Response
To the Editor,
We thank Louge et al for their interest in our article, “Skin Cancer Epidemiology and Sun Protection Behaviors Among Native Americans.” 1 Our program at the University of Arizona shares a similar goal to identify and decrease potential dermatologic disparities affecting Native Americans (NA).
It is important to note that our inclusion criteria aimed to identify a unique patient population of adult Native American members of federally recognized tribes with a history of living on a reservation. These criteria allowed us to reach a segment of the Native American population that had a higher likelihood of receiving care from the Indian Health Service or Tribal Health clinics, as their services are only available to registered Native American members of federally recognized tribes.2 Our cohort differed from the commenter’s study3 and therefore cannot be used as a comparison model. Reservation Native Americans are understudied in research, and we believe that a strength of our study is a subject group that features a mean length of time living on a reservation of 20 years. Furthermore, the referenced ‘sun-behavior score’3 did not appear to be methodologically defined in the commenter’s article with specific criteria, which made it difficult to compare their results directly to ours.
We wholeheartedly agree with the commenters that Native American patients fall on a wide spectrum of Fitzpatrick skin scores as a result of regional and national variation amongst tribes. However, when our data showed high rates of our cohort reporting phototoxicity with associated redness (90%) or peeling (82%), it seemed worthy of discussion, considering that Fitzpatrick Skin Phototyping Scores I-III are often cited as burning most readily.4 Due to our survey collection methods, which was largely sampled from Arizona, our cohort had an increased likelihood of having higher Fitzpatrick scores (III+) and also experiencing heightened sun exposure given the UV index present in the region. We clearly acknowledged that this was a discussion item with limitations, but we believe the exploration of high phototoxicity rates in our cohort was warranted. According to the Centers for Disease Control, Native Americans have the second highest incidence of melanoma5 and previous data has also shown that NA individuals are more likely to be diagnosed at a significantly higher stage of melanoma than non-Hispanic Whites.6
While we greatly appreciate Dr. Kee’s insight on Navajo sun safety habits, we would like to caution the commenters on utilizing anecdotal observations. One of our study authors, Shannon Zullo, is a member of the Navajo Nation who grew on the reservation in a sheep-herding family. In her experience, the customs of conservative attire and red clay sunscreen have become less common, and thus difficult to generalize their usage. Both parties agree that it is important to consider both cultural and modern aspects of behaviors and sun safety strategies available to a broad Native American population. Guided by Shannon’s observations on the Navajo reservation, we specifically designed our study to investigate the qualities Native American participants value in their sunscreen usage, and we believe that it is a strength of our study.
We acknowledge that our study is limited by the anonymity of clinical data (eg, Fitzpatrick score, eye, and hair color) due to design. Our group appreciates and encourages collaboration between researchers interested in illuminating Native American dermatologic health disparities. Furthermore, the body of Native American dermatologic research could also benefit from an examination of the heterogenicity of skin conditions and care practices among different NA tribes and geographic regions. We look forward to future studies and thank the New Mexico team for their thoughtful comments and contribution to the literature.
Shannon W. Zullo
University of Arizona College of Medicine Tucson, AZ
Vivian Y. Shi MD
University of Arizona, Department of Medicine Division of Dermatology Tucson, AZ
References:
1. Maarouf M, Zullo SW, DeCapite T, Shi VY. Skin cancer epidemiology and sun protection behaviors among native americans. J Drugs Dermatol. 2019;18(5):420-423.
2. Indian Health Service. Indian Health Manual: Chapter 1 - Eligibility for services. https://www.ihs.gov/ihm/pc/part-2/p2c1/. Updated June 28, 2017. Accessed October 24, 2019.
3. Logue ME, Hough T, Leyva Y, Kee J, Berwick M. Skin cancer risk reduction behaviors among american indian and non-hispanic white persons in Rural New Mexico. JAMA Dermatology. 2016;152(12):1382-1383.
4. Coups EJ, Stapleton JL, Hudson SV, Medina-Forrester A, Natale-Pereira A, Goydos JS. Sun protection and exposure behaviors among Hispanic adults in the United States: differences according to acculturation and among Hispanic subgroups. BMC Public Health. 2012;12:985.
5. U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on November 2018 submission data (1999-2016): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. https://gis.cdc.gov/Cancer/USCS/ DataViz.html. Updated June 2019. Accessed October 20, 2019.
6. Baldwin J, Janitz AE, Erb-Alvarez J, Snider C, Campbell JE. Prevalence and mortality of melanoma in Oklahoma among racial groups, 2000-2008. The Journal of the Oklahoma State Medical Association. 2016;109(7-8):311-316.
