Skin cancer is the most common cancer in the U.S. and worldwide, and it’s only becoming more so. The Skin Cancer Foundation estimates that the number of diagnosed new melanoma cases will increase by almost 6 percent in 2021. Even worse, many more cases will go undetected — especially in people with darker skin tones.
“In dermatology training or residency training, we just don’t see enough textbook examples of skin of color,” says Manhattan-based dermatologist Dr. Natalie Moulton-Levy. A 2018 study of medical textbooks found that only 4.5 percent of the images featured in four major textbooks featured darker skin tones. And in 2011, a study found that almost half of dermatology residents and dermatologists believed their training was inadequate to prepare them for diagnosing and treating melanoma in Black skin.
Dermatologist Dr. Jenna Lester, who leads the Skin of Color Clinic at University of California, San Francisco, said that her experience at medical school led her to do her own review of dermatology textbooks. “I wasn’t seeing Black skin very often in these books, apart from in select circumstances, but I wondered if I was imagining it,” she says. “Eventually, I carried out a formal study and found that roughly 20 percent of the general photos featured dark skin.” Of the Black patients who were pictured, most were concentrated in sections focusing on sexually transmitted infections.
Notably, the risk of developing melanoma is lower in people of color than it is for those with lighter skin tones. But it is more likely to be fatal when it does occur, usually because it goes undetected until it is too late to treat. (When melanomas are detected early, the five-year survival rate is high — about 99 percent.) What’s more, people of color are more likely to develop acral melanoma, which forms in places that are not typically exposed to the sun (under finger and toenails, on the soles of feet) and can be hard to find if you’re not looking for it.
Dr. Lester attributes the high fatality rate of skin cancer in people of color to lack of education in the dermatology field and beyond. “There needs to be acknowledgement for people of color who are trying to check their skin at home for moles that they may look different or be harder to recognize than in other skin tones,” says Dr. Lester. “They may just think the warnings about moles don’t apply to them because theirs don’t look like the examples they see.”
The issue goes beyond historical bias. Recently, a crop of artificial intelligence tools, like Google DermAssist, have appeared on the scene. These apps are designed to help people check their own moles at home by uploading photos on their smartphones; the app then tells them if it suspects the mole could be cancerous, precancerous, or benign. But even with machine learning, the same issues persist: Only 3.5 percent of the images used to teach the artificial intelligence powering DermAssist featured Black or dark-brown skin.
“Research can only ever be as strong as the methods behind it,” says Dr. Moulton-Levy. “If your data collection is poor, you can’t be sure of a good outcome.” The FDA has yet to approve any mole-checking apps, but a handful have been granted clearance in Europe.
Although it’s clear that better research and methods are necessary, the medical community continues to make the same mistakes and omissions, even across different types of conditions. For instance, in the past year, when doctors began to observe a symptom of COVID-19 known as “COVID toes,” there were few examples in medical literature that showed darker skin tones. “I still noticed that all the images of the rashes and papules in medical literature I was seeing were on light skin, which was especially perplexing given how much more susceptible to serious illness or death people of color have been to COVID-19,” says Dr. Lester.
Both Dr. Lester and Dr. Moulton-Levy stressed that there need to be changes in education so that dermatologists and other health-care providers learn to spot and diagnose a variety of skin conditions on all skin tones. “We need continuing education and continuing research so we can really parse what’s happening and understand what the risks are, to whom, and why,” says Dr. Lester.
And if you’re worried about any moles? Dr. Moulton-Levy recommends an annual skin check with a doctor or dermatologist for anyone over 18, perhaps more frequently if you get a lot of sun. “I’m a Black dermatologist, and I have lots of Black patients, and they come and tell me they shouldn’t worry about skin cancer, and that’s absolutely not the case. We all need to be vigilant.”