Skin Cancer

People with brown skin often have a false sense of security when it comes to skin cancer.  We tend to believe that our darker skin exempts us from this potential danger.  It is true that people of color, those with increased skin pigmentation, have added protection against the UV rays of the sun.  However, it is also true that those from African-American, Asian, Latino, and Native American backgrounds usually have higher morbidity and mortality rates for several types of skin cancer than their white counterparts.  This lower survival rate is a direct result of late detection or misdiagnosis.  Because there is a dearth of research on brown skin, there is little literature available to healthcare professionals to help educate them on the different ways skin cancer can manifest itself in darker skin.  For this reason, it is of the utmost importance that you choose physicians who are familiar with the unique characteristics of darker skin and ethnic skincare.  This can literally make the difference between life and death.

In addition to choosing an informed physician, it is also very important for each individual to be self-educated about the different ways in which cancer affects brown skin. There are three types of skin cancer: malignant melanoma (MM) squamous cell carcinomas (SCC) and basal cell carcinomas (BCC). In general, persons with brown skin are less likely to develop BCC than their white counterparts. SCC (especially those that develop from scars or burns) and melanomas are more common in ethnic skin. However, melanoma remains the most deadly form of skin cancer in brown skin, due mainly to its potential for rapid spread, and to late diagnosis.

Malignant Melanoma
Malignant melanoma is the most dangerous and deadly form of skin cancer in people of color.  Although it is often curable if discovered early, many cases aren’t discovered until it is too late to effectively treat the disease. Unlike other skin cancers, melanoma has great potential for metastasizing (spreading), and once it reaches other parts of the body, it is very difficult to treat.  There are two main reasons for late detection: 1) the melanomas on brown skin often occur on less sun-exposed areas—feet, palms, nails; and 2) they are sometimes misdiagnosed as plantar warts (foot wart), tinea nigra palmaris (fungus on the palm), or talon noir (dark nail).  Melanoma in non-sun-exposed skin especially the feet, palms, nails) is the most commonly seen in Asians, Native Americans, Africans, and African-Americans.  In Hispanics, melanoma malignancies occur most frequently on the legs.

Melanoma skin cancer is especially unique due to the fact that it is one of the only forms of cancer where the cause is felt to be known.  This cancer most often develops due to an individual’s overexposure to the sun and other forms of ultraviolet rays (i.e. artificial light). Despite myths that claim otherwise, people with brown skin do not have absolute protection from the sun.  Lighter-skinned Hispanics are particularly vulnerable, as they have less melanin than their darker counterparts to protect them from the sun.  However, Hispanics often do not consider themselves at risk for skin cancer and, because of their decreased tendency to sunburn, remain in the sun for dangerously long periods of time without adequate protection.

Melanoma tumors are malignant and originate in the pigment-producing cells within your skin (melanocytes).  Because of their location, melanoma tumors tend to be black or brown. They do, however, occasionally cause cells to stop producing pigment, which results in the appearance of a dark, pinkish, skin-colored growth. Usually, the tumors appear as multi-colored patches or bumps with irregular outlines.  These areas often begin to crust and bleed with time and many developments on the sites of pre-existing moles. Melanomas can be either in situ (a localized tumor usually located in one spot on the outer layers of your skin) or invasive (cancer cells that penetrate further into the skin and have begun to invade other parts of the body). If you spot irregularities in your skin, it is always advisable to consult a physician, since she will be able to provide an informed diagnosis.

There are four basic categories of melanomas: Acral Lentiginous, Superficial Spreading, Lentigo Maligna, and Nodular Melanoma.  The first three are in situ in the beginning, later advancing to the invasive stage.  The last is invasive from the beginning.

Acral Lentiginous is one of the most common forms of melanoma in people with brown skin, Asians and African Americans especially. This form of melanoma tends not to affect Caucasians. It is usually seen as a black or brown discoloration on the palms of hands and feet, or under the surface of nails, and is one of the least diagnosed because of its odd location. Acral Lentiginous spreads superficially before tumors begin penetrating deeper organs. 

Superficial Spreading melanoma is the most common type and accounts for about 70% of all melanoma cases.  Usually, it is located on the top layer of the skin and is slow to penetrate into the lower layers.  This type of skin cancer often begins as a flat patch of discoloration with irregular borders.  It is usually somewhat geometrical and ranges in color, with areas of tan, brown, black, red, blue, or white. These tumors usually start in old moles and begin to change form over time.  Although they can occur anywhere, they are usually found on the legs and upper backs.

Lentigo Maligna melanoma is very similar to the superficially spreading form.  It begins as a slightly elevated area of discoloration, usually a mottled patch, ranging from tan to dark brown.  The non-spreading form of this cancer is usually found in the elderly, or on people with chronic sun exposure.  This form is usually found on the face, upper trunk, arms, and ears.

