Skin cancer:
A colorblind disease
From where Garry Freeman is standing, life is good.
A former carpenter, Freeman, 52, is now working on a few special projects. A house for his daughter is one of them. A treehouse for his grandchildren is another.
His wife Minnie is particularly proud. “We are blessed,” she said. “He has had that spot for years. It could have been much worse.”
“That spot” was underneath his big toe on the sole of his foot. Though it was about the size of a nickel, Freeman says he didn’t think much about it at first and blamed the spot on wearing boots on construction sites.
“I thought it was just a discoloration in the skin,” he said.
It took a while, but Minnie grew tired of such excuses. She begged Freeman to get the spot looked at by a physician, but he consistently refused.
Freeman now says that was a mistake. Because there was no pain, Freeman says he didn’t take the spot seriously. That changed last year when a callous grew on the spot. He thought he could ease the pain by soaking his foot in warm water and Epsom salt. But the pain continued — and his limp got worse.
Much to Minnie’s delight, Freeman finally went to a podiatrist. During the visit, the callous was scraped down a bit and that was that.
But the pain persisted. A second appointment was made and the podiatrist, according to Freeman, didn’t like “the way it looked.”
The podiatrist did a biopsy that morning. By 7:30 p.m., Freeman learned that he had melanoma and was advised to see a surgeon who specializes in cancer.
Freeman never expected to hear that he had cancer. More surprisingly, Freeman had never heard of getting cancer on the sole of the foot.
Cancer of the skin is the most common cancer, numbering more then 1 million new cases a year. Basal cell and squamous cell cancers are the most common skin cancers and are less likely to spread to other parts of the body or result in death.
Melanoma, on the other hand, accounts for about 3 percent of skin cancer cases, but causes the majority of skin cancer deaths. The American Cancer Society estimates that about 62,500 new cases of melanoma will be diagnosed in this country this year, and over 8,000 people will die from it.
Melanoma begins in the melanocytes, the cells that make melanin, the protective brown pigment that gives skin its color.
Dr. Deborah A. Scott, a dermatologist at Brigham and Women’s Hospital, rightly points out that skin cancer in blacks as well as other people of color — Latinos, Asians, American Indians — is quite rare. “The problem,” Scott explains, “is that because skin cancer is so rare, blacks may ignore a new or changing growth, dismissing it as a benign lesion.”
Of the three skin cancers, blacks get squamous cell cancer (SCC) the most, followed by basal cell cancer (BCC), then melanoma.
SCC is more frequently seen in non-sun-exposed areas in African Americans, and is associated with albinism, burn scars, chronic inflammation and chronic discoid lupus. BCC accounts for up to 30 percent of skin cancers in American blacks, and is primarily related to prolonged, intensive ultraviolet light exposure.
The incidence of melanoma is significantly higher in whites. According to data from the Surveillance Epidemiology and End Results Program of the National Cancer Institute, from 2000 to 2004, the incidence of melanoma in whites was roughly 20 times that of blacks.
Death rates for whites were also higher, but not to the same degree. White people died from melanoma at five to nine times the rate for black people.
Although having darker skin lowers one’s risk of melanoma, it is not a guarantee of 100 percent protection.
And that’s the problem. It is a widely held belief among African Americans and other people of color that they are exempt from this deadly disease. Unfortunately, that is not the case.
While most cases of melanoma result from ultraviolet radiation from the sun, blacks tend to develop acral lentiginous melanoma (ALM), a “hidden melanoma” that occurs in parts of the body not exposed to the sun. Although ALM accounts for only about 5 percent of the cases of melanoma in white people, it occurs in more than half of all cases in darker skinned patients, and is extremely aggressive.
ALM forms more frequently on the soles of the feet or the palms of the hands. Bob Marley died of ALM that developed on his foot and metastasized when treatment was delayed. He was only 36 years old.
A typical site is the finger or toenails — particularly the thumb and big toe — and has a distinctive look. The cancer shows itself as a vertical black, brown or tan streak that appears without known injury to the nail.
The perception that African Americans are exempt from melanoma can prove to be deadly.
In a review of 649 patients treated for melanoma at the Washington Hospital Center in Washington, D.C. between 1981 and 2000, almost one-third of blacks compared to 13 percent of whites were first treated at stage III or IV, when survival rates are lower. The five-year survival rate was 58.8 percent in African Americans, compared with 84.8 percent in whites.
Another study conducted in Miami-Dade County in Florida had similar results. Although the majority of the patients with melanoma studied were white, again late-stage diagnoses were more common in Hispanics (26 percent) and blacks (52 percent) than in whites (16 percent).
One of the researchers of the 2006 Miami study, Dr. Robert S. Kirsner, has concluded that more often than not, dark-skinned patients do not realize they are at risk of melanoma. The lack of knowledge has been the subject of a growing amount of medical literature — as has the lack of public health warnings aimed at darker skinned people.
In 2004, Dr. Susan C. Taylor, a black dermatologist on the board of directors of the American Academy of Dermatology, explained in published reports that “most of the skin cancer warning messages are geared toward fair-skinned individuals with blue eyes and blond or red hair who sunburn easily.”
According to Kirsner, physicians are partially to blame for the lack of awareness. “There is evidence that about a third or fewer physicians perform a full-body exam on their patients, and only 50 percent of high-risk patients receive such an examination,” he said.
Though melanomas are not completely preventable, they have a high cure rate if found and treated early. The five-year survival rate is 98.5 percent if confined entirely to the organ of origin, and 15.3 percent if spread to distant parts of the body.
In order to detect melanoma in its infancy, Scott said that people should check their skin once a month, and also request a full-body exam by their doctors each year.
“Any spot that is changing, bleeding, growing, or any sore that is slow to heal warrants evaluation,” Scott explained. “Ninety-nine percent of the time, it’s nothing. But you should have it checked.”
And that is what Minnie wanted Freeman to do. Almost a year ago, Freeman was diagnosed with stage 3 melanoma.
The initial treatment recommended by his doctor was amputation of his leg below the knee. But Minnie insisted on a second opinion.
A resident of Texas, Freeman went to M.D. Anderson Cancer Center, a National Cancer Institute-designated comprehensive cancer center in Houston, where he underwent extensive testing. The melanoma had spread to lymph nodes in his groin. He had two toes removed in June of 2007, and the malignant nodes two weeks later.
Freeman is now on interferon — a naturally occurring protein that enhances the immune system — to make sure the doctors have gotten all of the cancer. He will be on interferon for a year, and though the treatment makes him fatigued, Freeman continues to work as a manager at a metal stamping company.
He has checkups every six months. He had one just recently, and everything looks good.
“I was blessed,” Freeman said. “I caught this in time.” |
(top) Garry Freeman did not realize that the spot on his foot was melanoma. Despite the removal of two toes, Freeman is back on the job as a manager at Star Manufacturing, LTD.
(bottom) (From left:) Danielle F. Smith, Nicole F. Steave, Minnie B. Freeman, Garry N. Freeman. Garry Freeman says he owes his successful treatment for melanoma to his wife, Minnie, who insisted he get a second opinion at M.D. Anderson Cancer Center in Houston.
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Deborah A. Scott, M.D.
Dermatologist
Brigham and Women’s Hospital
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