School of Nursing
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Melanoma: The Influence of Socioeconomic Status on Incidence and Prognosis

Tracey Boyle-Harvey

Main Content

traceyharvey95@gmail.com

Introduction

Melanoma is a form of skin cancer that develops from malignant nevi (Gatley, 2011). If untreated, it can spread rapidly throughout the body and can ultimately be life-threatening. Melanoma is a common cancer in New Zealand, with it being the fourth most diagnosed cancer among the population (Ministry of Health, 2016). This literature review will be focused on factors influencing melanoma incidence and prognosis in low and high socioeconomic groups. Following this, implications for nursing practice and recommendations based on the findings from the literature review will be discussed.

Clinical issue and rationale

In a recently published study by Whiteman, Green and Olsen (2016) it was found that New Zealand has now overtaken Australia for the highest rates of melanoma in the world, with 48 diagnosed per 100,000 people in Australia compared to 50 diagnosed per 100,000 people in New Zealand, in 2011. Nationally, melanoma is the most common form of cancer among men aged 25-44, and the second most common form of cancer in males and females aged 45-64 (Ministry of Health, 2016). These statistics demonstrate the unfortunate impact that melanoma has on New Zealand through both a global and national perspective. From a healthcare point of view, it is vital to acknowledge the impact that these high rates have on the healthcare system itself, institutions and staff that care for those diagnosed and most importantly, those who are diagnosed themselves. Therefore, this clinical issue was chosen as the topic for the following literature review.

Identifying the Research Question

To narrow down this clinical issue, research was performed around the risk factors of developing melanoma. Environmental and genetic factors are known to be the main contributors to the development of the disease (Gatley, 2011). A significant environmental risk factor is exposure to ultraviolet radiation (Craft & Gordon, 2011). The main source of ultraviolet radiation exposure occurs from the sun. A common sign of ultraviolet radiation exposure is sunburn, which increases the risk of melanoma, particularly if the individual has a history of intermittent, intense sunburns (Perlis & Herlyn, 2004). Melanocytic naevus, commonly known as moles, also increase the risk of developing melanoma. Individuals with 11 to 25 moles, are 1.5 times more likely to develop melanoma in comparison to those with 10 or less moles (Zaal, Mooi, Klip & van der Horst, 2005). Family history of melanoma can also impact on individual’s risk of development of the disease. Those with a first-degree relative diagnosed with melanoma are at 2 times higher risk of developing the disease (Cho, Rosner & Colditz, 2005).

Using databases such as ProQuest Health & Medicine, CINAHL Complete and PubMed, research was discovered around socioeconomic status being a possible risk factor for developing melanoma. This research led to the focus of the literature review; socioeconomic status and melanoma, with a beginning research question of ‘Does socioeconomic status impact on melanoma rates?’. To create a concise research question, the PICO/T model was utilised as shown below in the form of a table (Schneider & Whitehead, 2013). The resulting question from the PICO/T model is ‘When comparing low and high socioeconomic groups, what factors influence melanoma incidence and prognosis?’.   

PICOT Table

Factors that impact incidence and prognosis in those of a lower socioeconomic status

Research has shown that lower socioeconomic status can lead to poorer health outcomes, and ultimately higher mortality rates (Stringhini et al., 2017). This relationship has been discussed, dissected and analysed on countless occasions. Lack of education among those with a lower socioeconomic status is often a contributing factor of poor health outcomes. Pollitt, Swetter, Johnson, Patil and Geller (2012) assessed socioeconomic status using the education level of individuals newly diagnosed with melanoma. They found that those with a high-school level of education were more likely to believe that melanoma was not a very serious disease, compared to those with a college level of education (Pollitt et al., 2012). They also found that those with a high school education were less likely to know the ‘ABCD’ melanoma rule or detect differences between melanoma and normal skin growths (Pollitt et al., 2012). These findings are also reflected in a 2007 study where it was found that those who had a low level of melanoma education and general educational attainment, had a higher tumour thickness at the time of diagnosis in comparison to those with a higher level of education (Baumert, Plewig, Volkenandt & Schmid-Wendtner, 2007). Differences amongst mortality rates for those with a low socioeconomic status and low education level has also been observed. A Swedish study has found that those of a lower education level and socioeconomic status had an 81% higher excess mortality rate in the five years post melanoma diagnosis, in comparison to those with a higher level of education and socioeconomic status (Strömberg et al., 2016). The relationship between low socioeconomic status and low education level can often influence health outcomes. As stated previously, it can lead to a low level of health knowledge and detection which can negatively impact on the prognosis for melanoma.

