often can spare fingers and toes from amputation.
The procedure involves surgically removing skin cancer layer by layer and examining the tissue under a microscope until there are clear margins - that is, healthy, cancer-free tissue around the site of the tumour. Surgeons who practice the Mohs procedure must undergo additional training, and not all skin cancer surgeons perform it.
“It's highly effective, and you don't have to take drastic measures that are unnecessary,'' such as amputation, says Ali Hendi, a skin cancer specialist who has been trained in Mohs surgery. “It is a tissue-conserving surgery to remove only the cancer and nothing more. It's not available in many areas, so people are not always aware of it as an option.''
As for ALM survivor Betty Jordan, she undergoes a full-body examination every six months and she frequently examines her nails, palms and the soles of her feet. “This was something I never thought about before,'' she says. “But I pay close attention now.''
What is skin cancer and how can you avoid it?
There are three main types:
Melanoma: the most deadly.
Squamous cell and basal cell: the most common in humans, the slowest-growing and also the easiest to treat.
In African Americans, squamous cell carcinomas occur mainly on the legs and genital area, and sometimes arise from scarring or chronic inflammation, according to the Skin Cancer Foundation. They can be more aggressive and dangerous for African Americans than for whites, due in part to later detection and treatment. Smoking and infection with human papillomavirus are risk factors, according to Ali Hendi, a spokesman for the foundation.
For Caucasians, sun exposure is the greatest risk factor for all types of skin cancers. Although dark-skinned individuals enjoy greater protection than whites, they are not immune.
People of all ethnicities should heed the following guidelines from the Skin Cancer Foundation:
US Surgeon general warns about skin cancer” “tanned skin is damaged skin”
By Brady Dennis
Acting US Surgeon General Boris D. Lushniak wants to shine a spotlight on the nation's ever-growing number of skin cancer cases, calling it a “major public health problem that requires immediate action.”
In a report last week, Lushniak highlights some disquieting facts about the disease and its most deadly form, melanoma. There are 63 000 new cases of melanoma diagnosed in the United States each year, it says, and an estimated 9 000 annual deaths from the disease, many of them involving teens and young adults. (The American Cancer Society uses slightly different statistics.)
The report, the first time the surgeon general has publicly focused on skin cancer, urges ordinary Americans to take long-recommended preventive steps such as wearing sunscreen and seeking shade when outdoors. But it also calls on other sectors of society, from researchers to policymakers, to play a role in turning back the tide of the disease.
Lushniak spoke to The Post ahead of the report's release. The following transcript has been edited for length and clarity:
QUESTION: Your report mentions indoor tanning. What role do we believe indoor tanning plays in melanoma? And what more can be done about that? There are state regulations. The FDA has proposed some tighter regulation on tanning beds.
ANSWER: I've got to, as acting surgeon general, call out the facts. And the facts are that indoor tanning is a source of ultraviolet radiation, period. Ultraviolet radiation is a known carcinogen, period. This is a needless exposure to ultraviolet radiation. According to research... we're looking at about 400 000 cases of skin cancer, about 6 000 of them melanomas, that are estimated to be related to indoor tanning in the United States each year. So I have to look at this as being a major problem. We certainly know it's something that's become popular amongst youth. And much like the surgeon general comes out very vehemently against youth smoking, I am coming out quite vehemently against youth exposing their skin to ultraviolet radiation in tanning booths.
We still have an issue with the concept of social norms. Is tan a good thing or a bad thing? A lot of times we compliment people, “Oh, you look so tan. You're so relaxed. You must have been on vacation.” Part of the thing we really want to emphasise in this call to action is that tanned skin is damaged skin.
Q: How do you look at melanoma in comparison to other cancers? There are cancers that more people die from than this.
A: I am a dermatologist, so this is an area I've been passionate about. I've trained in skin diseases. I've seen patients with a variety of skin cancers, including people who have died from skin cancer. And it brings to the forefront the facts about melanoma: It's the deadliest form of skin cancer. Each year we have 63 000-plus cases diagnosed, nearly 9 000 people die. That's one person every single hour that's dying from melanoma. I mentioned the increase over the past 30 years. But also, it's one of the most common types of cancer amongst US teens and young adults. So when we're looking at impact, the term in epidemiology that we use is “years of potential life lost.” We're really talking about a tragic disease here, something that really affects the young. That's something, from a public health perspective, we have to do something about.
Check moles and other spots for skin cancer warning signs
The American Cancer Society offers these “ABCDE” warning signs of melanoma, which can appear on the skin as a mole, lesion or spot:
Asymmetry: One half of a mole doesn't match the other half.
Border: The border is irregular, notched, blurred or ragged.
Colour: The mole or lesion has a variety of colours, including shades of brown, tan or black, sometimes with patches of pink, red, white or blue.
Diameter: The suspicious area is new or at least a quarter-inch in diameter (the size of a pencil eraser).
Evolving: The mole is changing in size, shape or colour.
Other warning signs:
- A sore that does not heal.
- Spread of pigment from the border of a spot to surrounding skin.
- Redness or a new swelling beyond the border.
- Change in sensation: itchiness, tenderness or pain.
- Change in the surface of a mole: scaliness, oozing, bleeding or the appearance of a bump or nodule.
For people of colour, it also is critical to be on the lookout for skin changes that appear in less-pigmented areas of the body, such as the palms of the hands, soles of the feet and nail beds. A skin cancer specialist should promptly examine any suspicious lesions on those sites.