Disparities in Basal Cell Carcinoma: A Comparative Analysis of Hispanic and Non-Hispanic White Individuals

J Clin Aesthet Dermatol. 2024;17(10):24–27.

by Miguel A. Aristizabal, MD; Daniel Zieman, MD; Hannah S. Berman, MD; Kyle A. Williams, MD; Dane J. Markham, BS; Michael G. Heckman, MS; Alex Hochwald, MS; Naiara S. Barbosa, MD; and Catherine Degesys, MD

Drs. Aristizabal, Zieman, Berman, Williams, Barbosa, and Degesys are with the Department of Dermatology at Mayo Clinic in Jacksonville, Florida. Mr. Markham is with the Mayo Clinic Alix School of Medicine in Jacksonville, Florida. Messrs Heckman and Hochwald are with the Division of Clinical Trials and Biostatistics at Mayo Clinic in Jacksonville, Florida.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors have no conflicts of interest relevant to the contents of this article.

ABSTRACT: Objective. We sought to examine possible differences in BCC characteristics and treatment patterns between two matched cohorts of Hispanic White and non-Hispanic White individuals.

Methods. In this single institution, retrospective matched cohort study, data from patients with biopsy proven BCC from June 2005 to May 2022 was collected. Demographic, BCC, and treatment characteristics were compared between Hispanic White and non-Hispanic White individuals using a Wilcoxon rank-sum test, for continuous and ordinal variables, and Fisher’s exact test, for categorical variables.

Results. A total of 604 individuals with a diagnosis of biopsy-proven BCC were matched in a 1:1 fashion by age (± 0 years) and sex, based on self-identified ethnicity as Hispanic or non-Hispanic. Since all patients self-identified as White race, the two cohorts were labeled Hispanic White (n=302) and non-Hispanic White (n=302). The most frequent location for BCC was in the H area, 129 [42.7%] White Hispanic group vs 132 [43.7%] White non-Hispanic group (p = 0.87). In both Hispanic White and non-Hispanic White groups, the predominant subtype of BCC was the nodular (149 [50.2%] vs 164 [54.7%], p = 0.25). The median BCC pre-operative size in the Hispanic White group was 0.9 cm, whereas in the non-Hispanic White group, it was 1.0 cm (p = 0.004). Furthermore, the MMS defect size in the Hispanic White group had a median of 1.3 cm, while in the non-Hispanic White group, it was 1.6 cm (p < 0.001).

Limitations. retrospective design, single-center study, and self-reported race and ethnicity.

Conclusion. Both groups had similar demographics, tumor features, treatments, and post-operative complications. Notably, preoperative lesion and MMS defect sizes were larger in non-Hispanic Whites than in Hispanic Whites, contrary to expectations. Despite assumptions of poorer skin cancer outcomes among Hispanics, our findings indicate increased sizes in non-Hispanic Whites. Given the diversity in genetics and clinical traits within ethnicities, especially Hispanics, more research is needed for precise insights into disease outcomes across diverse backgrounds.

Keywords: Basal cell carcinoma, nonmelanoma skin cancer, skin cancer, healthcare disparities, skin of color, race, ethnicity

Introduction

Basal cell carcinoma (BCC) is the most common type of skin cancer in the United States (US), with an annual incidence of 2.7 to 4.3 million. The lifetime risk of BCC is approximately 30 percent for White populations and 20 percent overall.^1,2 Despite these insights, a significant data gap exists regarding BCC risk within the evolving and diverse patient population across the changing demographics of the United States.

Traditionally, individuals with skin of color (SOC) have a lower incidence of skin cancers, including BCC.³ Given the diversity of racial and ethnic groups identified as having SOC, many factors are likely to play a role in this decreased skin cancer incidence, including increased skin pigmentation and scarce population-based cancer registries. Recent reports suggest an increasing incidence of BCC in Hispanic individuals over time.^4,5 Generally, data on the prognosis of BCC is limited, and in patients with SOC, no differences in BCC-associated morbidity have been identified between Black and White individuals.⁶ However, disparities in diagnosis and treatment times, which result in worse outcomes, have been identified in squamous cell carcinoma and melanoma among patients with SOC.^7,8 

The concept of “Hispanic” ethnicity dates to the 1970s when it was first introduced during the US Census, utilizing a self-identification approach.⁹ Those collectively identified as Hispanic trace, their origin or descent to Puerto Rico, Cuba, Mexico, other Spanish-speaking Central and South American countries, and Spanish-speaking island nations of the Caribbean, excluding individuals from Portuguese-speaking backgrounds. Origin, in this context, encompasses nationality group, lineage, or the person’s heritage, which may include their country of origin or that of their parents or ancestors. It is crucial to note that individuals identifying their origin as Hispanic may belong to any race.¹⁰ In consequence, Hispanics exhibit a heterogeneous racial subgrouping, challenging existing practices that often overlook these distinctions.

In this study, we analyzed data from a single academic institution to investigate the differences of BCC characteristics and treatments among Hispanic White and non-Hispanic White individuals. 