There has been a wide range of research around the prognosis for those of a lower socioeconomic status who have been diagnosed with melanoma. An Italian study investigated the association of socioeconomic status with the thickness of melanoma at diagnosis, and the survival rate for these individuals (Mandala et al., 2011). Mandala et al. (2011) found that the 10-year disease free survival rate in those of higher socioeconomic status was 91.8% in comparison to those of lower socioeconomic status with 81.7%. The study also found that 27.5% of those in a lower socioeconomic status had a Breslow thickness greater than 3mm, compared with 9.41% in those of a higher socioeconomic status (Mandala et al., 2011). The incidence between low socioeconomic status and high Breslow thickness was also reflected in a United States of America study (Linos, Swetter, Cockburn, Colditz & Clarke, 2009). The authors found that from the period of 1992-2004 those in the lowest quintile had the highest increase in the incidence of tumours thicker than 4mm (Linos et al., 2009). An Australian study also had similar findings in a study that assessed socioeconomic status and melanoma tumour thickness (Youl, Baade, Parekh, English, Elwood & Aitken, 2011). The authors found that 23% of those who have a lower level of educational achievement, and therefore socioeconomic status, had a melanoma thicker than 2mm, compared to 8.4% of those with a higher educational achievement (Youl et al., 2011). Some possible explanations for higher melanoma tumour thickness in those of a lower socioeconomic status is lack of access to timely healthcare, lack of awareness around regular skin detection and lack of knowledge around melanoma and its severity (Mandala et al., 2011). Unfortunately, these factors put those of a lower socioeconomic status at a disadvantage as thickness of melanoma tumours are a significant indicator of prognosis (Youl et al., 2011).

Factors that impact incidence and prognosis in those of a higher socioeconomic status

Higher socioeconomic status is often linked to better access to health care, therefore better overall health outcomes (Stringhini et al., 2017). As observed in preceding paragraphs this statement proves true in relation to melanoma prognosis. However, when it comes to incidence of melanoma, those who have a high socioeconomic status have an increased risk. In New Zealand, a Ministry of Health report on cancer trends showed that over the period 1981-2004 those with a high income had a melanoma incidence of 1 quarter to 1 third higher than low income New Zealanders (Blakely et al., 2010). This trend was also reported in a Californian study of adolescent and young adult females (Hausauer, Swetter, Cockburn & Clarke, 2011). Hausauer et al. (2011) found that over the study period 216 females in the lowest socioeconomic percentile were diagnosed with melanoma, in comparison to 1184 females diagnosed from the highest socioeconomic percentile. This trend was also supported by a Canadian study where the incidence of melanoma was, again, higher in those from a higher socioeconomic status (Johnson-Obaseki, Labajian, Corsten & McDonald, 2015).

Multiple factors have been put forth about the increased incidence of melanoma in those of a higher socioeconomic status. A possible explanation for this incidence is increased exposure to ultraviolet radiation. Hausauer et al. (2011) found that those from the highest socioeconomic status and neighbourhoods with higher ultraviolet radiation exposure were 73% more likely to develop melanoma than those from the lowest socioeconomic status and neighbourhoods with higher ultraviolet radiation exposure. Another theory relating to the increased exposure to ultraviolet radiation is the incidence of sunny holidays in those of a higher socioeconomic status (Idorn & Wulf, 2014). Mackie, Hauschild and Eggermont (2009) supported this statement, theorising that higher incidence in the higher socioeconomic groups could be due to access to sunnier climates in winter months, and recreational activities that increase ultraviolet radiation exposure. However, the association of melanoma incidence, sunny holidays and higher socioeconomic status may be a null argument in society today due to the decreasing cost of travel (Idorn & Wulf, 2014).

