Why Are Black People Less Likely to Get Melanoma But More Likely to Die From It?
Jacqueline Smith was shocked when she received a stage III melanoma diagnosis at the young age of 21. As a black woman, she didn’t think it could happen to her. “Growing up, I learned that middle-aged, fair-skinned Caucasian women were at high risk for skin cancer,” Smith tells SELF. Smith, now 39, is a melanoma awareness advocate and public speaker who devotes much of her time to spreading knowledge of skin cancer risks, especially to other black women who may underestimate their chances of developing this potentially deadly disease.
Yes, black people can get skin cancer. What’s more, when they do, they’re much more likely to die from it.
“Skin cancer in [people] of color absolutely happens. It tends to be a perfect storm, which is why people who have darker skin and who develop skin cancer tend to have a much poorer prognosis,” dermatologist Brooke Jackson, M.D., who specializes in skin of color at Northwestern Memorial Hospital, tells SELF.
A July 2016 study in the Journal of the American Academy of Dermatology found that of all racial groups, non-Hispanic black people had the lowest rates of melanoma diagnoses, but they were also the most likely to be diagnosed at a later stage.
The research pulled data from 96,953 patients given a melanoma diagnosis between 1992 and 2009. White people had the highest rate of skin cancer, with 45.8 diagnoses per 100,000 people, while black people had the lowest, with 1.35 diagnoses per 100,000 people. But despite the low incidence of melanoma in minority groups, these patients had significantly shorter survival rates than white patients.
According to the most recent data available from the American Cancer Society, the five-year melanoma survival rate is 93 percent for white people, but only 69 percent for their black counterparts.
There’s a whole host of complex reasons why black Americans are more likely to die from skin cancer than white Americans. To fully explore them, you first have to know a bit about what skin cancer really is.
Skin cancer happens when your skin cells grow abnormally and out of control. It’s the most common form of cancer in the United States.
Over 5 million people in the United States are diagnosed with skin cancer each year, according to the American Cancer Society’s 2017 report. The most common forms of this disease are basal cell carcinoma, squamous cell carcinoma, and melanoma.
Your skin’s outermost layer is called your epidermis, and it has three main types of cells, according to the American Cancer Society. The squamous cells in the outer part of your epidermis are flat and constantly slough off so new ones can take their place. Basal cells, which are deeper in the epidermis, divide to make new cells to replace the old squamous ones. Then there are melanocytes, which create melanin. It’s the brown pigment that, by making some people’s skin darker than others, allows for the human race to have such a beautifully diverse range in skin tones.
While everyone has a similar number of melanocytes, genetics determine how much of this pigment those cells actually make, according to the American Academy of Dermatology (AAD). The more melanin you have, the darker your skin.
The most prevalent types of skin cancer correspond with these different cells. Around 8 in 10 skin cancers in the United States are basal cell carcinomas, making this the most common form of this disease, according to the American Cancer Society. Basal cell carcinoma typically develops on areas most often exposed to the sun, like the head and neck, and grow slowly. They can present in a multitude of different ways, including as flat, firm, pale, or yellow areas, raised reddish patches, strange bumps, growths with raised edges, and open sores.
Squamous cell carcinoma, which makes up around 2 in 10 skin cancers, normally crops up on sun-exposed areas like the face, ears, neck, lips, and back of the hands, though it also sometimes shows up in the genital area. It often looks like a rough or scaly red patch, raised lump, open sore, or growth similar to a wart. Like basal cell carcinoma, it also grows slowly. The American Cancer Society estimates that these cancers kill around 2,000 people each year in the United States, although it’s hard to pinpoint the exact number of people who die from basal and squamous cell skin cancers annually because cancer registries don’t track them.
Melanoma, which starts in those pigment-providing melanocytes, can be much more lethal. “Melanoma isn’t the most common cancer, but we hear about it so often because it is the most deadly [skin cancer],” oncologist Michael K. Wong, M.D., Ph.D, a professor in the department of melanoma medical oncology at The University of Texas MD Anderson Cancer Center, tells SELF. Melanoma only makes up around 1 percent of skin cancers, but it’s expected to kill around 9,320 people in the United States in 2018. Melanoma is more likely to be fatal because it’s aggressive and typically quicker to spread when left untreated than basal and squamous cell skin cancers.
Melanoma usually shows up as a new mole on your skin that may change in size, shape, or color. Experts use what’s known the ABCDE rule to summarize melanoma warning signs: Asymmetry that means the mole doesn’t look uniform all over, a strange border around the mole’s edge, uneven color, a diameter larger than around ¼ inch, and a mole that is evolving in shape, size, or color.
Melanoma most often appears on the chest and back in men and the legs in women, though it can really occur almost anywhere on your body, according to the American Cancer Society. The most common form is superficial spreading melanoma, according to the U.S. National Library of Medicine. (This is what Smith had.)
Black people are actually more susceptible to the least common subtype of the disease, known as acral lentiginous melanoma. This kind of melanoma shows up in unexpected places, like the palms of the hands, soles of the feet, and under the nails. This unexpected presentation causes it to fly under the radar, which is one reason why black people are more likely to be diagnosed with skin cancer at a later stage. Another reason: the damaging myths about black people being exempt from skin cancer.
There’s a dangerous, pervasive, and categorically inaccurate idea that melanin offers sufficient protection from the sun’s harmful UV rays.
