Racial Differences in the Prognosis and Survival of Cutaneous Melanoma From 1990 to 2020 in North America: A Systematic Review and Meta-Analysis

Differences in time to surgery and defect sizes after Mohs micrographic surgery for black versus white patients with cutaneous squamous cell carcinoma

Few studies have examined outcomes for Mohs micrographic surgery (MMS) for cutaneous squamous cell carcinoma (cSCC) in Black versus White patients. We compared time to surgery and defect sizes after MMS between Black versus White patients with cSCC. Patients with biopsy-proven cSCC treated with MMS at the Hospital of the University of Pennsylvania were identified from a prospectively maintained database (2006-2023). Our primary outcomes included time to surgery (days from the diagnostic biopsy to the first MMS) and defect size (final MMS defect surface area). Univariate and multivariate linear regression models were performed to compare outcomes between Black and White patients with adjustments for age, gender, and tumor location. We identified 8445 cSCC, including 8329 (98.2%) in White patients and 116 (1.4%) in Black patients. Mean time to surgery was 31% longer for Black (76 ± 3.9 days) versus White patients (58 ± 0.5 days) [p < 0.001]. Mean post-MMS cSCC defect size was nearly four times larger for Black (18.6 ± 1.2 cm2) versus White patients (4.8 ± 0.1 cm2) [p < 0.0001]. These differences remained significant when adjusted for age, gender, and tumor location [p < 0.0001]. In conclusion, Black patients with cSCC have significantly longer treatment delays and larger MMS defects than White patients. This study highlights the need for earlier diagnosis and more timely access to MMS for Black patients with cSCC.

The benefit of sentinel lymph node biopsy in elderly patients with melanoma: A retrospective analysis of SEER Medicare data (2010-2018)

BACKGROUND

Sentinel lymph node status is critical for melanoma staging and treatment. However, the factors influencing SLNB and its oncologic benefits in elderly patients are unclear.

METHODS

We conducted a retrospective analysis of patients aged ≥65 with clinically node-negative melanoma and Breslow depth ≥1 ​mm, using Surveillance, Epidemiology, and End Results Medicare database (2010-2018). Multivariable logistic regression assessed SLNB likelihood by demographic and clinical factors, and Cox-proportional hazard models evaluated overall and melanoma-specific mortality (MSM) for SLNB recipients versus non-recipients.

RESULTS

Of 13,160 melanoma patients, 62.29 ​% underwent SLNB. SLNB was linked to reduced all-cause mortality (HR: 0.65 [95%CI 0.61-0.70]) and MSM (HR: 0.76 [95%CI 0.67-0.85]). Older age, non-White race, male sex, and unmarried status was associated with decreased SLNB likelihood, while cardiopulmonary, neurologic, and secondary cancer comorbidities were associated with increased SLNB likelihood.

CONCLUSIONS

Though less frequently performed, SLNB is associated with lower mortality in elderly melanoma patients. Advanced age alone should not contraindicate SLNB.

Disparities in Survival Outcomes Among Patients With Metastatic Melanoma in Texas: Implications for Policy and Interventions in the Era of Immune Checkpoint Inhibitors

OBJECTIVES

Disparities exist in the length and quality of survival from melanoma. This study evaluated, in a Texas cohort, patient factors associated with melanoma survival and examined if newer immune-oncologic agents extend survival compared with conventional therapies.

METHODS

A retrospective analysis of patients diagnosed with metastatic melanoma from 2011 to 2018 in the Texas Cancer Registry database. Multivariable Cox proportional hazard regression was used to evaluate patient characteristics associated with cancer-specific survival (CSS) and overall survival (OS). The patient cohort was then grouped based on receipt of first-line immunotherapy or other therapies. The association between receipt of immunotherapy and survival was assessed with Kaplan-Meier analysis and inverse probability treatment weighted Cox regression.

RESULTS

There were 1372 patients with metastatic melanoma. Factors associated with increased melanoma mortality risk (CSS) included being male (HR: 1.13, 95% CI: 1.02-1.26), non-Hispanic black (HR: 1.28, 95% CI: 1.13-1.45), living in poorer counties (HR: 1.40, 95%CI: 1.20-1.64), and having multimorbidity (HR: 1.35, 95% CI: 1.05-1.74). All minority races and Hispanics had poorer OS compared with non-Hispanic Whites. Patients who received first-line immunotherapy had significantly longer median (interquartile range) survival (CSS: 27.00 [21.00 to 42.00] mo vs. 16.00 [14.00 to 19.00] mo; OS: 22.00 [17.00 to 27.00] mo vs. 12.00 [11.00 to 14.00] mo). They also had reduced mortality risk (HR for CSS: 0.80; 95% CI: 0.73-0.88; P <0.0001; HR for OS: 0.76; 95% CI: 0.69-0.83; P <0.0001) compared with the nonimmunotherapy cohort.

