10.5826/dpc.1304a273
Introduction: A low socioeconomic status (SES) is associated with lower survival rates in cutaneous malignant melanoma (CMM). In South America, there are few studies that analyze CMM data according to SES.
Objectives: To determine the differences in microstaging and overall survival in CMM between public and private health care centers.
Methods: Retrospective cohort study. Histopathological reports with a diagnosis of CMM from two public hospitals (PuH) and one private health care center (PrH) in Santiago from 2008 to 2018 were included. Patients’ death certificates were obtained to estimate overall survival.
Results: 1014 MMC were found. The mean age was 58.6 ± 16.8 years and 59.9% corresponded to female patients. Of these, 33.9% received treatment at PuH and 66.1% at PrH. Patients from PuH had an increased risk of having an invasive CMM and a &gt;1 mm thickness melanoma compared to PrH (OR 2.77 and 6.06, respectively). Patients with invasive CMM from the PuH were 6.29-fold more likely to die than a patient from the PrH.
Conclusions: We observed a great disparity in tumor thickness between the socioeconomic sectors, reflecting a later detection and lower survival rate in PuH. Our results highlight a gap on which National Public Health should focus.
text/xml
2160-9381
3329
en
Nadia Vega
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
socioeconomic status
Cutaneous Malignant Melanoma in Chile: Differences in Tumor Thickness and Overall Survival Between Patients From Public and Private Health Care Centers
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-10-31
2023-03-13
2023-10-31
2024-01-16
e2023273
Dermatol Pract Concept
Introduction: A low socioeconomic status (SES) is associated with lower survival rates in cutaneous malignant melanoma (CMM). In South America, there are few studies that analyze CMM data according to SES.
Objectives: To determine the differences in microstaging and overall survival in CMM between public and private health care centers.
Methods: Retrospective cohort study. Histopathological reports with a diagnosis of CMM from two public hospitals (PuH) and one private health care center (PrH) in Santiago from 2008 to 2018 were included. Patients’ death certificates were obtained to estimate overall survival.
Results: 1014 MMC were found. The mean age was 58.6 ± 16.8 years and 59.9% corresponded to female patients. Of these, 33.9% received treatment at PuH and 66.1% at PrH. Patients from PuH had an increased risk of having an invasive CMM and a &gt;1 mm thickness melanoma compared to PrH (OR 2.77 and 6.06, respectively). Patients with invasive CMM from the PuH were 6.29-fold more likely to die than a patient from the PrH.
Conclusions: We observed a great disparity in tumor thickness between the socioeconomic sectors, reflecting a later detection and lower survival rate in PuH. Our results highlight a gap on which National Public Health should focus.
Nadia Vega
2023/10/31
10.5826/dpc.1304a273
e2023273
Department of Dermatology, Faculty of Medicine, University of Chile, Santiago, Chile.
2160-9381
socioeconomic status
en
e2023273
Quaglino P, Ribero S, Osella-Abate S, et al. Clinico-pathologic features of primary melanoma and sentinel lymph node predictive for non-sentinel lymph node involvement and overall survival in melanoma patients: a single centre observational cohort study. Surg Oncol. 2011;20(4):259-264. DOI: 10.1016/j.suronc.2010.11.001. PMID: 21145730.
Cutaneous Malignant Melanoma in Chile: Differences in Tumor Thickness and Overall Survival Between Patients From Public and Private Health Care Centers
https://dpcj.org/index.php/dpc/article/download/3329/2383
             Cutaneous Malignant Melanoma in Chile:
            Differences in Tumor Thickness and Overall
              Survival Between Patients From Public
                  and Private Health Care Centers
Guisella Martínez1, Francisco Bobadilla1,2, Francisca Kinzel1, Javier Fernández3, Ivo Sazunic4,
       María Magdalena Delgado5, Laura Segovia6, Andrea Zamudio7, Nadia Vega1,8