As mentioned, Nodular melanoma is invasive from the start and is the most aggressive form of melanomas.  One usually will notice this type of tumor when the spreading forms a lump in the skin.  It is most often blackish in color, but can also develop in browns, or as a gray, white, red, or pink bump.   Nodular Melanoma is found most often on the trunk and limbs of patients and is most common in the elderly.  Fortunately, however, it is also the least common form of melanoma, accounting for only 10-15% of patient cases.

Basal Cell Carcinoma (BCC)
Overall, basal cell carcinoma is the most common of the three forms of skin cancer. In fact, almost 75% of non-melanoma skin cancers are basal cell carcinomas.  This disease affects almost 800,000 Americans each year. Although BCC occurs less frequently in people with darker skin, it is still important to be aware of your risk of contracting this disease. 

BCC is cancer that is located in basal cells– those on the bottom of the outer layer of the skin. These cells are continuously renewing themselves throughout life and work to form hair, sebaceous glands, and apocrine glands. Tumors usually arise from the epidermis and occasionally arise from the outer root sheath of a hair follicle.  Although BCC is not the most dangerous form of skin cancer, it is still important to watch for it because of the sharply growing number of cases over the last decades, especially in women. 

This kind of cancer develops slowly over time and is usually caused by chronic sun exposure, with carcinomas occurring most frequently on body parts that are most exposed to the sun–head, face, shoulders, and back. In rare occasions, these tumors may occur in non-exposed areas.  These rare incidences are usually the result of contact with arsenic; exposure to radiation; and complications of burns, scars, vaccinations, or tattoos.  This form of skin cancer is known to affect the elderly more than any other age group although we are seeing it more often in younger people.  Historically, BCC was most common in men, as they were the ones who primarily worked outdoors.  However, due to the increased number of women in outdoor professions and other recreational activities, as well as the popularity of tanning, there has been a sharp increase of BCC cancers in women. 

Generally, those with brown skin are less likely to develop this form of cancer, as it primarily affects people with fairer skin and blue, green, or gray eyes. BCC rarely metastasizes (spreads). However, since the disease tends to affect the head, face, and neck, the cosmetic disfigurement that can occur if it is left untreated is very noticeable and socially devastating. Some patients also suffer from loss of vision, and, with very deep tumors, the loss of nerve function. With proper therapy, the prognosis is often good, but BCC is known to have a high mortality rate when it is allowed to progress.

There are some typical characteristics that signify the onset of BCC. By learning to recognize these signs and checking yourself regularly for them you can avoid the risk of late-onset diagnosis. BCC tumors will usually exhibit two or more of the following characteristics:

• the appearance of one or more open sores that often bleed, ooze, form crusts, or remain open for three or more weeks;
• a red or irritated patch on the skin, which usually appears on the torso or legs (some people notice that the patch will crust, hurt, or itch);
• shiny bumps that are slightly translucent and usually pink, red, or white in color (commonly tan, black, or brown in skin of color and often confused with moles or beauty marks);
• a small pink growth with elevated borders and a crusted indentation in the middle, which usually enlarge slowly and often develop small blood vessels on the surface;/li>
• Development of scar-like areas on the skin, which are usually white or yellow in color and waxy with ill-defined boarders. Note: Although this is the least frequent of BCC’s characteristic signs, it is usually an indicator of an aggressive tumor.

It is important to check with your doctor anytime you suspect that growth on your skin might be abnormal. The above characteristics are easily spotted but often overlooked, especially by people with brown skin, who often confuse BCC for other non-cancerous skin conditions, such as psoriasis and eczema.

Squamous cell carcinoma(SCC)
Squamous cell carcinoma is the second most common form of skin cancer and more popular than BCC in people with brown skin. SCC affects over 200,000 people a year in the United States.  Fairer-skinned and lighter-eyed individuals are at a higher risk for SCC, but anyone with a history of long sun exposure is at risk.  People with brown skin are at much lower risk of developing this cancer, but SCC accounts for more than 66% of the incidences of cancer in people with brown skin.

SCC occurs in the epidermis and resembles the squamous cells that are present in the upper layer of the skin. Although this cancer begins in the epidermis and usually remains there for quite some time, it will occasionally spread to underlying tissues if left untreated.  In the rare occasion that it begins to invade these tissues, there is the possibility that the disease will spread to other tissues and organs and can eventually be fatal.  SCC cancers that spread most often are usually located on sites of chronic inflammatory skin conditions (such as sores or ulcerations), mucous membranes, and on the lips.