Although those from a higher socioeconomic status may be highly represented in incidence of melanoma statistics, their overall prognosis is far more favourable than those in a lower socioeconomic status. This can be attributed to the thinner melanoma tumours found in those of a higher socioeconomic status at the time of diagnosis (Mandala et al., 2011). Reyes-Ortiz, Goodwin and Freeman (2005), also argued that higher socioeconomic status lead to a thinner melanoma tumour at diagnosis. Supporting this, a study performed in the Netherlands found that 57% of those in a higher socioeconomic status were diagnosed with a melanoma less than 1mm, in comparison to 51% of those in a lower socioeconomic status (van der Aa, de Vries, Hoekstra, Coebergh & Siesling, 2011). A possible explanation for the thinner tumour size is access to healthcare and increased awareness around melanoma (Downing, Newton-Bishop & Forman, 2006). A United States of America study also supported this theory through analysing access to health care based on health insurance status and ethnicity (Halpern et al., 2008). They found that those who were underinsured, or had no insurance, were more likely to present with later stage melanoma, than those who had private insurance, and therefore greater access to healthcare (Halpern et al., 2008). Pollitt et al. (2011) observed findings contradicting this. They found that those of a lower socioeconomic status did not perceive any barriers to accessing health care, and that later stage diagnosis in those of a lower socioeconomic status was instead, influenced by education (Pollitt et al., 2011). These articles point to a trend of melanoma found at a thinner tumour size and stage of disease in those of a higher socioeconomic status, with a possible explanation being better access to healthcare and education. However, another possible theory for the incidence of thinner melanoma in those of a higher socioeconomic status could be a result of a melanoma diagnostic drift. A melanoma diagnostic drift can be described as the classification of “benign disease as malignant” (Shuster, 2009, para. 1). Levell, Beattie, Shuster and Greenberg (2009) attributed a rise in stage 1 melanoma incidence in East Angolia to this diagnostic drift. This theory was also supported by Weyers (2011), who suggested that melanoma diagnostic categories needed to be well established and unambiguous to avoid over diagnosis.

Implications

So, what implications for nursing practice does this literature review produce? Comparing melanoma in higher and lower socioeconomic status’ reveals two significant disparities. First, the incidence of increased tumour thickness in those of a lower socioeconomic status. The literature reviewed on this topic consistently implied that high tumour thickness was more common in those of a lower socioeconomic status. The impact that tumour thickness has on melanoma prognosis is significant, therefore this is an important issue that nurses can address through effective education. As stated previously, education proved a hindrance in attaining timely health care for melanoma treatment (Baumert et al., 2007). An implication for nursing practice would be to be aware of those at high risk of advanced melanoma and provide the opportunity for education on melanoma detection techniques, appropriate to their level of health knowledge. It would also be beneficial for nurses to educate these individuals on the importance of timely access to health care if they detect suspicious moles, however their low socioeconomic status may prove to be a barrier to accessing these health services.

The second disparity revealed is the high incidence of melanoma in those of a higher socioeconomic status. Most of the literature reviewed for this topic implied that those of a high socioeconomic status were at an increased risk of thinner melanoma and overall melanoma incidence, however Levell et al. (2009) suggested that the increase in thinner melanoma diagnosis may be due to a diagnostic drift. Nevertheless, the overall implications suggest that those of a high socioeconomic are at a significant risk. An implication for nursing practice would be to perform melanoma education as it may be useful in addressing these incidence rates. Again, it would be beneficial for nurses to be aware of the significant risk that melanoma imposes on this socioeconomic group. Emphasis could be placed on environmental risk factors such as increased ultraviolet radiation exposure through holidays to sunnier climates, which has been a suggested explanation in high melanoma incidence in this group (Mackie et al., 2009). To summarise, melanoma education in those at risk, in both high and low socioeconomic groups, is an important implication for nurses to apply to their practice. Tailoring this education to learning needs and individual risk factors would allow for a stronger therapeutic relationship, and hopefully a stronger adoption of the melanoma education given.