1 Department of Dermatology, Faculty of Medicine, University of Chile, Santiago, Chile
2 Dermatology Service, Hospital Barros Luco Trudeau, Santiago, Chile
3 Centro Internacional de Estudios Clínicos, Probity Medical Research, Santiago, Chile
4 Histodiagnostic Laboratory Málaga, Santiago, Chile
5 Department of Pathology, National Cancer Institute, Santiago, Chile
6 Department of Pathology, Hospital Barros Luco Trudeau, Santiago, Chile
7 Royal Australian College of General practitioners, Australia
8 Dermatology Service, Hospital Clínico Universidad de Chile, Santiago, Chile



Key words: melanoma, health care disparities, tumor thickness, Breslow, socioeconomic status
Citation: Martínez G, Bobadilla F, Kinzel F, et al. Cutaneous Malignant Melanoma in Chile: Differences in Tumor Thickness and Overall
Survival Between Patients From Public and Private Health Care Centers. Dermatol Pract Concept. 2023;13(4):e2023273. DOI: https://doi​
.org/10.5826/dpc.1304a273
Accepted: May 18, 2023; Published: October 2023
Copyright: ©2023 Martínez et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Francisca Kinzel, Servicio de Dermatología, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999,
Santiago de Chile. Phone number: 56229788173 E-mail: francisca.kinzel.m@gmail.com




                       Introduction: A low socioeconomic status (SES) is associated with lower survival rates in cutaneous
  ABSTRACT             malignant melanoma (CMM). In South America, there are few studies that analyze CMM data ac-
                       cording to SES.
                       Objectives: To determine the differences in microstaging and overall survival in CMM between public
                       and private health care centers.
                       Methods: Retrospective cohort study. Histopathological reports with a diagnosis of CMM from two
                       public hospitals (PuH) and one private health care center (PrH) in Santiago from 2008 to 2018 were
                       included. Patients’ death certificates were obtained to estimate overall survival.
                       Results: 1014 MMC were found. The mean age was 58.6 ± 16.8 years and 59.9% corresponded to




Original Article | Dermatol Pract Concept. 2023;13(4):e2023273                                                                         1
                      female patients. Of these, 33.9% received treatment at PuH and 66.1% at PrH. Patients from PuH
                      had an increased risk of having an invasive CMM and a >1 mm thickness melanoma compared to PrH
                      (odds ratio 2.77 and 6.06, respectively). Patients with invasive CMM from the PuH were 6.29-fold
                      more likely to die than a patient from the PrH.
                      Conclusions: We observed a great disparity in tumor thickness between the socioeconomic status, re-
                      flecting a later detection and lower survival rate in PuH. Our results highlight a gap on which National
                      Public Health should focus.




