To the Editor:
Asian American (AA) individuals are the fastest-growing racial population in the United States, projected to reach 46 million by 2060.1 Despite reduced melanoma risk, AA patients have poorer prognoses compared to non-Hispanic White patients.2 Existing melanoma research commonly aggregates AA and Native Hawaiian and Other Pacific Islander (NHOPI) individuals into a single category, limiting knowledge surrounding differences in melanoma outcomes among disaggregated AA and NHOPI populations.3 We examined differences in stage at diagnosis and melanoma-specific mortality among aggregated and disaggregated AA and NHOPI populations within the Surveillance, Epidemiology, and End Results 17-registries program to characterize their melanoma-related health disparities.
We identified 206,707 Asian American, Native Hawaiian, Pacific Islander, and non-Hispanic White patients with first histologically confirmed primary malignant cutaneous melanoma diagnosed from 2004 through 2019 (Supplemental Figure 1). Chi-square and Kruskal-Wallis tests were performed to examine differences in demographic variables among populations. Unadjusted Kaplan-Meier survival analyses and log-rank tests assessed melanoma-specific survival differences. Multivariable logistic regression and Cox proportional hazards models were performed to examine stage at diagnosis and melanoma-specific mortality, respectively, comparing each disaggregated population to both non-Hispanic White and Chinese patients.
Overall, AA and NHOPI individuals were generally younger and had higher rates of acral lentiginous and lower extremity melanoma (Supplemental Tables I and II). When examining stage at diagnosis, aggregated AA and NHOPI populations were significantly more likely to present with distant metastases than non-Hispanic White patients (adjusted odds ratio, [aOR]=2.76, 95% confidence interval [CI]=2.20–3.47) (Table I). Among disaggregated groups, Filipino (aOR=3.81, 95% CI=2.37–6.13), NHOPI (aOR=3.93, 95% CI=2.36–6.54), and Vietnamese patients (aOR=8.69, 95% CI=4.35–17.40) had significantly higher odds of distant metastases than non-Hispanic White patients. This was also observed compared to Chinese patients among Filipino (aOR=3.33 95% CI=1.49–7.47) and Vietnamese patients (aOR=7.69, 95% CI=2.93–20.20) (Table I). Regarding survival, we observed significant survival differences among populations, with the lowest 5-year melanoma-specific survival rate observed in Vietnamese patients (68%) (Figure 1). In adjusted analyses, aggregated AA and NHOPI patients had significantly greater melanoma-specific mortality than non-Hispanic White patients (adjusted hazard ratio, [aHR]=1.59, 95% CI=1.42–1.78). Among disaggregated groups, Filipino (aHR=1.64, 95% CI=1.28–2.10) and NHOPI (aHR=1.88, 95% CI=1.44–2.46) patients had greater melanoma-specific mortality than non-Hispanic White patients (Table I).
Table I.
Multivariable logistic regression and Cox proportional hazards models of Asian American, Native Hawaiian, and Other Pacific Islander populations on melanoma stage at diagnosis and melanoma-specific survival, respectively.
| Stage at Diagnosis1 | Melanoma-Specific Mortality 1 | |||
|---|---|---|---|---|
| Localized | Regional | Distant | ||
| Non-Hispanic White vs. AA and NHOPI Population (Sample Size) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aHR (95% CI) |
| Non-Hispanic White2 (205,198) | Reference | Reference | Reference | Reference |
| AA and NHOPI (1,509) | 0.41 (0.36, 0.47)*** | 1.91 (1.67, 2.19)*** | 2.76 (2.20, 3.47)*** | 1.59 (1.42, 1.78)*** |
| Non-Hispanic White vs. Disaggregated AA and NHOPI Populations (Sample Size) | ||||
| Non-Hispanic White2 (205,198) | Reference | Reference | Reference | Reference |
| Chinese (261) | 0.41 (0.30, 0.55)*** | 2.44 (1.82, 3.28)*** | 1.22 (0.65, 2.29) | 1.46 (1.11, 1.93) |
| AIP (92) | 0.32 (0.20, 0.52)*** | 2.25 (1.33, 3.80)** | 4.25 (1.90, 9.51)*** | 1.22 (0.77, 1.94) |
| Filipino (245) | 0.34 (0.25, 0.46)*** | 1.98 (1.44, 2.71)*** | 3.81 (2.37, 6.13)*** | 1.64 (1.28, 2.10)*** |
| Japanese (169) | 0.53 (0.35, 0.79)** | 1.64 (1.07, 2.50) | 2.12 (0.99, 4.54) | 1.64 (1.17, 2.29) |
| Korean (101) | 0.47 (0.29, 0.78)** | 1.87 (1.13, 3.11) | 1.73 (0.66, 4.52) | 1.78 (1.20, 2.63) |
