To the Editor:
Foreign-born individuals represented 14% of the US population in 2020 yet remain underrepresented in health research due to immigration status, language barriers, and sociopolitical factors.1 Understanding skin cancer trends among foreign-born populations may help identify groups that benefit from public health intervention or clinical surveillance.1 This study aimed to compare self-reported skin cancer prevalence and risk factors between foreign-born and US-born groups. Then, to compare prevalence and risk factors among foreign-born individuals across different levels of acculturation.
The National Health Interview Survey (NHIS) annually measures health behaviors and sociodemographic characteristics among US civilians; data were analyzed from 2000–2018. NHIS unconditional response rates were 53.0–74.3%. Analyses were weighted in accordance with NHIS survey design to produce nationally representative prevalence estimates and subpopulation variance. Results were included if coefficient of variation met a priori reliability threshold of <30%. First, self-reported history of skin cancer (including melanoma, non-melanoma skin cancer, and skin cancer but “don’t know what kind”) and skin cancer risk factors were compared between foreign-born and US-born participants using logistic regression models adjusted for sociodemographics, health behaviors, and phototype. Second, outcomes were compared among foreign-born participants by markers of acculturation (US citizenship, years lived in US, interview language). Benjamini-Hochberg procedure was used to adjust for multiple comparisons with 11 outcomes to limit false discovery rate to 5%. Analyses were performed on Stata Version 17.0 with two tailed t-tests with p <0.05 considered significant.
From 2000–2018, 363,138 Non-Hispanic Whites (16,878, 4.6% foreign-born), 94,507 Hispanics (56,543, 59.8%), and 26,906 (20,531, 76.3%) Asians were included (Table 1). Skin cancer prevalence was lower among foreign-born than US-born individuals across race/ethnicity groups: Non-Hispanic Whites (weighted prevalence; 95% CI, 2.49; 2.21–2.79 versus 4.08; 3.99–4.17), Hispanics (0.27; 0.22–0.32 versus 0.44; 0.36–0.53), and Asians (0.16; 0.10–0.25 versus 0.85; 0.61–1.18). Foreign-born participants across race/ethnicity groups were less likely to sunburn or receive total body skin examinations (TBSE) (Table 2). Among foreign-born participants, lack of citizenship was associated with lower skin cancer prevalence (adjusted odds ratio 0.30; 95% CI, 0.15–0.57) and those who spoke some/no English were more likely to wear long-sleeved clothing and stay under shade (Supplementary Table 2). Years lived in the US was not associated with skin cancer prevalence or risk factors.
Table 1:
Demographic Characteristics of National Health Interview Survey Respondents from 2000–2018 Stratified by Race and Foreign-Born Status
| N (prevalence estimates) | |||||||
|---|---|---|---|---|---|---|---|
| Variable | Non-Hispanic White (n=363,138) | Hispanic (n=94,507) | Asian American (n=26,906) | ||||
| Foreign-Born (16,878) | US-Born (346,260) | Foreign-Born (56,543) | US-Born (37,964) | Foreign-Born (20,531) | US-Born (6,375) | ||
| Age (years) | 18–49 | 8,262 (53.0) | 168,546 (53.6) | 39,061 (70.6) | 27,882 (77.8) | 13,219 (64.5) | 4,141 (72.1) |
| 50–64 | 4,005 (25.1) | 90,377 (26.1) | 10,446 (19.4) | 5,942 (14.3) | 4,077 (22.6) | 1,039 (15.0) | |
| 65–74 | 2,202 (11.2) | 45,614 (11.1) | 4,345 (6.2) | 2,499 (4.9) | 1,995 (8.3) | 539 (6.3) | |
| 75–84 | 1,657 (7.6) | 30,106 (6.8) | 2,141 (3.0) | 1,297 (2.3) | 967 (3.6) | 405 (4.5) | |
| >85 | 752 (3.2) | 11,617 (2.4) | 550 (0.8) | 344 (0.6) | 273 (1.1) | 251 (2.1) | |
| p | <0.001 | <0.001 | <0.001 | ||||
| Sex | Male | 7,510 (47.7) | 156,871 (48.4) | 25,679 (51.2) | 16,312 (49.4) | 9,459 (47.2) | 3,105 (49.6) |
| Female | 9,368 (52.3) | 189,389 (51.6) | 30,864 (48.8) | 21,652 (50.6) | 11,072 (52.8) | 3,270 (50.4) | |
| p | 0.13 | <0.001 | <0.001 | ||||