Introduction
Cutaneous malignant melanoma (CMM) is the most ­frequent             Methods
cause of skin cancer-related deaths, its incidence has globally
                                                                     This is a retrospective cohort study, which included all his-
increased, and it has been estimated to further grow [1]. Due to
                                                                     topathologic reports found with the diagnosis of CMM
its high prevalence in a younger population, it has great epide-
                                                                     between January 2008 and December 2018 at two pub-
miological relevance and repercussions for public health [2,3].
                                                                     lic hospitals (Hospital San José and Hospital Barros Luco
    In Chile, the incidence varies significantly by geographic lo-
                                                                     Trudeau) and one private health care center (Laboratorio
cation, with an average of 2.4 to 3 cases for 100000 inhabitants
                                                                     Histodiagnóstico Málaga) in Santiago, Chile.
and an increasing mortality rate between 1997 and 2015 [4,5].
                                                                        The exclusion criteria considered recurrent tumors, bi-
    The survival for CMM varies according to the tumoral
                                                                     opsies of extracutaneous melanoma, CMM metastasis,
depth at the time of diagnosis, with higher mortality rates
                                                                     and incisional biopsies. Transected CMM (positive inferior
in advanced stages [2]. Observational studies have demon-
                                                                     margins) with a depth ≤4 mm (<T4 according to American
strated differing mortality rates depending on an individual´s
                                                                     Joint Committee on Cancer (AJCC) 8th edition) were also
socioeconomic status (SES) [6-9]. Rutherford et al showed
                                                                     excluded due to the risk of underestimating tumoral depth.
that a reduction in socioeconomic inequality was associated
                                                                        Death certificates were used to calculate the overall
with a significant reduction in melanoma mortality rate
                                                                     ­survival rates of invasive CMM. Two research ethics com-
5 years from diagnosis [9].
                                                                     mittees (North and South Metropolitan Health care Chilean
    The Chilean health care system includes both private (PrH)
                                                                     Services) approved this study as the patients’ anonymity was
and public (PuH) health care centers. Public hospitals mostly
                                                                     safeguarded during the statistical analysis.
benefit those patients with lower SES, and for those individu-
als of higher SES, PrH is their main health care provider [4,10]     Statistical Analysis
    In Chile there is a lack of data on the differences in
                                                                     The Shapiro-Wilk test was used to determine data distribu-
­tumor thickness and survival in CMM according to the SES,
                                                                     tion. The inferential analysis was performed by Fisher exact
making it challenging to establish prognostic differences
­
                                                                     test and T student. Performed a logistic regression with an
among these patients.
                                                                     odds ratio (OR) and confidence interval of 95%.
                                                                        Survival analysis was performed by Kaplan-Meier method.
Objectives                                                           Log-Rank was used to compare different chances of survival
                                                                     and Cox regression was used to assess different variables, esti-
The objective of this study is to determine differences in tu-
                                                                     mating hazard ratio (HR) and confidence interval (CI) of 95%.
moral thickness at the time of diagnosis and survival rates
                                                                        The level of significance was defined as P <0.05. The sta-
among patients diagnosed with CMM based on their health
                                                                     tistical analysis was performed using the statistical software
care provider.
                                                                     STATA 13® (StataCorp).




2                                                                        Original Article | Dermatol Pract Concept. 2023;13(4):e2023273