Methods

After Institutional Review Board approval, a retrospective matched cohort study was conducted involving patients receiving care at the Mayo Clinic Florida between June 2005 to May 2022. A total of 302 Hispanic White individuals diagnosed with BCC were matched in a 1:1 fashion by age (± 0 years) and sex to 302 non-Hispanic White individuals. Information was collected regarding demographic characteristics (age at biopsy, sex), disease and treatment characteristics (location of BCC, BCC subtype, immunosuppression, type of treatment, pre-operative size, Mohs defect size, number of stages, repair) and outcomes (post-operative complications, recurrence after treatment, metastasis after treatment).

Statistical analysis. Continuous variables were summarized using sample median and range, and categorical variables were summarized with number and percentage of patients. Variables were compared between Hispanic and non-Hispanic individuals using the Wilcoxon rank-sum test for continuous and ordinal variables, and Fisher’s exact test for categorical variables. Log-rank tests were used to compare recurrence and metastasis after treatment between the two groups, where patients were censored at the date of last follow-up. All statistical tests were two-sided. Statistical analyses were performed using R Statistical Software (version 4.1.2; R Foundation for Statistical Computing, Vienna, Austria). 

This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

Results

General demographics. By design, the Hispanic White group (n=302) and non-Hispanic White group (n=302) displayed similar age at biopsy (67.5 vs. 67.6 years) and sex distribution (59.9% vs. 59.9% male). Table 1 lists demographic characteristics. 

BCC characteristics and immunosuppression. Across both groups, the most frequent location for BCC was in the H area (42.7% White Hispanic vs. 43.7% White non-Hispanic, p=0.87), followed by the M area (28.8% vs. 25.2%, p=0.36). The H area was defined as the central face, eyelids eyebrows, nose, lips, chin, ear, and periauricular skin, temple. Area M was defined as cheeks, forehead, scalp, neck, jawline. There were no statistically significant differences in rates of immunosuppression between the groups.

In both groups, the predominant subtypes of BCCs were nodular (50.2% vs. 54.7%, p=0.25), superficial (16.8% vs. 15.7%, p=0.83), and infiltrative (13.8% vs. 14.3%, p=0.91). No statistically significant differences between the groups were noted (Table 2).

Outcomes and complications. Mohs micrographic surgery (MMS) was the most utilized treatment option in both groups (51.8% vs. 56.2%, p=0.37), followed by electrodessication and curettage (EDC) (18.3% vs. 18.7%, p=1.0), and wide local excision (WLE) (3.3% vs. 6.7%, p=0.090). There were no statistically significant differences observed in Mohs stages (p=0.81), repair techniques (p=0.46) or post-operative complications. Notably, one patient in the Hispanic White group developed metastatic BCC, but this was not statistically significant.

Noteworthy statistical differences identified were, pre-operative size (Hispanic White group median: 0.9 cm vs. non-Hispanic White group median: 1.0 cm, p=0.004) and Mohs surgery defect size (Hispanic White group median: 1.3cm vs. non-Hispanic White group median: 1.6 cm, p<0.001) (Table 3).

Discussion

Limited studies address BCC in minority ethnic groups, often overlooking the heterogeneity within these populations. Subdividing ethnic groups into biologically relevant categories is essential to avoid over-generalization. Research has shown that grouping by ethnicity alone may fail to capture population heterogeneity.¹¹ Our study compares Hispanic White and non-Hispanic White individuals, refining BCC patterns and outcomes between diverse ethnic groups with similar skin phenotypes. Notably, the SOC nomenclature may not be specific enough, encompassing an even more heterogeneous population.

Both groups exhibited comparable demographic characteristics, disease features, treatment profiles, and post-operative complication rates. Notably, the preoperative lesion size in our non-Hispanic White cohort was statistically larger compared to the Hispanic group, though the clinical relevance of this difference is likely minimal. Additionally, MMS defect size was also observed to be larger in the non-Hispanic White group, likely related to a larger lesion size. This contrasts with previous evidence in non-melanoma skin cancer, where MMS defect sizes were found to be larger in Hispanic patients compared to non-Hispanic White patients, presumably due to larger tumor size.⁷ Furthermore, our findings contrast with previous reports on BCC, indicating that preoperative size may differ significantly among individuals of White and Hispanic ethnicity.⁵

The exploration of race and ethnicity is complex and frequently in the medical setting, race is determined by phenotypic characteristics, including skin color and hair type, while ethnicity is shaped by the interplay of biological and cultural factors, intertwined with geographic origins.¹² In the case of Hispanics, a growing body of evidence highlights differences in health-related outcomes between Black and White Hispanic individuals, unlocking new paradigms in the understanding of SOC outcomes.¹³ 

It is noteworthy that in our study, the assessment of race and ethnicity was conducted independently (e.g., White, and Hispanic), indicating the potential widespread adoption of this comprehensive approach and its contribution to improved ethnic characterization.

Limitations. Limitations include a retrospective design, being a single-center study, and reliance on self-reported race and ethnicity. 

Conclusion

Our study underscores the importance of adopting a nuanced approach to comprehend BCC disparities, surpassing simplistic ethnic classifications. Caution is warranted when utilizing ethnicity as a proxy for skin of color, as demonstrated by the unexpected variations in lesion size.

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