CONCLUSIONS

This study showed differences in risks from melanoma survival based on patient demographic and clinical characteristics. Low socioeconomic status increased mortality risk, and first-line immunotherapy use favored survival. Health policies and tailored interventions that will promote equity in patient survival and survivorship are essential for managing metastatic melanoma.

Sexual Orientation and Lifetime Prevalence of Skin Cancer Across Racial and Ethnic Groups

Importance

Sexual minority (SM) persons have been found to have differential rates of skin cancer, but limited data exist on differences across racial and ethnic groups and by individual sexual identities.

Objective

To examine differences by sexual orientation in the lifetime prevalence of skin cancer among US adult females and males across racial and ethnic groups and by individual sexual identity.

Design, Setting, and Participants

This cross-sectional study used data from the Behavioral Risk Factor Surveillance System from January 1, 2014, to December 31, 2021, for US adults from the general population. Data were analyzed from December 1, 2023, to March 1, 2024.

Main Outcomes and Measures

Self-reported lifetime prevalence of skin cancer by sexual orientation. Age-adjusted prevalence and adjusted prevalence odds ratios (AORs) compared heterosexual and SM adults in analyses stratified by individual race.

Results

Of 1 512 400 participants studied, 805 161 (53.2%) were heterosexual females; 38 933 (2.6%), SM females; 638 651 (42.2%), heterosexual males; and 29 655 (2.0%), SM males. A total of 6.6% of participants were Hispanic; 3.4%, non-Hispanic Asian, Pacific Islander, or Hawaiian; 7.5%, non-Hispanic Black; 78.2%, non-Hispanic White; and 4.3%, other race and ethnicity. Mean (SE) age was 48.5 (0.03) years (incomplete data for age of respondents ≥80 years). The lifetime prevalence of skin cancer was overall higher among SM males compared with heterosexual males (7.4% vs 6.8%; AOR, 1.16; 95% CI, 1.02-1.33), including specifically among Hispanic males (4.0% vs 1.6%; AOR, 3.81; 95% CI, 1.96-7.41) and non-Hispanic Black males (1.0% vs 0.5%; AOR, 2.18; 95% CI, 1.13-4.19) in analyses stratified by race and ethnicity. Lifetime prevalence rates were lower among SM females compared with heterosexual females among non-Hispanic White females (7.8% vs 8.5%; AOR, 0.86; 95% CI, 0.76-0.97) and were higher among Hispanic (2.1% vs 1.8%; AOR, 2.46; 95% CI, 1.28-4.70) and non-Hispanic Black (1.8% vs 0.5%; AOR, 2.33; 95% CI, 1.01-5.54) females in analyses stratified by race and ethnicity.

Conclusions and Relevance

In this cross-sectional study of US adults, differences in the lifetime prevalence of skin cancer among SM adults compared with heterosexual adults differed across racial and ethnic groups and by individual sexual identity among both females and males. Both Hispanic and non-Hispanic Black and SM females and males had higher rates of skin cancer compared with their heterosexual counterparts. Further research addressing the individual factors contributing to these differences is needed to inform screening guidelines and public health interventions focused on these diverse, heterogeneous populations.

Distinct presentation of melanoma in Black patients may inform strategies to improve outcomes

INTRODUCTION

Melanoma guidelines stem largely from data on non-Hispanic White (NHW) patients. We aimed to identify features of melanoma within non-Hispanic Black (NHB) patients to inform strategies for earlier detection and treatment.

METHODS

From 2004 to 2019 Surveillance, Epidemiology, and End Results (SEER) data, we identified nonmetastatic melanoma patients with known TN category and race. Kaplan-Meier cancer-specific survival (CSS) estimates and multivariable Cox proportional hazard modeling analyses were performed.