To the Editor,
We thank Louge et al for their interest in our article, “Skin Cancer Epidemiology and Sun Protection Behaviors Among Native Americans.” 1 Our program at the University of Arizona shares a similar goal to identify and decrease potential dermatologic disparities affecting Native Americans (NA).
It is important to note that our inclusion criteria aimed to identify a unique patient population of adult Native American members of federally recognized tribes with a history of living on a reservation. These criteria allowed us to reach a segment of the Native American population that had a higher likelihood of receiving care from the Indian Health Service or Tribal Health clinics, as their services are only available to registered Native American members of federally recognized tribes.2 Our cohort differed from the commenter’s study3 and therefore cannot be used as a comparison model. Reservation Native Americans are understudied in research, and we believe that a strength of our study is a subject group that features a mean length of time living on a reservation of 20 years. Furthermore, the referenced ‘sun-behavior score’3 did not appear to be methodologically defined in the commenter’s article with specific criteria, which made it difficult to compare their results directly to ours.
We wholeheartedly agree with the commenters that Native American patients fall on a wide spectrum of Fitzpatrick skin scores as a result of regional and national variation amongst tribes. However, when our data showed high rates of our cohort reporting phototoxicity with associated redness (90%) or peeling (82%), it seemed worthy of discussion, considering that Fitzpatrick Skin Phototyping Scores I-III are often cited as burning most readily.4 Due to our survey collection methods, which was largely sampled from Arizona, our cohort had an increased likelihood of having higher Fitzpatrick scores (III+) and also experiencing heightened sun exposure given the UV index present in the region. We clearly acknowledged that this was a discussion item with limitations, but we believe the exploration of high phototoxicity rates in our cohort was warranted. According to the Centers for Disease Control, Native Americans have the second highest incidence of melanoma5 and previous data has also shown that NA individuals are more likely to be diagnosed at a significantly higher stage of melanoma than non-Hispanic Whites.6
While we greatly appreciate Dr. Kee’s insight on Navajo sun safety habits, we would like to caution the commenters on utilizing anecdotal observations. One of our study authors, Shannon Zullo, is a member of the Navajo Nation who grew on the reservation in a sheep-herding family. In her experience, the customs of conservative attire and red clay sunscreen have become less common, and thus difficult to generalize their usage. Both parties agree that it is important to consider both cultural and modern aspects of behaviors and sun safety strategies available to a broad Native American population. Guided by Shannon’s observations on the Navajo reservation, we specifically designed our study to investigate the qualities Native American participants value in their sunscreen usage, and we believe that it is a strength of our study.
We acknowledge that our study is limited by the anonymity of clinical data (eg, Fitzpatrick score, eye, and hair color) due to design. Our group appreciates and encourages collaboration between researchers interested in illuminating Native American dermatologic health disparities. Furthermore, the body of Native American dermatologic research could also benefit from an examination of the heterogenicity of skin conditions and care practices among different NA tribes and geographic regions. We look forward to future studies and thank the New Mexico team for their thoughtful comments and contribution to the literature.
Shannon W. Zullo
University of Arizona College of Medicine Tucson, AZ
Vivian Y. Shi MD
University of Arizona, Department of Medicine Division of Dermatology Tucson, AZ
References:
1. Maarouf M, Zullo SW, DeCapite T, Shi VY. Skin cancer epidemiology and sun protection behaviors among native americans. J Drugs Dermatol. 2019;18(5):420-423.
2. Indian Health Service. Indian Health Manual: Chapter 1 - Eligibility for services. https://www.ihs.gov/ihm/pc/part-2/p2c1/. Updated June 28, 2017. Accessed October 24, 2019.
3. Logue ME, Hough T, Leyva Y, Kee J, Berwick M. Skin cancer risk reduction behaviors among american indian and non-hispanic white persons in Rural New Mexico. JAMA Dermatology. 2016;152(12):1382-1383.
4. Coups EJ, Stapleton JL, Hudson SV, Medina-Forrester A, Natale-Pereira A, Goydos JS. Sun protection and exposure behaviors among Hispanic adults in the United States: differences according to acculturation and among Hispanic subgroups. BMC Public Health. 2012;12:985.
5. U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on November 2018 submission data (1999-2016): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. https://gis.cdc.gov/Cancer/USCS/ DataViz.html. Updated June 2019. Accessed October 20, 2019.
6. Baldwin J, Janitz AE, Erb-Alvarez J, Snider C, Campbell JE. Prevalence and mortality of melanoma in Oklahoma among racial groups, 2000-2008. The Journal of the Oklahoma State Medical Association. 2016;109(7-8):311-316.