Recommendations

Based on the findings from the literature review and implications for practice, three recommendations have been formed. The first recommendation would be to increase focus on melanoma education in those at high risk in New Zealand which are; individuals of higher socioeconomic status (Blakely et al., 2010) and both males and females aged 25-65 (Ministry of Health, 2016). This recommendation would work in conjunction with the current 2015-2018 New Zealand cancer plan, which has an outline of actions and targets to be implemented into the health care system around the prevention and early detection of cancer (Ministry of Health, 2014). It would be relevant and beneficial to include melanoma education in the Ministry of Health’s recommended actions and targets due to the high rate of melanoma in New Zealand (Ministry of Health, 2016). A possible strategy to apply this recommendation may be to increase targeted prevention activities at those who have been identified at high risk. This could be through nationwide public health promotion that incorporates the appropriate statistics for those at high risk and alerts those individuals to the importance of melanoma prevention and early detection. It may also prove beneficial to create health prevention activities aimed at those of school-lever age, to decrease the incidence of melanoma at males aged 25-44 (Ministry of Health, 2016). A government led melanoma education strategy would hopefully improve melanoma incidence in New Zealand and, therefore, reduce the impact it has on the New Zealand health system and the individuals diagnosed.

The second recommendation is implementing melanoma awareness promotion in primary health services in higher socioeconomic areas. The literature revealed a significant incidence of melanoma in those of a higher socioeconomic status, therefore a targeted prevention activity at a primary health service level may be beneficial (Blakely et al., 2010). This strategy would be implemented in the summer months, where sun exposure is increased. The promotion could involve an information stand installed in the primary health service with a range of educational tools around melanoma risk, prevention and detection. To complement this information stand, a melanoma awareness clinic may be beneficial. This could be in the form of a special event in a high socioeconomic community setting where doctors and nurses provide an opportunity for mole checks, skin maps and information on prevention and detection techniques. This recommendation will increase the awareness of melanoma risk to those of a high socioeconomic status and may reduce the incidence of melanoma in this group.

The last recommendation reiterates the implication for nursing practice, discussed previously. It is recommended that nurses keep up to date with the latest research around melanoma, the possible education points that stems from this research and give this education in an individualised manner that is suitable for the patient. This recommendation is based on the findings from the literature review that stated lack of melanoma education in those of a lower socioeconomic status may have led to an increase in tumour thickness and therefore, worse prognosis (Mandala et al., 2011). Nurses should be aware of relevant, significant research around melanoma developments, and use evidence-based studies as a basis for their practice and inform the education they provide to patients (Hanon, Laffoy & Wynne, 2012). The education given should use a range of tools, that meets the individuals learning requirements and assessment of the individual’s understanding of the information should be performed (Russell, 2013). These actions will help inform nurse’s best practice, provide the best possible education to individuals and ensure the education given will create a meaningful impact on their melanoma awareness, prevention and detection methods, which may impact on overall melanoma incidence and prognosis in both socioeconomic groups.

Conclusion

This literature review has analysed a range of research focused on comparing melanoma incidence and prognosis in individuals of both high and low socioeconomic status to find out what factors influence these differences. The research has found that overall, melanoma incidence is higher in those of a higher socioeconomic status, however the prognosis is worse in those of a lower socioeconomic status. Some possible factors for this outcome has been identified as education, access to healthcare and ultraviolet radiation exposure. Implications and recommendations stemming from the literature review has been focused on education, as increased melanoma awareness, prevention and detection will lead to better health outcomes for both high and low socioeconomic status’. Overall, melanoma can be a deadly disease for all those diagnosed, regardless of socioeconomic status. However, researching the factors impacting the incidence and prognosis relating to socioeconomic status highlights areas that health professionals can target to reduce these incidences, and improve prognosis.

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