A health equity framework for melanoma diagnosis and outcomes in ethnic minorities
Dr. Schwarzenberger is the physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, FAAD, May 1, 2023
In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with David Polsky, MD, PhD, FAAD, from NYU Langone health, about his JAAD paper, ‘A health equity framework to address racial and ethnic disparities in melanoma.’
DermWorld: You and your fellow authors recently published a very brief, yet powerful article proposing a health equity framework to address racial and ethnic disparities in melanoma. Can we start by discussing what those disparities look like?
Dr. Polsky: The racial and ethnic health disparity in melanoma that is probably of greatest significance is the difference in survival between non-Hispanic white (NHW) populations, and those of Black or Hispanic race and ethnicity. For example, one recent study using the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry found that the five-year, melanoma-specific survival for melanomas diagnosed on or after 2010 was 93% for NHWs, but only 87% for Hispanic patients, and 75% for Black patients.
DermWorld: How do you think we got here?
Dr. Polsky: There are several factors that contribute to this health disparity. One factor is that melanoma is very rare among Black and/or Hispanic patients. As such, it is not a health priority. Patients in these groups may falsely believe that they cannot get melanoma because they rarely if ever get sunburned. Secondly, Black and Hispanic patients are more likely to be of lower socioeconomic status (SES) than NHW patients, and we know that there are substantial disparities in melanoma outcomes based on differences in SES at the individual and community level. Communities with lower SES tend to have reduced access to health care, including fewer dermatologists compared to communities of higher SES. Taken together, we believe these factors contribute to the greater tumor thickness and more advanced stage at initial diagnosis that we observe among Black and Hispanic patients compared to NHW patients.
DermWorld: Tell us about your proposed Melanoma Health Equity Framework. How was this created and has a similar framework been used for other diseases?
Dr. Polsky: We were very fortunate to partner with Dr. Azizi Seixas, a population health researcher who has a PhD in clinical psychology. Dr. Seixas developed a similar framework for his work on health disparities in sleep apnea. Dr. Seixas distilled the relevant barriers that patients face into the five A’s: Barriers to Awareness, Access, Assessment, Acceptance, and Adherence.
DermWorld: You mentioned the social determinants of knowledge and access to care as being very important factors in this health inequity. Is one more relevant than the other? Can we make an impact by addressing one, or do we need to address them both equally?
Dr. Polsky: To be successful, we need to address both of these barriers. For example, if we were able to raise awareness of the importance of identifying melanomas at early stages among Black and Hispanic people, and increased their rates of skin self-examination, we would not be truly successful if we did not increase their access to proper diagnostic evaluations.
DermWorld: You propose using trained community health workers to help people navigate the complexities of the health care system. Can you explain this concept? Is this a novel idea, or have they been proposed, or utilized, to facilitate care in other settings?
Dr. Polsky: Community health workers (CHWs) are public health professionals who serve as trusted liaisons between patients and health care systems. The roles of CHWs vary but include: providing education/awareness; identifying and addressing barriers to care at the individual level; scheduling and/or attending appointments; providing appointment reminders and pre-appointment counseling; providing referrals to medical services; and arranging transportation.
While we do not endorse population-wide melanoma screening since there is not sufficient evidence that the potential benefits outweigh the potential harms, in the cancer arena, several studies have highlighted the efficacy and feasibility of a CHW approach to improving breast, colorectal, and cervical cancer screening rates among racial-ethnic minorities, thereby facilitating access to clinical assessments and care.
The efficacy of CHW interventions in melanoma has minimally been studied so far. One intervention at a community health fair showed that a 10–15-minute melanoma information session with a CHW resulted in substantial self-reported increases in knowledge of melanoma signs (6% vs. 94% aware of ABCDEs; p <.001) and confidence in self-screening (3% vs. 50% very confident; p<.001).
For melanoma care, CHWs could help patients learn how to examine their skin for concerning lesions, find dermatology clinics, subsequently schedule, and perhaps attend appointments, and expedite appointments for changing or growing lesions. As telemedicine-based imaging modalities become more effective, CHWs could assist patients in engaging with these platforms. CHWs could similarly help patients navigate follow-up care by assisting with scheduling of appointments and helping patients overcome socioeconomic barriers that may prevent them from adhering to follow-up care (e.g., connect with social service agencies).
Want to read more?
Check out the archives of the most popular Clinical Applications columns.
DermWorld: Do you have an idea of how many people we could be helping with your proposed interventions?
Dr. Polsky: It is very difficult to accurately estimate the number of people who could be helped through our proposed interventions. We envision deploying these interventions to lower SES communities regardless of race and ethnicity since health disparities related to socioeconomic status are very important, and overlap with the racial and ethnic disparities in melanoma.
At a minimum, there are approximately 100,000 invasive melanomas being diagnosed in the United States per year. A recent study found that about 30% were stage T2 and higher (greater than 1.0mm in thickness). We hope that our intervention could lead to a decrease in higher-stage tumors, since the care of these patients is more complex and costly, and associated with greater mortality. The same study suggests there would likely be additional benefits to diagnosing thinner T1 tumors (e.g., <0.5mm in thickness) compared to thicker T1 tumors, so we hope our intervention could help reduce tumor thickness overall among many low SES communities.
David Polsky, MD, PhD, FAAD, is an Alfred W. Kopf, MD, professor of Dermatologic Oncology at Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine, professor in the Department of Pathology at NYU Grossman School of Medicine, vice chair of research of the Ronald O. Perelman Department of Dermatology, and director of Pigmented Lesion Service. He has no relevant commercial or financial conflicts of interest. His paper appeared in JAAD.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.
AAD Skin of Color Curriculum
Check out the Academy’s curriculum for the diagnosis and effective treatment of Skin of Color disease and conditions.