Results                                                             situ and 43.9% were invasive. There was a statistically signif-
                                                                    icant difference in the depth of infiltration of invasive CMM
A total of 1014 melanomas were identified in both PuH and           between the PuH and PrH (P < 0.001) (Table 1).
PrH. The gender distribution was 59.9% (N = 607) women                 Using multivariable logistic regression analysis (ad-
and 40.1% (N = 407) men. The mean age at the time of diag-          justed for age and gender), being diagnosed with CMM in
nosis was 58.6 ± 16.8 years (range: 12-98 years).                   a PuH would increase the risk of having an invasive tumor
      In the PuH patients, tumors were located on the head          by 2.77-fold (OR 2.77; CI 2.08-3.68). It also increases the
and neck (29.9%), trunk (20.3%), palms and soles (16.9%),           risk of having an invasive melanoma with an infiltration
lower extremities (16.6%), upper extremities (12.5%) and            greater than 1mm in depth by 6.06-fold (OR 6.06; CI 4.03-
perineal area (1.4%). On the other hand, in the PrH it was          9.11), adjusted by age and sex when compared with patients
more frequent to find melanomas in the trunk (24.8%),               seen at PrH.
followed by lower extremities (22.7%), head and neck                   Overall survival rates at the 5-year were 82.4%, with
(20.7%), upper extremities (18.5%), palms and soles (3.7%)          a significant difference between PuH (65.6%) and PrH
and perineal area (0.9%). There were statistically signifi-         (94%) (P < 0.001). Patients with invasive CMM in PuH had
cant differences in tumor location between these two groups         6.29-fold higher risk of dying than those on PrH (HR 6.29;
(P < 0.001).                                                        P < 0.001; CI 3.91-10.14) (Table 2).
      Distribution by health care provider showed that 33.9%           5-year overall survival curves according to tumoral depth
of cases (N = 344) were diagnosed in PuH, while 66.1%               are shown in Figure 1 for PuH and in Figure 2 for PrH.
(N = 670) were diagnosed in PrH. There was a statistically
significant difference (P < 0.001) in the mean age at the time
of diagnosis, with patients in PuH being older with a mean
                                                                      Table 2. 5-year overall survival by health care
age of 64.2 ± 15.7 years (range: 20-98) compared to PrH
                                                                              center according to thickness.
patients with a mean age of 55.6 ± 26.6 years (range: 12-92).
                                                                                                   5-year OS         CI 95%
There was no statistically significant difference by gender,
                                                                     Public Hospital                65.6%        57.9%- 72.1%
with 63.1% of women and 36.9% of men in the PuH and
                                                                     T1                             86.7%        74.9%- 93.1%
58.2% of women and 41.8% of men in PrH (Table 1).                    T2                             81.5%        63.2%- 91.3%
      About the degree of infiltration, there was a statistically    T3                             54.9%        38.7%- 68.5%
significant difference between public and private health care        T4                             28.5%        14.1%- 44.7%
centers (P < 0.001). In PuH, 34.9% of melanomas were in              Private health care center     94%          90.2%- 96.4%
situ and 65.1% were invasive, while in PrH, 56.1% were in            T1                             95.6%        91.4%- 97.8%
                                                                     T2                             95.2%        70.7%- 99.3%
                                                                     T3                             94.4%        66.6%- 99.2%
Table 1. Characteristics of patients with primary                    T4                             75%          40.8%- 91.2%
cutaneous melanoma stratified by public hospital                    CI = confidence interval; OS = overall survival.
  (PuH) and private health care center (PrH)a.                      Thickness as T1≤ 1 mm, T2 >1.0–2.0 mm, T3 >2.0–4.0 mm and
                                                                    T4 >4.00 mm
                           PuHa            PrHa            P
    Gender
    Female             217 (63.1)       390 (58.2)       0.134
    Male               127 (36.9)       280 (21.8)
    Age (years)b       64.2 ± 15.7      55.6 ± 16.6     <0.001
    Infiltration
    In situ            120 (34.9)       376 (56.1)      <0.001
    Invasive           224 (65.1)       294 (43.9)
    Thickness
    T1                  70 (31.5)       223 (76.9)      <0.001
    T2                  43 (19.4)        35 (12.1)
    T3                  57 (25.7)         19 (6.5)
    T4                  52 (23.4)         13 (4.5)
a
  Data are provided as number (percentage), unless otherwise
indicated.
b
    Age in years ± Standard deviation

