(Akiit.com) Until it started hurting this spring, about 15 years after first appearing, Garry Freeman never thought much about the dark spot on the underside of his foot.
Freeman, an African-American, finally went to a podiatrist, who initially thought it was an infected callus. But a biopsy eventually revealed stage 4 skin cancer and, when all was said and done, it took the amputation of two toes to save him from a worse fate.
“When I told my friends, they’d say, ‘skin cancer? I never heard of black people getting skin cancer,'” says Freeman, 51, who last week returned to his carpentry business, following rehab from the last of three surgeries. “I’d respond, ‘me either.'”
In fact, blacks do get skin cancer, though not as much as white people do. But the bad news is that when they are diagnosed, blacks are more likely to be in advanced and possibly fatal stages. Reggae musician Bob Marley was the most famous black to die of melanoma.
The entire phenomenon is something of a mystery. There’s little consensus on what causes skin cancer in blacks and most, though not all, experts think it’s rarely related to sun exposure.
“The bottom line is, we don’t know that much about skin cancer in blacks,” says Dr. Jeffrey E. Lee, a professor of surgical oncology at the University of Texas M.D. Anderson Cancer Center in Houston. “We do know that the mortality rates are of concern and that blacks and their physicians should be more vigilant.”
Experts mostly attribute blacks’ higher mortality rate from skin cancer — one recent University of Miami study found them three times more likely than whites to have a late-stage diagnosis — to a lack of awareness that they face a risk, a lesser attunedness to things like screenings and personal mole inspections.
But Lee notes that even when researchers adjust for the the stages at which patients are diagnosed with skin cancer, blacks have slightly worse outcomes. That could mean the biology of the cancer is more aggressive, as is the case with breast cancer in black women; or that blacks get different care, perhaps for socioeconomic or cultural reasons.
Indeed, experts say that it’s easy to miss skin cancer in blacks if a doctor isn’t properly trained. Janet Williams, a Houston African-American woman with seborrheic keratosis, says she was misdiagnosed from 2001 to 2006 because doctors confused one cancerous lesion with the benign skin condition.
What is undeniable is that the melanin in darkly pigmented skin confers protection against the harmful ultraviolet radiation that causes skin cancer in whites. Melanoma, for instance, is diagnosed in nearly 60,000 Americans a year, but it’s 20 times less common in blacks than whites.
In addition, the sites blacks most commonly get skin cancer tend not to be exposed to the sun — the soles of the feet, the palms of the hands, underneath their fingernails and toenails. Lee notes that whites never get skin cancer in such locations.
But some researchers aren’t convinced sun exposure isn’t an important consideration concerning skin cancer in blacks. After all, they note, cancers occasionally develop on black skin exposed to the sun.
“I’d say the jury’s still out on sunlight’s role,” says Dr. Robert Kirsner, a University of Miami professor of dermatology and the lead author of the study that found blacks are diagnosed later. “From a public health standpoint, I don’t think it’s appropriate at this point to rule out sun exposure as a factor.”
Kirsner argues that sunlight can have a systemic effect, suppressing the immune system and causing indirect effects like changes to moles in unexposed areas. He also cites another study by his team that found more skin cancer among U.S. blacks and Hispanics the farther south they lived and the more time they spent in the sun.
Lee responds that a more recent study, using a larger database, failed to confirm any association between UV exposure, southerly latitudes and non-white populations. He added that a relationship between sunlight-exposure-related immune suppression and skin cancer on unexposed skin, though reasonable sounding, is unproven.
Instead, experts point to other factors thought to contribute to skin cancer in blacks: genetics; compromised immune systems; trauma, such as from chronic injury, scars or prior radiation; burns, such as from a fire; and skin conditions such as lupus.
What everyone agrees on is the need for more education — that blacks need to check moles for changes in color, border irregularity and size, just like anyone else. After all, when melanoma is caught before it spreads, the five-year survival rate is 98 percent. But because of their typically late diagnoses, the five-year survival rate for blacks is just 59 percent. (Whites’ is 84 percent.)
Freeman is foremost among those urging greater education and vigilance.
“Had I known that blacks can get skin cancer, I might not have lost two toes,” says Freeman. “That should be the lesson for blacks — routinely check your moles if you want to catch skin cancer in time.”
By TODD ACKERMAN