Cutaneous Melanoma and Other Skin Cancer Screening Among Hispanics in the United States: A Review of the Evidence, Disparities, and Need for Expanding the Intervention and Research Agendas FREE

Skin pigmentation and sun sensitivity vary widely among US Hispanics,¹ whose median number of nevi (the strongest melanoma risk factor) is somewhat lower than in whites yet higher than in Asians or blacks.² The correlation between number of nevi and age is stronger in Hispanics and non-Hispanic whites than in other ethnoracial groups.² Among Hispanics, acculturation to the United States might lead to decreased sun safety practices.³ Nationwide data from 1992 through 2007 reveal that melanoma incidence among Hispanics increased by more than 22%.^4- 5 Hispanics display higher rates of thick melanoma at diagnosis, and in the absence of cure, targeted prevention might be the best strategy for countering the epidemic.⁶ Hence, our objective was to synthesize the evidence about skin cancer screening among US Hispanics.

We identified observational population-based US studies on melanoma or other skin cancer screening that evaluated participants of Hispanic descent, without any age, time, or language restrictions. Hispanic or Latino ethnicity was defined as Mexican, Puerto Rican, Cuban, or Central or South American heritage regardless of race.⁷ Screening techniques included skin self-examination (SSE), clinical skin examination (CSE), dermoscopy, and biopsy. We conducted an extensive literature search through October 2010 using MEDLINE (from 1950), EMBASE (from 1974), CancerLit (from 1963), and Lilacs (from 1982) and reviewed the bibliographies of all relevant articles. The following keywords and indexing terms were used: melanoma, skin neoplasms, self-examination, early detection of cancer, and mass screening. From the 1029 retrieved articles, we excluded duplicates, reviews, non-US studies, and those with patient or survivor samples, selecting 138 articles for detailed review. Studies with missing ethnoracial data were excluded. Nine studies met all inclusion criteria, and from each we extracted the age range, population type, health care access status, setting, number and/or percentage of Hispanics with reported melanoma or other skin cancer screening, year of assessment and measurement method.

The reviewed articles^8- 16 are summarized in the Table. Heterogeneity was observed in sample size and composition, SSE and CSE definitions, and screening reference periods. An estimate of the relative odds ratio for CSE by ethnicity was available in only 1 study, indicating that Hispanics were almost 40% less likely to report a recent CSE than non-Hispanic whites.⁸ Overall, SSE was reported by 14% to 50% of Hispanics, while CSE was reported by 7% to 17%. Only 1 study showed screening rates by sex, with 18.2% of Hispanic women and 8.3% of Hispanic men reporting SSE within the past 2 months.⁹ Research with nationally representative samples documented a decreasing trend in CSE prevalence, possibly attributable to measurement modification in the most recent assessment.⁸ Specifically, 5.6%, 5.7%, and 3.7% of Hispanics reported a recent CSE in 1992, 1998, and 2000, respectively (the corresponding percentages among whites were 11.4%, 12.5%, and 8.9%).⁸ No studies on dermoscopy or skin biopsies by Hispanic ethnicity were found; also none pertained to melanoma screening among children or adolescents. All 9 studies relied on self-reports, and none documented CSE validation. The paucity of research along with considerable heterogeneity in sample characteristics and screening measures prevented subgroup analyses or meta-analyses.

The US Hispanic population is rarely the focus of melanoma screening research despite sufficient epidemiologic evidence that this population merits increased attention. Our review suggests that Hispanics' high rate of advanced melanoma could be attributed to insufficient prevention initiatives,^6,10- 11 lack of SSE instruction or awareness about signs or symptoms,¹² delay in seeking follow-up care for suspect lesions,¹³ and decreased risk awareness among individuals and physicians.¹² Our review further suggests that health care access might not be the strongest enabling factor in melanoma screening of Hispanics.

A limitation of this review was the inability to make skin color or skin sensitivity distinctions among Hispanics because such data were not provided in the studies. One of the reviewed studies noted that Hispanics were less likely than non-Hispanic whites to report oral cancer screening,¹¹ whereas another study observed a significant link between CSE and breast, colorectal, or prostate cancer screening.⁸

Recent research highlights the lack of relevance of skin cancer to Hispanics, whose knowledge about the disease is not derived primarily from physicians but rather from the media,¹⁷ which has also been identified as a reason for SSE.¹³ However, applicability of the ABCDE rule for Hispanics remains to be clarified. Research notes that physicians' experience with non-Hispanic whites and melanoma diagnosis patterns might not be relevant to Hispanics.⁶ The extremely high costs for thick melanoma management further warrant an increased emphasis on developing early detection strategies.¹⁸

The Hispanic population growth rate is over 3 times higher than that of the total US population,¹⁹ which has strong implications for health care providers, policy, and research. Potential similarities in important melanoma risk factors such as skin or nevi characteristics between Hispanics and non-Hispanic whites, the high rates of thick melanoma among Hispanics, and the suboptimal prevention efforts with Hispanics strongly reinforce the need for increased public health focus to correct misconceptions about skin cancer, improve the frequency and efficacy of SSE and CSE, and reduce existing disparities.

Correspondence: Dr Andreeva, PhD, Nutritional Epidemiology Research Unit, (UREN), University of Paris XIII, 74, rue Marcel Cachin, Bobigny 93017, France (v.andreeva@uren.smbh.univ-paris13.fr).

Author Contributions: Dr Andreeva had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Andreeva and Cockburn. Acquisition of data: Andreeva. Analysis and interpretation of data: Andreeva and Cockburn. Drafting of the manuscript: Andreeva. Critical revision of the manuscript for important intellectual content: Cockburn. Study supervision: Cockburn. Data abstraction: Andreeva.

Financial Disclosure: None reported.

Funding/Support: This work was supported in part by Centers for Disease Control and Prevention grant 36 U55/CCU921930-02, National Institute of Environmental Health Sciences grant 5P3037 ES07048, and National Cancer Institute grant R01 CA121052 (Dr Cockburn) and by a doctoral dissertation fellowship from the Department of Preventive Medicine, Keck School of Medicine, University of Southern California (Dr Andreeva).

Role of the Sponsors: The sponsors had no role in the design or conduct of the study; in the collection, analysis, or interpretation of data; or in the preparation, review, or approval of the manuscript.