This cancer can occur anywhere on the body. However, it is most common in areas with the most exposure to sunlight. Tumors are more common on exposed areas like the scalp, face, and torso.  Areas which are often forgotten during suntan lotion application–such as the ears and lips–are especially vulnerable to this type of cancer, due to their delicate nature.  SCC tumors can also be caused by injury to the dermis, such as burns, scars, and long-standing sores.  They also occur on sites previously exposed to prolonged X-rays or certain chemicals.  In addition, medical conditions that suppress the immune system over an extended period can increase the risk of squamous cell carcinoma. SCC can also rise spontaneously on seemingly healthy, undamaged skin.

Many researchers believe that this type of skin cancer is commonly due to family history. There are also certain precursor skin conditions that you should pay close attention to are worth because they are sometimes associated with the later development of squamous cell carcinoma.  These include:

• Actinic (or solar) keratosis–rough and scaly patches that are usually slightly raised growths, ranging in color from brown to red that can grow up to one inch in diameter;
• Actinic cheilitis–a type of keratosis that is pale in color or white and usually appears on the lower lip (which often receives more sun exposure than the upper lip), causing it to appear dry and cracked;
• Leukoplakia–white patches on the tongue or inside of the mouth that often transform into squamous cell carcinoma;
• Bowen’s disease–causes the skin to form scaly reddish-brown patches that resemble eczema or psoriasis.

The other warning signs of SCC are usually simple to spot and quite similar to those of BCC:

• the development of a wart-like growth that crusts and occasionally bleeds;/li>
• persistent, scaly, red patches–some with an irregular boarder that crusts over and bleeds;
• open sores that remain for weeks and often crust and bleed.

In addition, any change in already existing moles and marks, or the development of a new growth or open sore that fails to heal, should prompt you to make a visit to your doctor. If it is a precursor condition, early treatment will prevent it from developing into a squamous cell carcinoma.

Treatment
If it is determined that you do have a form of skin cancer, it is very important that you seek treatment immediately.  For skin cancers, the usual treatment is to remove the cancerous cells.  This usually involves cutting out the tumor and a small amount of skin in the surrounding area. Surgery on small and non-melanoma tumors is usually 100% successful, especially when the tumor is removed before the cancer cells begin to spread.  Also, the removal of additional tissue in the surrounding areas helps increase the chances of preventing cancer in the system.  Some BCC and SCC cancers that cannot be surgically removed, respond well to radiotherapy. In some cases in which the cancer has spread, other treatments must be begun. Once melanoma has spread, it is very aggressive and hard to treat and usually cannot be cured.  Often immunotherapy and other types of chemotherapy treatments can work to prolong life, but will not completely contain or destroy the disease. Although melanoma and other skin cancers have an average cure rate of 96%, African Americans and others with brown skin show much lower rates of survival.  As mentioned, this is due largely to late diagnosis.

Bottom Line
Having brown skin makes you unique and beautiful, but it also makes you vulnerable to cancer in ways that are different from those of your paler counterparts.  You should not only be sure to visit your doctor regularly to discuss any concerns you have, but you must also protect yourself from the sun and other dangers and check yourself regularly for any changes to your skin. The American Academy of Dermatology recommends that you follow certain guidelines to limit your risk of overexposure to the sun:

• >Try to avoid outdoor activities between 10 a.m. and 4 p.m. when the sun’s rays are the strongest.
• Seek shade whenever possible. Wear a broad-spectrum sunscreen of SPF15 or higher and sun-protective clothing and accessories, such as wide-brimmed hats and sunglasses.
• Follow the “shadow rule” – if your shadow is shorter than you are, the sun’s damaging rays are at their strongest and should be avoided.

Now that you are more informed about what to look for, it is important to examine your skin regularly for signs of any of the aforementioned types of cancer.  Although only a doctor can diagnose you, self-examination can lead to discovering a tumor early, saving you from possible disfigurement and even death.  It is important to check yourself once a month or more if you are at high risk—i.e. have paler skin, past cancerous skin lesions, or a family history of skin cancer.  Also, as a person of color, it is important to check the bottom of your feet, since many cases of skin cancer in adults develop on the soles of the feet.  During self examinations, include your entire body.  It will be helpful to use a full-length mirror, accompanied by a hand mirror to check hard-to-reach spots.

Some general guidelines to follow when examining yourself are included in the ABCD rules of pigmented lesions: 

• “A” is for asymmetry. Moles are normally symmetrical, so abnormally-shaped moles are often a sign of melanoma. 
• “B” is for border irregularity. Areas of skin that have rough, raised, or uneven borders are often characteristics of cancerous cells. 
• “C” stands for color variations. Most moles are one color, so mottled or multicolor moles can signify the development of cancer. 
• “D” is for diameter. Any mole with a diameter larger than 6 mm should be examined because it may be cancerous.

These guidelines are an easy way to check moles or developing abnormalities on your skin.  If you notice any of the warning characteristics or any other abnormal changes in your skin consult with your doctor immediately.  Your doctor will be able to determine if your skin abnormality is cancerous or not and to advise you on follow-up visits, and treatment if necessary.