RESULTS

Of 492 597 patients, 1499 (0.3%) were NHB, who were younger (21% vs. 17% age <50) and more commonly female (54% vs. 41%) than NHW, both p < 0.0005. For NHBs, lower extremity was the most common site (52% vs. 15% for NHWs, p < 0.0001), T category was higher (55% Tis-T1 vs. 82%; 27% T3-T4 vs. 8%, p < 0.0001) and stage at presentation was higher (19% Stage III, vs. 6%, p < 0.0001). Within the NHB cohort, males were older, and more often node-positive than females. Five-year Stage III CSS was 42% for NHB males versus 71% for females, adjusting for age and clinical nodal status (hazard ratio 2.48).

CONCLUSIONS

NHB melanoma patients presented with distinct tumor characteristics. NHB males with Stage III disease had inferior CSS. Focus on this high-risk patient cohort to promote earlier detection and treatment may improve outcomes.

Association of Fitzpatrick Skin Type with metastatic risk from uveal melanoma in 854 consecutive patients at a single center

OBJECTIVE

To assess the association of skin color using Fitzpatrick Skin Type (FST) with metastatic risk of uveal melanoma.

SUBJECTS

854 consecutive patients with uveal melanoma and documented FST.

METHODS

Retrospective detailed review of patient charts was performed for FST (type I- white, II-fair, III-average, IV-light brown, V-brown, VI-black), clinical details of the patient and the uveal melanoma, tumor cytogenetic classification according to The Cancer Genome Atlas (TCGA), and outcome of melanoma-related metastasis and death.

RESULTS

The FST classification was type I (n = 97 patients), type II (n = 665), type III (n = 79), type IV (n = 11), type V (n = 2), type VI (n = 0). A comparison of patient FST (type I vs. II vs. III-V) revealed significant differences in mean age at presentation (64.1 vs. 58.5 vs. 49.8 years, p < 0.001), race white (100% vs. 98% vs. 75%, p < 0.001), presence of ocular melanocytosis (3% vs. 3% vs. 10%, p = 0.01), visual acuity <20/200 at presentation (6% vs. 7% vs. 13%, p = 0.03), genetic results showing TCGA group B tumors (11% vs. 14% vs. 26%, p = 0.01) or TCGA group D tumors (22% vs. 11% vs. 9%, p = 0.01), 10-year incidence of melanoma-related metastasis (25% vs. 15% vs. 14%, p = 0.02) and 10-year incidence of melanoma-related death (9% vs. 3% vs. 4%, p = 0.04). FST was a significant predictor of melanoma-related metastasis (p = 0.02, Hazard ratio 2.3).

CONCLUSIONS

Fitzpatrick skin type may be a predictor of melanoma-related metastasis, with metastasis and TCGA Group D tumors being more common in patients with FST I.

Race-inclusive and equitable access to immune checkpoint inhibitor therapy: What are the biggest hurdles?

A real‐world data analysis evaluating the clinical outcomes of consolidation durvalumab after concurrent chemoradiation in Black versus non‐Black patients with unresectable stage III non–small cell lung cancer demonstrates that there was no overall difference in survival or toxicity between the two groups. The study addresses the important issue of race‐ and ethnicity‐related disparities in clinical trial accruals that limit the generalizability of the results across the patient population. Larger multi‐institutional prospective studies evaluating racially underrepresented populations are warranted to evaluate the contribution of individual factors, optimize treatment strategies, and narrow the disparities in cancer care.

Progress in melanoma treatment: Patient's perspectives

Upon the 20th Anniversary of the Society for Melanoma Research, we highlight the perspectives of patients aiming to help improve future experiences, outcomes, and their quality of life over the next 20 years. Five melanoma patients generously shared their inspiring and enlightening stories of diagnosis, treatment, and outcomes. Many patients had excellent medical teams that synergistically worked together to provide an accurate diagnosis, effective treatment options, and supportive care. However, it is clear that health inequities persist in communities where people of color are predominant, affecting early detection, patient experience, and outcomes. These stories shed light on the unique challenges faced by patients and how the lack of melanoma awareness and adequate resources, especially in communities of color or low socioeconomic status, can contribute to disparate outcomes in melanoma care. We expect that these stories will raise awareness about the progress in melanoma treatment but also the existent disparities in melanoma diagnosis and treatment and the importance of early detection and prevention.

A practical nomogram and risk stratification system predicting the cancer-specific survival for patients aged >50 with advanced melanoma

Objective

To investigate risk factors for advanced melanoma over 50 years of age and to develop and validate a new line chart and classification system.

