Challenges to Intersectional Analyses and Building Capacity for Skin Cancer Research in Minority Populations

We thank Joshi and Lipoff for their commentary on our research letter assessing skin cancer prevalence and risk factors among foreign-born individuals in the United States,¹ recognizing heterogeneity within racial/ethnic minority subgroups in epidemiologic research.² In echoing these important sentiments, we highlight methodological limitations of existing datasets that preclude intersectional analyses of racial/ethnic minority subgroups by foreign-born status and call for efforts to collect relevant skin health data from under-sampled racial/ethnic subgroups.

Low skin cancer prevalence among foreign-born racial/ethnic groups precluded our ability to analyze these outcomes reliably within Black/African American, Hispanic/Latinx, and Asian American subgroups. National Health Interview Survey (NHIS) requires estimates to meet a priori reliability guidelines with coefficient of variation <30% to generate reliable nationally representative estimates; many of these outcomes failed to meet reliability thresholds in disaggregated analyses by country of origin and by race/ethnicity subgroups.¹ Skin cancer risk factors and phototype were only collected in select NHIS years, further limiting the available sample. We previously performed disaggregated analysis of skin cancer risk factors among Asian American subgroups using NHIS data.³ However, only Asian Indians, Chinese Americans, and Filipino Americans were able to be examined reliably as subgroups; some subgroups identified by Joshi and Lipoff remained aggregated by NHIS into an “other Asian” category.^2,3 Similarly, the U.S. National Health and Nutrition Examination Survey also collects data to describe skin cancer risk factors and self-reported race/ethnicity. However, data are not publicly available given limited number of participants within each subgroup. Unfortunately, complete disaggregated analyses suggested by Joshi and Lipoff are not feasible with currently available data.⁴ Existing efforts to sample individuals from many racial/ethnic subgroups have yet to yield adequate sample sizes for disaggregated analyses. Additional work is required to understand and overcome barriers to data collection in these underrepresented subgroups.

The NHIS was substantively redesigned in 2019 and no longer permits pooling years of data before and after its redesign.⁵ Its impact on our ability to adequately sample racial/ethnic subgroups for disaggregated analyses with updated survey data remains to be seen. The redesigned NHIS continued to collect skin cancer prevalence annually and skin cancer risk factors under its sun care and protection control and prevention module periodically. These survey items will require many years of pooled data before statistically reliable subgroup analyses are possible. Oversampling racial/ethnic subgroups to accelerate minority health research would require innovative solutions to overcome language barriers and other logistical challenges.⁴ Beyond spreading awareness of subgroup heterogeneity, dermatologists and public health professionals should advocate for structural changes aimed to build capacity for skin cancer research in minority populations. Routine collection of skin health data in national surveys with oversampling of historically underrepresented subpopulations are needed to develop robust knowledge on how skin cancer risks and risk factors may differ across populations with intersectional minority statuses, such as racial/ethnic minority groups and foreign-born populations.