Until she received her diagnosis, Smith says she believed that since she had dark skin, she didn’t need to protect herself from the sun. “I hear all too often that melanin is our natural sunscreen,” she says. She’s far from alone; a 2015 study in the Journal of the American Academy of Dermatology found that non-Hispanic black women were significantly less likely to regularly protect their face or other exposed areas with sunscreen than non-Hispanic white women. Overall, sunscreen use was lowest in people whose skin didn’t tend to burn. But your skin doesn’t need to actually burn in order for you to have skin damage—even a slight tan after sun exposure is a sign your skin has been injured, according to the Centers for Disease Control and Prevention (CDC).
The authors of the study, which was a nationally representative survey of 4,033 people, posited that people whose skin isn’t as sensitive to the sun may think they don’t need sun protection. While the study had its limitations, like relying on people’s self-reported sunscreen use, it points to what experts say is a commonly held belief. “The misperception is that melanin is universally protective and [dark-skinned people] do not need to wear sunscreen,” Dr. Jackson says.
It's true that melanin does offer some protection from the sun by absorbing or deflecting harmful ultraviolet rays (invisible radiation from the sun that can damage the DNA of genes that control skin cell growth)—but it's not enough to completely ward off the threat of skin cancer, no matter how dark your skin may be.
That’s why sunscreen—and people knowing they need it—is essential; it absorbs, reflects, or scatters sunlight to protect against UV rays, according to the CDC. The American Cancer Society suggests wearing a broad spectrum sunscreen (meaning it protects against both UVA and UVB rays) with SPF 30 or higher. Experts also recommend wearing accessories like hats and sunglasses, long-sleeved clothing in dark colors (or even with SPF), and trying to stay in the shade between 10:00 A.M. and 4:00 P.M. when UV rays are most intense.
But dutifully slathering on sunscreen and taking other protective measures isn’t enough to completely ward off skin cancer. In fact, the acral lentiginous melanoma that is more likely to affect black people can show up in areas that are rarely exposed to the sun, like the bottoms of the feet. No one knows precisely what causes non-UV related skin cancer to develop, Dr. Jackson explains, but potential factors include gene mutations, a family history of cancer or skin cancer, and various inherited syndromes that raise skin cancer risk, according to the American Cancer Society.
But make no mistake—the racial disparities in skin cancer survival rates are not solely based on insufficient information and sunscreen. There are many more factors at play.
Factors tied to lower socioeconomic status, like a lack of access to preventive screenings, absent or low-quality health insurance, and poor medical care can translate into worse health outcomes for people of color, according to the American Cancer Society’s 2016-2018 report on cancer in African Americans. And without insurance, skin cancer screenings are likely to be an afterthought. According to the United States Census Bureau’s 2016 report, all non-white populations had higher uninsurance rates than white people: 16 percent of Hispanic-origin people were uninsured, compared with 10.5 percent of black people, 7.6 percent of Asian people, and 6.3 percent of white people.
Even the toll of combatting discrimination and racism can affect health disparities, as chronic socioeconomic and race-related stress may contribute to poorer health outcomes, according to the American Psychological Association.
Even when someone is able to access medical treatment, health professionals aren’t immune from the misperception that black people don’t need to worry as much about skin cancer. “Sometimes people who evaluate you are of the belief, ‘Oh, you’ve got dark skin—we don’t have to worry about you,’” Dr. Jackson says. And unfortunately, this can lead to delayed diagnosis and treatment. “There’s definitely a correlation between delayed diagnosis and poor prognosis,” Dr. Jackson says.
This is a lot of heavy, disheartening information. But that doesn’t mean all hope is lost: Prevention and detection make it possible to survive skin cancer.
Melanoma, as deadly as it can be, is most survivable when it’s found and treated as soon as possible.
To catch any strange spots as soon as they pop up, Dr. Wong emphasizes the importance of checking your skin regularly for any new marks. Anything that gives you pause is worth flagging for your doctor, but that’s especially true if you’re a black woman and find spots in areas where acral lentiginous melanoma is most likely to develop. If you see an unexplained, persistent mark on the soles of your feet, under your nails, or on the palms of your hands, make an appointment with your dermatologist, Dr. Wong says, and get a second opinion if you don’t feel they’re taking you seriously. The right doctor will fully evaluate both your mark and medical history, then potentially decide to remove the spot for a biopsy, according to the Mayo Clinic.
If you do in fact have skin cancer, your treatment will depend on the type and stage of your disease. In the early stages, your doctor may be able to surgically remove the cancerous skin without any additional treatment, according to the Mayo Clinic. If your cancer has spread, though, it may also require radiation or chemotherapy.
Thanks to her diagnosis and treatment, Smith is alive, well, and determined to help others avoid the same fate.
After surgery, a clinical drug trial, and radiation, Smith’s cancer status is N.E.D., or “no evidence of disease.” She now works with the Melanoma Research Foundation, is a commissioner on Maryland’s Montgomery County Commission on Health, and has served on the District of Columbia Cancer Action Partnership. She plans to make her life's work helping other cancer patients through research and advocacy.
“I would like people to realize melanoma is largely preventable,” Smith says. “Had I known I would develop melanoma, I would have diligently used sunscreen and made a better effort to shield myself from sun exposure. However, I am thankful for my life and health, the people I've met along the way, and my overall journey.”
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