Methods

The SEER database was screened for patients diagnosed with advanced melanoma from 2010 to 2019 and Cox regression analysis was applied to select variables affecting patient prognosis. The area under curve (AUC), relative operating characteristic curve (ROC), Consistency index (C-index), decision curve analysis (DCA), and survival calibration curves were used to verify the accuracy and utility of the model and to compare it with traditional AJCC tumor staging. The Kaplan-Meier curve was applied to compare the risk stratification between the model and traditional AJCC tumor staging.

Results

A total of 5166 patients were included in the study. Surgery, age, gender, tumor thickness, ulceration, the number of primary melanomas, M stage and N stage were the independent prognostic factors of CSS in patients with advanced melanoma (P<0.05). The predictive nomogram model was constructed and validated. The C-index values obtained from the training and validation cohorts were 0.732 (95%CI: 0.717-0.742) and 0.741 (95%CI: 0.732-0.751). Based on the observation and analysis results of the ROC curve, survival calibration curve, NRI, and IDI, the constructed prognosis model can accurately predict the prognosis of advanced melanoma and performs well in internal verification. The DCA curve verifies the practicability of the model. Compared with the traditional AJCC staging, the risk stratification in the model has a better identification ability for patients in different risk groups.

Conclusion

The nomogram of advanced melanoma and the new classification system were successfully established and verified, which can provide a practical tool for individualized clinical management of patients.

Skin of colour: essentials for the non-dermatologist

Doctors-in-training often receive an inadequate dermatology education. Furthermore, studies have highlighted the under-representation of skin of colour (SOC) in dermatological teaching, learning resources and research. Our image-based questionnaire, distributed to all internal medicine trainees in southwest England, highlighted knowledge gaps regarding SOC among training physicians. It is intrinsically more challenging for clinicians to confidently formulate dermatological diagnoses in SOC. In this review, we provide guidance for physicians to help make the diagnostic process more straightforward. First, we outline how skin colour is determined and classified. We discuss how inflammation presents in SOC, with the typical 'erythema' that physicians often associate with inflammation being a less prominent feature in darker skin tones. We then summarise nine important conditions that we believe physicians working in all specialties should be able to identify in patients with SOC, covering both conditions encountered on the medical take and conditions disproportionately affecting individuals with SOC. The population of the UK is rapidly diversifying; thus, as physicians, we have a professional duty to educate ourselves on dermatological conditions in SOC to provide the best quality of care for all our patients, regardless of their skin type.

Adherence to Adjuvant Therapy in Patients with Resected Melanoma: An Application of the Theory of Planned Behavior

INTRODUCTION

Adherence to adjuvant therapy is crucial for effective disease management in patients with resected melanoma. This study assessed patient-reported adherence to adjuvant therapy and identified behavioral/belief constructs associated with adherence in patients with resected melanoma.

METHODS

Patients with resected stage III/IV melanoma were recruited through the Melanoma Research Foundation and a patient panel to complete an online survey. Patient characteristics, medical history, and adherence to therapy were captured. In accordance with the theory of planned behavior (TPB), the survey measured behavioral, normative, and control beliefs, and intention to adhere to therapy. Structural equation modeling (SEM) examined their relationships with adherence.

RESULTS

Among all patients who received adjuvant therapy and completed the survey (n = 184), 69% received intravenous and 31% received oral therapy; the majority (85.3%) were somewhat involved in deciding to start therapy. Mean age was 45 years, 44% of patients were female, and 83% had stage III/IV disease at diagnosis. Patients had a mean disease duration of 1.5 years, a time since complete resection of 10 months, and an adjuvant therapy duration of 8 months. Adherence to adjuvant therapy was high overall and higher with intravenous than with oral therapy (98.4% versus 91.2%, P = 0.002). All underlying TPB constructs were significant in the SEM model, which explained 60.3% of the variance in intention to adhere. Control beliefs had the strongest association with intention to adhere (standardized estimate = 0.47, P < 0.001) and intravenous therapy was associated with greater adherence than oral therapy (standardized estimate = 0.26, P < 0.001).

CONCLUSIONS

This study found that patients with resected melanoma are highly engaged in the decision to initiate systemic adjuvant therapy, with an overall high adherence rate to prescribed adjuvant treatment. Enhancing patients' view of their capability to adhere to treatments may further improve the adherence rate to melanoma adjuvant therapy.