| NHOPI (260) | 0.45 (0.33, 0.62)*** | 1.50 (1.06, 2.13) | 3.93 (2.36, 6.54)*** | 1.88 (1.44, 2.46)*** |
| Vietnamese (68) | 0.15 (0.09, 0.25)*** | 3.41 (1.98, 5.90)*** | 8.69 (4.35, 17.40)*** | 1.79 (1.15, 2.77) |
| Other (313) | 0.56 (0.41, 0.76)*** | 1.54 (1.12, 2.12) | 1.98 (1.14, 3.44) | 1.40 (1.04, 1.87) |
| Chinese vs. Disaggregated AA and NHOPI Populations (Sample Size) | ||||
| Chinese2 (261) | Reference | Reference | Reference | Reference |
| AIP (92) | 0.74 (0.42, 1.33) | 0.91 (0.50, 1.68) | 3.54 (1.23, 10.10) | 0.98 (0.55, 1.74) |
| Filipino (245) | 0.77 (0.51, 1.18) | 0.89 (0.58, 1.37) | 3.33 (1.49, 7.47)** | 1.24 (0.85, 1.82) |
| Japanese (169) | 1.27 (0.77, 2.09) | 0.67 (0.40, 1.13) | 1.53 (0.56, 4.20) | 1.15 (0.74, 1.81) |
| Korean (101) | 0.98 (0.55, 1.75) | 0.88 (0.49, 1.59) | 1.55 (0.49, 4.92) | 1.52 (0.91, 2.53) |
| NHOPI (260) | 1.07 (0.69, 1.68) | 0.63 (0.39, 1.00) | 3.16 (1.35, 7.37) | 1.42 (0.94, 2.14) |
| Vietnamese (68) | 0.35 (0.19, 0.64)*** | 1.39 (0.75, 2.58) | 7.69 (2.93, 20.20)*** | 1.29 (0.76, 2.20) |
| Other (313) | 1.27 (0.83, 1.94) | 0.67 (0.43, 1.03) | 1.60 (0.69, 3.72) | 0.85 (0.56, 1.28) |
Abbreviations: AA = Asian American, AIP = Asian Indian or Pakistani, NHOPI = Native Hawaiian or Other Pacific Islander, aOR = Adjusted odds ratio, aHR = Adjusted hazard ratio, CI = Confidence interval
P < 0.001
P < 0.01. Only p-values that reached significance (ɑ = 0.004) after Bonferroni correction were annotated.
Multivariable analyses were adjusted with age, sex, histologic subtype, anatomic site, median household income, rurality, and geographic location, with stage at diagnosis and receipt of first-line surgery included as additional covariates in survival analyses.
Reference levels were selected based on known group with largest number of patients.
Figure 1.
Unadjusted Kaplan-Meier analyses of melanoma-specific survival among non-Hispanic White, Asian American, Native Hawaiian, and Other Pacific Islander populations.
Abbreviations: AIP = Asian Indian or Pakistani, NHOPI = Native Hawaiian or Other Pacific Islander.
We identified significant differences in melanoma presentation and outcomes among disaggregated AA and NHOPI populations. The etiology of such differences is likely multifactorial and due to differences in healthcare access, cultural practices, sun-protective behaviors, and skin phototypes.3–5 AA and NHOPI populations also had higher rates of acral lentiginous melanoma, and thus differences in tumor biology may impact prognosis. Our results suggest that certain communities, including Filipino, NHOPI, and Vietnamese, may benefit from increased educational and preventative efforts to reduce late-stage diagnoses. Study limitations include small patient numbers in some groups and the inability to account for other potential confounders like healthcare access and utilization, education level, distance from facility, insurance status, and treatments. Further research is needed to better characterize melanoma outcomes in AA and NHOPI individuals and to identify potential targeted interventions to mitigate disparities.
Funding sources:
Dr. Hartman is funded by the Melanoma Research Foundation and the VA Integrated Service Network 1 (VISN-1). Dr. Dee is funded in part through the Cancer Center Support Grant from the National Cancer Institute (P30 CA008748).
Abbreviations
- AA
Asian American
- NHOPI
Native Hawaiian and Other Pacific Islander
- AIP
Asian Indian or Pakistani
- aOR
adjusted odds ratio
- CI
confidence interval
- aHR
adjusted hazard ratio
Footnotes
Conflicts of Interest:
Mr. Kim is a paid consultant at Verve Therapeutics and SeQure Dx, unrelated to this research. Dr. Hartman is a scientific officer for Evereden, unrelated to this research. Mr. Kim and Dr. Hartman’s interests were reviewed and are managed by Mass General Brigham in accordance with their conflict-of-interest policies.
IRB approval status:
IRB approval was not required due to the use of deidentified and publicly available data.
Patient Consent:
Not applicable.
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Supplemental Link: https://data.mendeley.com/datasets/k48ycg497h/1
References
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