Skin Cancer Within Special Populations

In this interview, Jane Margaret Grant-Kels, MD, FAAD, discusses the unique screening challenges, the importance of early detection, and strategies for reducing disparities in melanoma outcomes. Learn practical approaches for improving diagnosis, leveraging dermoscopy, and enhancing patient education in high-risk groups.

Dr Grant-Kels is a professor of dermatology, pathology, and pediatrics at UConn Health in Farmington, CT. She serves as vice chair of the department of dermatology and is the director of the cutaneous oncology center and melanoma program. Additionally, she holds the role of assistant residency program director, contributing to the education and training of future dermatologists.

Transcript:

Military personnel, firefighters, and rural patients face unique environmental and occupational risks for melanoma. What key factors should dermatologists consider when screening and educating these high-risk populations?

I think that people who are at high risk need to be seen by their dermatologist at least once a year. And for people who have risks like firefighters from breathing in carcinogens, one should make sure to also examine mucosa as well as the external skin. So the mouth, the nose, the genitalia, the anal perianal area. And for firemen in particular, and for all of them, people you mentioned above, they need to wear sun protective clothing and sunscreens and hats and sunglasses. But for firefighters, they need to wear protective clothing. So the soot and the chemicals don't get on their skin as well as masks, so they don't breathe it in.

Melanoma in patients with skin of color is often diagnosed at later stages. What are the biggest gaps in early detection, and what strategies can dermatologists use to improve outcomes in this population?

So, the first is to let people who are of skin of color that they are--their risk is not zero, which is what most of them believe, and where they tend to get, although they can get melanoma on sun exposed areas, they most commonly get their melanomas in areas that a lot of people don't examine, like the hands and the feet and the nails and the mucosa. So for those patients, I educate them to make them aware, particularly being skin of color is a tremendous variation in how dark a patient is. And some patients just look like they have a tan, and other patients can be very dark brown and more protected. But either group can get melanoma, particularly on mucosa and on their palm cells and nails. And so education and examining those areas clinically and with your dermatoscope is very, very important. There is a healthcare disparity because the patients aren't aware, they're at risk. A lot of physicians aren't aware that that subgroup of patients are at risk, and a lot of people don't examine those sites. And so by the time those sites are examined, the lesion is quite thick or ulcerated, and so the prognosis is very poor. And then the final issue is that a lot of those patients live in rural areas or may not have good insurance and may not have access to a dermatologist who would be aware of their risks and would examine them appropriately.

How does pregnancy influence melanoma prognosis and management, and what adjustments should dermatologists make when treating melanoma in pregnant patients?

There is a misconception that women who are pregnant have a higher risk of melanoma or have a higher risk of getting melanoma. I understand why people think that women who are pregnant are immunosuppressed. That's how they can carry the fetus. Who represents half the father, so it's not antigenically the same as the mother. And we get some darkening in our skin or the nipples and other areas of the skin darkened during pregnancy. So there are reasons. There's increased ability to form blood vessels and lymphatics during pregnancy. That's, again, been very well studied. But despite all that theoretical stuff, the actual studies on women who are pregnant show that their prognosis is exactly the same as if they weren't pregnant. Now, the difference is that if they develop a superficial melanoma, it's easy. You just cut it out, which you can do during pregnancy.

It's considered relatively safe to use local anesthesia in the skin. But if they have a deep melanoma and they need sentinel lymph node biopsy or general anesthesia or MRIs, then you have to try to avoid, try to avoid the first trimester for general anesthesia or MRIs. And some people suggest if possible, waiting till after the birth to do a sentinel lymph node biopsy, although it has been done quite safely in pregnant patients. So you have to take risk and to the child and the mother into consideration. And finally, if a mother has stage four melanoma, which is metastatic melanoma, the newer targeted treatments are teratogenic and also cross the milk barrier, the breast milk barrier. So, you can't. A woman who's pregnant can't take those medications, and a woman who's breastfeeding shouldn't take those medications, and they have to wait a certain amount of time. But it is a miscommunication, a miseducation, at least to what we know to date, that women who get pregnant who have melanoma, their prognosis is not worse.

I follow patients who don't have a personal family or personal or family history of melanoma. I follow them the same as anybody else when they're pregnant. Now, if they've had a melanoma or if there's a strong family history of melanoma or they have a lot of nevi or a lot of atypical nevi, I tend to see them every trimester. And I do that not because I worry that if they get a melanoma, it's going to behave worse. I worry that they're not being checked and there's so much going on with their body. So if they have that strong personal or family history or have a lot of atypical nearby, I tend to see them each trimester just if they, God forbid, get a melanoma, I want to pick it up as early as I can.

With healthcare disruptions caused by the COVID-19 pandemic, have you observed long-term impacts on melanoma diagnosis and treatment delays? How should dermatologists address these challenges moving forward?

Yes, I think the pandemic kept people at home. People were very afraid to go to the doctor a period of time. Everything was closed down, even physician offices except for emergencies. And there was a spike in deeper melanomas post pandemic that were diagnosed, but the pandemic is now gratefully in the rear view mirror. And so I think that things are back to normal. The major problem is that unfortunately, there are still not enough dermatologists, and a lot of primary care docs just don't have the time or the knowledge to examine the skin as thoroughly as they should. And so patients who are at high risk really do need to get themselves in to see a dermatologist, particularly someone who's a pigmented lesion specialist, if they've had a family history or personal history of melanoma and someone skilled in using the dermatoscope, which is an instrument that we use to look at lesions very closely.

Given the diverse risk factors and barriers to care in these special populations, what are the most critical steps dermatologists can take to enhance melanoma prevention and early detection in their practice?

I think educating the population. That people think that if they get a tan, that they're safe to go out in the sun, which some people go to suntan polls to get a tan before the summer. They can, which is anytime you get a tan, you're damaging your skin. So people need to embrace the color guard made them and not try to alter that in any way. And that need to reeducate themselves that that is one carcinogen that we can control. We can control the amount of sunlight that hits our skin. There's another misnomer that if you do need some amount of sunlight to make vitamin D, but you can get vitamin D through supplements and through diet, and you don't need a lot of vitamin, you don't, even when you're wearing sunscreens, you're not applying it the way you're supposed to, which is using a shot glass full, reapplying it every 2 hours. Nobody does that, not even dermatologists. So you're getting plenty of sun. And so, if you worried, you can get a vitamin D level and take supplements, but the ultra YL light is unequivocally a carcinogen. And that's one thing we can control. And so I would just educate people and ask them to protect their skin from the environment.

Is there anything else you’d like to share with your colleagues regarding melanoma in special populations?

No, I just think people need to--it’s just like pediatric melanoma. I've heard pediatricians say, oh, a child can never get a melanoma. Well, I have to tell you, it's rare, but I've diagnosed it in children, even pre-adolescent. It's much more in adolescence. But I have seen it even pre-adolescent. So it is a rare phenomenon. But never use the word never. Isn't that what you always tell your children and grandchildren? Well, certainly in this case. So if somebody comes in with a changing pigmented lesion that's worrisome to you, you make sure that that patient gets seen by an expert or dermatologist to evaluate that lesion. Don't assume because they're black or because they're a child, that it's nothing. Because it may in fact be a skin cancer or a melanoma that needs to be addressed. And so that would be, I would especially say to pediatricians and primary care docs, listen to the chest with the shirt off while you're listening to the lungs. Look at the back. If you see anything that's an outlier, call your local dermatologist and get that patient in to be evaluated.