| Sunburn Propensitya | Severe burn | 324 (8.7) | 7,040(9.8) | 548(4.2) | 338(4.1) | 92(2.3) | 50(4.0) |
| Mild to moderate burn | 1,545 (45.4) | 38,336(56.1) | 3,828 (31.3) | 2,900 (36.8) | 954 (24.2) | 426 (36.7) | |
| Tan without burn | 1,146(36.3) | 19,330 (28.1) | 6,426 (55.1) | 4,036 (53.2) | 2,289 (62.7) | 632 (53.6) | |
| Do not go out in sun | 384 (9.7) | 4,883 (6.0) | 1,312 (9.5) | 580 | 426 (10.7) | 80 (5.6) | |
| p | <0.001 | <0.001 | <0.001 | ||||
| Skin Tan Propensitya | Dark tan | 451 (13.9) | 8,674 (12.7) | 2,353 (20.2) | 1,732 (21.7) | 670 (19.0) | 248 (24.2) |
| Mild to moderate tan | 1,856 (57.6) | 40,691 (60.0) | 6,908 (59.6) | 4,555 (61.2) | 2,187 (60.5) | 713 (58.5) | |
| Freckle or no tan | 615 (17.0) | 14,127 (20.3) | 1,228 (9.5) | 825 (9.9) | 276 (7.4) | 123 (10.9) | |
| Do not go out in sun | 448 (11.5) | 5,688 (7.0) | 1,485 (10.7) | 667 (7.1) | 513 (13.2) | 93 (6.4) | |
| p | <0.001 | <0.001 | <0.001 | ||||
Sunburn propensity after one hour of sun exposure and skin tanning propensity after daily sun exposure for two weeks without sun protection were variables available only in 2000, 2005, 2010, and 2015
Table 2:
Prevalence Estimates and Adjusted Odds Ratios comparing Skin Cancer Prevalence and Risk Factors Between Foreign-born and US-born individuals of the Same Self-Reported Race.
| Prevalence Estimates (%, 95% confidence interval) | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Non-Hispanic White | Hispanic | Asian American | |||||||
| Skin cancer history | Foreign | US | Adjusted Oddsa | Foreign | US | Adjusted Oddsa | Foreign | US | Adjusted Oddsa |
| Any skin cancerc | 2.5 (2.2–2.8) | 4.1 (4.0–4.2) | 0.55 (0.48–0.63) | 0.27 (0.22–0.32) | 0.44 (0.36–0.53) | 0.65 (0.48–0.88) | 0.16 (0.10–0.25) | 0.85 (0.61–1.18) | 0.19 (0.09–0.41) |
| Skin cancer risk factorsd | Foreign | US | Adjusted Oddsb | Foreign | US | Adjusted Oddsb | Foreign | US | Adjusted Oddsb |
| Sunburns during the past yeare | 29.8 (42.4–43.4) | 43.6 (43.0–44.1) | 0.59 (0.53–0.65) | 19.5 (18.6–20.4) | 33.6 (32.0–35.1) | 0.63 (0.56–0.71) | 15.2 (13.9–16.7) | 31.2 (27.7–34.9) | 0.56 (0.45–0.71) |
| Seeking shadee | 39.3 (30.1–31.0) | 30.1 (29.6–30.6) | 1.63 (1.48–1.79) | 40.6 (39.3–41.8) | 40.4 (39.1–41.7) | 1.10 (1.01–1.20) | 41.1 (39.0–43.3) | 37.6 (34.1–41.3) | 1.37 (1.11–1.70) |
| Wear a long- sleeved shirte | 13.6 (12.2–15.0) | 9.7 (9.4–10.0) | 1.46 (1.25–1.70) | 19.2 (18.2–20.3) | 12.1 (11.3–13.0) | 1.52 (1.34–1.7272) | 20.6 (19.2–22.1) | 12.1 (10.0–14.7) | 1.91 (1.42–2.58) |
| Wear long clothing to the anklesf | 26.5 (24.5–28.6) | 27.2 (26.6–27.8) | 1.08 (0.95–1.23) | 40.7 (39.3–42.1) | 31.5 (29.9–33.2) | 1.42 (1.27–1.58) | 39.2 (37.0–41.4) | 22.8 (19.7–26.4) | 2.42 (1.86–3.13) |
| Wear a hate | 18.1 (16.6–19.7) | 15.9 (15.5–16.3) | 1.22 (1.06–1.40) | 16.5 (15.7–17.4) | 12.7 (11.7–13.7) | 1.26 (1.10–1.44) | 17.4 (16.0–19.0) | 12.8 (10.6–15.5) | 1.37 (0.99–1.90) |
| Wear a capf | 29.5 (27.3–31.7) | 33.0 (32.5–33.6) | 0.92 (0.81–1.05) | 31.9 (30.7–33.2) | 27.0 (25.5–28.5) | 1.19 (1.05–1.34) | 25.9 (23.9–27.9) | 23.8 (20.0–28.1) | 1.02 (0.77–1.34) |
| Sunscreen with an SPF ≥ 15e | 34.3 (32.3–36.4) | 34.0 (33.5–34.5) | 0.98 (0.87–1.11) | 18.8 (17.9–19.7) | 24.0 (22.8–25.2) | 0.98 (0.87–1.10) | 25.2 (23.5–27.0) | 32.6 (29.3–26.0) | 0.77 (0.61–0.99) |
| ≥ 1 sun-protective behaviore | 68.4 (66.4–70.2) | 67.6 (67.1–68.0) | 1.09 (.98–1.22) | 67.6 (66.4–68.8) | 68.4 (67.0–69.7) | 1.14 (1.03–1.26) | 69.4 (67.4–71.3) | 66.8 (63.1–70.2) | 1.36 (1.08–1.71) |
| Tanned indoors during the past yearf | 5.4 (4.6–6.4) | 9.6 (9.2–10.0) | 0.48 (0.39–0.60) | 3.1 (2.5–3.7) | 5.2 (4.6–6.0) | 0.60 (0.46–0.77) | 2.6 (2.0–3.4) | 4.7 (3.1–6.9) | 0.73 (0.40–1.30) |
| Ever underwent a total bodye skin examination | 21.4 (19.7–23.1) | 24.7 (24.2–25.1) | 0.76 (0.68–0.85) | 5.9 (5.4–6.6) | 9.0 (8.3–9.8) | 0.71 (0.59–0.85) | 7.0 (6.1–8.1) | 13.4 (11.1–16.2) | 0.43 (0.32–0.59) |
p <0.05
Adjusted for age, sex, educational level, family income, region of the US, insurance status, smoking, alcohol use, obesity, and survey year.
