SEVERAL TIMES OVER THE COURSE of his decades-long career, George Cohen, a dermatologist at USF Health in Tampa, Florida, was asked to help solve a mystery. An oncologist called him up, unable to find the primary tumor in a cancer patient and asked Cohen for an evaluation.
Cohen had an idea of where to look. He’s well-aware that Black Americans such as himself are at increased risk for a particularly problematic kind of cancer called acral lentiginous melanoma (ALM), a deadly disease that occurs in one in five Black patients with melanoma, compared with just one in 100 of those who are white.
Typically originating on the soles of the feet, palms of the hand, or nail beds, ALM can easily be overlooked by patient and doctor alike, especially since people with darker skin tones generally face a far lower risk of skin cancers caused by ultraviolet light exposure. But Cohen has a bead on the disease.
“Lo and behold, on more than one occasion, I’d take the person’s shoes and socks off and find the primary tumor on the foot,” Cohen says.
Unfortunately, Cohen’s knowledge and vigilance about ALM are the exception to the norm. A study published in the Journal of the American Academy of Dermatology this July offers the latest evidence of what experts say is a well-known and growing disparity in melanoma outcomes between white Americans and those of color.
The study analyzed the data of more than 205,000 American men diagnosed with cutaneous melanoma, the deadliest form of skin cancer, between 2004 and 2018.
Black men were most likely to present with advanced cancer, occurring in about half of cases in that population, followed by Hispanic (40%), Asian (38%), Indigenous (29%), and white (21%).
For Black men, melanoma appears in places that are rare for skin cancers in other populations. Learn how to watch for signs in these overlooked spots.
Check strange places. Experts emphasize examining the extremities: foot soles, toes, palms, fingers and nail beds. A 2023 study in the Journal of the American Academy of Dermatology found that about half of melanomas among Black patients originated on the lower extremities, compared with just 10% among white patients.
Think CUBED. Dermatologists have developed the CUBED method to identify rare but deadly acral lentiginous melanoma (ALM): dark in Color, Uncertain diagnosis, Bleeding, Enlargement and Delay in healing. When in doubt, get it checked out: ALM tumors can sometimes mimic other conditions, such as bruising under the fingernail.
Access health care. While U.S. medical guidelines don’t currently recommend annual visits to a dermatologist for all Americans, experts say it can’t hurt, especially for anyone over the age of 50 or who finds a questionable skin mark. Don’t delay, as lead times for dermatology appointments can run months. And being in the system will make it easier to get an evaluation if something concerning does appear.
Be proactive. Americans of all colors should be checking their own skin regularly or asking a loved one to do so. Taking cell phone pictures of any marks on the skin can build a helpful visual record. And it’s OK to insist that health care providers examine the feet and other extremities during evaluations.
Following the progression of their illness, Black men also were least likely to survive five years after diagnosis. About half died of the disease, compared with about a third of Asian, Hispanic and Indigenous and a quarter of white patients.
Cohen says the study unfortunately fits into a long-running understanding among experts that Black people in particular face an underappreciated risk of dying from skin cancer, dating back at least to the 1981 death of reggae legend Bob Marley, who died of ALM at just 36.
“Black people get these [ALM] melanomas, and they are detected at a later stage when a tumor is larger or likely to have spread, and consequently our outcomes are worse,” Cohen says.
Signs of Improvement
Vito Rebecca, a molecular biologist at the Johns Hopkins University Bloomberg School of Public Health in Baltimore, also understands the frustrating nature of melanomas among people of color.
In 2022, an analysis he co-authored in the journal Nature Reviews Cancer noted that survival rates for melanoma among many Americans, including Black Americans, improved between 2000 and now, buoyed by new treatment methods like immunotherapy.
“There were a lot of breakthrough treatments,” Rebecca says. “Revolutionary new strategies to make the immune system increase its chances to recognize and kill the tumor.”
While that’s good news, Rebecca’s analysis also found outcomes had improved the most for white Americans, effectively widening the disparity between them and patients of color.
What exactly is driving the gap—genetics or environment—remains a mystery, but the answer is likely to be complex.
Bently Doonan, an oncologist at University of Florida Health in Gainesville, says researchers believe repetitive foot injuries are likely a risk factor for ALM. That could disproportionately affect Black Americans, who are over-represented in physically demanding professions such as a U.S. soldier or blue-collar worker. Black Americans are also diagnosed with diabetes at higher rates than white Americans, increasing the risk that ALM tumors may be misdiagnosed as diabetic ulcers.
But ultimately, Doonan says, the overall low incidence rate of ALM—about 1,000 to 2,000 a year in the United States—presents a challenge to figure out exactly why there are disparities.
“It’s still so rare, it’s honestly difficult to study,” Doonan says.
Then, Rebecca adds, layer on top socioeconomic challenges facing Black Americans and others of color.
“Depending on if you have Medicaid or Medicare, that changes your access to treatments or time to access these treatments,” Rebecca says.
Still, experts say there are solutions. Education about the risks of ALM and other deadly melanomas, particularly among people of color, can be effective. The medical community needs to include more people of color in clinical trials that test melanoma treatments. And doctors should perform more regular and thorough evaluations for patients at greater risk for ALM.
In other words, there need to be a lot more shoes and socks coming off at the doctor’s office.
“The message needs to go out. Absolutely have people look at your feet,” Cohen says.
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