Thickness as T1≤ 1 mm, T2 >1.0–2.0 mm, T3 >2.0–4.0 mm and           Figure 1. Overall survival curves according to tumoral depth in
T4 >4.00 mm.                                                        public hospitals (PuH).



Original Article | Dermatol Pract Concept. 2023;13(4):e2023273                                                                   3
                                                                         Overall survival rate at 5 years in our study was 82.4%,
                                                                      and there were differences between PrH and PuH. Patients
                                                                      with invasive CMM in PuH had 6.29-fold more mortality
                                                                      risk than patients in PrH, as shown by clear discrepancies
                                                                      in the Kaplan-Meier curve. These findings are consistent
                                                                      with international studies, which have shown that patients
                                                                      with higher SES have more favorable odds of survival
                                                                      [6,19,21-23].
                                                                         When analyzing the possible causes of these survival
                                                                      differences, besides education and access to dermatologists,
                                                                      insurance, and therefore treatment access, are evident fac-
                                                                      tors to consider. Recently, Rosenthal et al published an arti-
                                                                      cle comparing two forms of health insurance in the United
                                                                      States, one with an integrated health care system and the
Figure 2. Overall survival curves according to tumoral depth in the   second group including other private insurances [11]. This
private health care center (PrH).                                     study showed that patients in non-integrated private insur-
                                                                      ances that had lower income, had a 70% increased risk of
                                                                      dying from CMM compared to those with higher income,
Conclusions                                                           while in the integrated health care system, there was no in-
                                                                      creased risk between SES groups.
In recent years, there has been an increasing focus on the
                                                                         The location of CMM in the SPu and SPr exhibited sta-
influence of socioeconomic status (SES) on melanoma out-
                                                                      tistically significant differences, with a greater prevalence of
comes. Most studies show that SES is a strong predictor of
                                                                      head and neck melanomas and acral melanomas in the SPu
CMM-specific mortality [11-14]. In Chile and South Amer-
                                                                      compared to the SPr. However, due to the focus of our study
ica, the influence of socioeconomic status on CMM has been
                                                                      on identifying disparities in tumor thickness and overall
rarely studied. Our study revealed a significant difference in
                                                                      survival between healthcare systems, we did not extensively
the degree of infiltration between PuH and PrH, with 34.9%
                                                                      explore the analysis of location. Nevertheless, it is worth
of in situ melanomas in PuH versus 56.1% in PrH. This
                                                                      noting that location could be an important factor to investi-
difference was confirmed in the multivariable analysis, indi-
                                                                      gate in future studies.
cating a 2.77-fold higher risk of invasive CMM in patients
                                                                         Despite its contributions, our study has some limitations.
treated at PuH.
                                                                      For instance, being a retrospective study may have limita-
    Several studies have demonstrated significant disparities
                                                                      tions in data collection and analysis. Also, even though we
in tumoral depth and survival rates between individuals with
                                                                      obtained data from two PuH, we had more patients from
high and low SES (6,15). Mandalá et al reported that 27.5%
                                                                      PrH than PuH, which may not reflect the national distribu-
of patients with low SES had a Breslow >3 mm at diagnosis,
                                                                      tion of melanoma patients. Additionally, histopathological
compared to 9.41% for those patients with higher SES [15].
                                                                      analysis was performed by different pathologists. However,
In our study, 68.5% of PuH tumors had a Breslow >1mm,
                                                                      given the multicentric nature of the study, it was not feasible
compared to 23.1% for those in PrH. Reflecting an increased
                                                                      to have all the data analyzed by a single specialist. Moreover,
risk of thick melanoma in PuH by 6.06-fold.
                                                                      this study did not include other confounding factors, such as
    Multiple studies have attempted to explain the gap be-
                                                                      comorbidities or smoking, and did not assess the impact of
tween different SES groups. Education has been proposed
                                                                      patient-specific melanoma treatments.
as a relevant factor [16-18]. Lower education levels are as-
                                                                         The results in the present study have significant clinical
sociated with thicker tumors and more advanced stages at
                                                                      relevance. Specifically, the greater tumoral depth in PuH, re-
the time of diagnosis, while patients with higher education
                                                                      flects that lower-income patients probably have a delay in the
levels attend more frequently for skin checks and therefore
                                                                      detection of CMM and consequently a reduced survival rate.
tend to be diagnosed at earlier stages [17,18]. However, the
                                                                      Public health strategies should focus on this gap, in order to
literature shows that even after adjusting for education level,
                                                                      benefit the population at risk, for example by considering
a low SES remained an independent predictor for advanced
                                                                      both clinical-pathologic features and nevus count which rep-
stages [19]. Individuals with high SES have greater access to
                                                                      resents an easy to access prognostic factor and pathologic
dermatologists and therefore to an early diagnosis [8]. On
                                                                      ones (in patients with previous melanoma) [(24,25]. This can
the other hand, lower SES populations may have a lower
                                                                      be achieved by creating targeted prevention and early detec-
recognition of early signs of skin cancer [20].
                                                                      tion programs that are accessible and effective for patients



4                                                                         Original Article | Dermatol Pract Concept. 2023;13(4):e2023273
from lower socioeconomic backgrounds. In conclusion, fu-                   15. Mandalà M, Imberti GL, Piazzalunga D, et al. Association of
ture strategies should consider the impact of specific pre-                    Socioeconomic Status With Breslow Thickness and Disease-Free
                                                                               and Overall Survival in Stage I-II Primary Cutaneous M ­ elanoma.
vention campaigns and early detection programs for people
                                                                               Mayo Clin Proc. 2011;86(2):113–119. DOI: 10.4065/mcp
from lower SES to reduce disparities in melanoma outcomes.
                                                                               .2010.0671. PMID: 21282485. PMCID: PMC3031435.
                                                                           16. Strömberg U, Peterson S, Holmberg E, et al. Cutaneous malig-

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Original Article | Dermatol Pract Concept. 2023;13(4):e2023273                                                                                 5