Adjusted for age, sex, educational level, family income, region of the US, insurance status, smoking, alcohol use, obesity, survey year, phototype, and personal skin cancer history
Data from survey years 2000–2018. Skin cancer includes melanoma, non-melanoma skin cancer, and skin cancer “but don’t know what kind” type as defined by NHIS
Adjusted for age, sex, educational level, family income, region of the US, insurance status, smoking, alcohol use, obesity, survey year, phototype, and personal skin cancer history
Data from survey years 2000, 2005, 2010, 2015
Data from survey years 2005, 2010, 2015
Skin cancer prevalence and risk factors were lower among foreign-born than US-born individuals and higher among those with US citizenship. Lower skin cancer prevalence may relate to differences in TBSE or socioeconomic selection biases associated with immigration.2 This finding supports the immigrant paradox, which describes when foreign-born groups exhibit better health outcomes when compared to US-born counterparts.3 Prior studies describe a negative association between acculturation and sun-protective behaviors among foreign-born US Hispanics, which may contribute to differences in skin cancer prevalence.4 US citizenship association with increased skin cancer prevalence may stem from US-acculturated beauty standards favoring tanned skin.5 Study limitations included self-reported outcomes and survey administration in predominantly English and/or Spanish. Dermatologists should assess skin cancer risk factors and further study the influence of acculturation among foreign-born individuals.
Supplementary Material
Acknowledgments
Funding sources:
Dr Yeung is supported in part by Developmental Funds from the Winship Cancer Institute of Emory University and by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under award numbers L30AR076081 and K23AR075888. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Department of Veterans Affairs.
Footnotes
Twitter handle: @HowaResearch
Patient Consent on File: Consent for the publication of recognizable patient photographs or other identifiable material was obtained by the authors and included at the time of article submission to the journal stating that all patients gave consent with the understanding that this information may be publicly available.
Prior presentation: Study abstract has been presented as a poster presentation at the Society of Investigative Dermatology meeting in Portland, OR on May 20, 2022.
IRB approval status: Exempt from review by Emory University IRB
Reprint requests: Howa Yeung
Supplemental Material: Demographic Characteristics and Skin Cancer Prevalence and Risk Factors with Differing Markers of Acculturation (https://data.mendeley.com/datasets/zfjzsmn262/1)
Conflicts of Interest: Dr. Chen receives royalties from for-profit companies that license quality of life instruments for which Emory holds copyright. Dr. Supapannachart and Mr. Gangal have no conflicts of interest to declare.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
References
- 1.Jacobsen AA, Galvan A, Lachapelle CC, Wohl CB, Kirsner RS, Strasswimmer J. Defining the Need for Skin Cancer Prevention Education in Uninsured, Minority, and Immigrant Communities. JAMA Dermatol 2016;152:1342–7. [DOI] [PubMed] [Google Scholar]
- 2.Akresh IR, Frank R. Health selection among new immigrants. Am J Public Health 2008;98:2058–64. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Ruiz JM, Steffen P, Smith TB. Hispanic mortality paradox: a systematic review and metaanalysis of the longitudinal literature. Am J Public Health 2013;103:e52–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Andreeva VA, Cockburn MG, Yaroch AL, Unger JB, Rueda R, Reynolds KD. Preliminary evidence for mediation of the association between acculturation and sun-safe behaviors. Arch Dermatol 2011;147:814–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Maymone MBC, Neamah HH, Secemsky EA, Kundu RV, Saade D, Vashi NA. The Most Beautiful People: Evolving Standards of Beauty. JAMA Dermatol 2017;153:1327–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.