Journal Information
Vol. 112. Issue 10.
Pages 943-949 (November - December 2021)
Vol. 112. Issue 10.
Pages 943-949 (November - December 2021)
Case and Research Letters
Open Access
Risk Factors for Melanoma in a Latin American Population: A Case-Control Study
Factores de riesgo para melanoma en una población latinoamericana: estudio de casos y controles
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L.M. Aguirrea,b, A.M. Muñoza,b, M.S. Aluma-Tenoriob, N. Jaimesc,d,
Corresponding author
njaimes@med.miami.edu

Corresponding author.
a Servicio Dermatología, Universidad Pontificia Bolivariana, Medellín, Colombia
b Aurora Centro Especializado en Cáncer de Piel, Medellín, Colombia
c Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
d Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, United States
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Tables (3)
Table 1. Sociodemographic, Phenotypic, and UV Radiation Exposure Characteristics.
Table 2. Characteristics of Patients With Melanoma (n = 62).
Table 3. Bivariate and Multivariate Analysis of Risk Factors for Melanoma.
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Additional material (1)
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To the Editor,

Melanoma incidence continues to rise in different populations and ethnic groups worldwide.1–3 Epidemiological data and known risk factors for melanoma are mostly based on studies of US, Australian, and European populations. Few population-based studies have been conducted in Latin American or Hispanic communities.4

Latin America is known for its significant ethnic diversity secondary to interracial relationships that vary from one country to the next depending on population structure and migration history. In Colombia, for example, the population results from interactions between indigenous/native populations, Spanish people, and Africans, with mestizos representing the largest segment. The aim of this study was to identify possible risk factors for cutaneous melanoma in a Colombian population in the city of Medellín, Colombia.

We conducted a retrospective age- and sex-matched case-control study. Cases were patients with a histopathologically confirmed diagnosis of in situ or invasive melanoma, while controls were randomly selected patients without a personal history of melanoma who were seen for any dermatologic condition. The ratio of cases to controls was 1:2. We analyzed the medical records of patients older than 18 years seen at Clínica Aurora, a specialized skin cancer center, in Medellín between May 2014 and October 2017. We included both incident and prevalent cases of melanoma. In other words, we studied patients newly diagnosed with melanoma during the study period and those with an existing diagnosis. The required sample size was estimated at 62 cases and 125 controls using an alpha error of 5%, a beta error of 20% (95% confidence level and 80% statistical power) and an odds ratio (OR) of 3 associated with the presence of multiple melanocytic nevi as the main risk factor for melanoma. The calculations were performed in the statistical software program Epi Info.

We analyzed the medical records of 187 patients (62 cases and 125 controls). Their phenotypic, sociodemographic, and sun exposure characteristics are given in Table 1. Table 2 summarizes the characteristics of the patients with melanoma. Table 3 presents the results of the bivariate and multivariate analyses.

Table 1.

Sociodemographic, Phenotypic, and UV Radiation Exposure Characteristics.

Variable  Controls  Cases  Total 
  N = 125 (%)  N = 62 (%)  N = 187 (%) 
Sociodemographic characteristics
Sex
Male  61 (49)  35 (56)  96 (51) 
Female  64 (51)  27 (44)  91 (49) 
Median age (interquartile range), ya  53 (37-63)  53 (35-66)   
Civil status
Married  93 (74)  44 (71)  137 (73) 
Single  32 (26)  18 (29)  50 (27) 
Place of residence
Urban  106 (85)  58 (94)  164 (88) 
Rural  15 (12)  2 (3)  17 (9) 
Abroad  4 (3)  2 (3)  6 (3) 
Social security regime
None  10 (8)  7 (11)  17 (9) 
Subsidized  1 (1)  1 (2)  2 (1) 
Contributive  19 (15)  7(11)  26 (14) 
Private  95 (76)  47(76)  142 (76) 
Phenotypic characteristics
Red/blonde hair  13 (10)  7 (11)  20 (10) 
Blue/green/gray eyes  22 (18)  13 (21)  35 (19) 
Facial freckles  4 (3)  0 (0)  4 (2) 
Fitzpatrick skin type I or II  34 (27)  10 (6)  44 (23) 
> 5 clinically dysplastic nevi or at least 2 per condition  15 (12)  18 (29)  33 (17) 
Sun-damaged skin  103 (82)  46 (74)  149 (80) 
Personal history of melanoma  5 (4)  5 (8)  10 (5) 
Personal history of nonmelanoma skin cancer  23 (18)  6 (10)  29 (15) 
Family history of melanoma in a first- to third-degree relative  14 (11)  10 (16)  24 (13) 
Number of common nevi
0-20  44 (35)  8 (13)  52 (28) 
20-50  32 (25)  10 (16)  42 (22) 
50-100  17 (14)  12 (19)  29 (16) 
> 100  27 (22)  11 (18)  38 (20) 
Not described  5 (4)  21 (34)  26 (14) 
Number of nevi on trunk and upper extremities (based on photographs)
0-20  45 (36)  8 (13)  53 (29) 
20-50  32 (26)  12 (19)  44 (23) 
50-100  23 (18)  11 (18)  34 (18) 
> 100  18 (14)  10 (16)  28 (15) 
Not described  7 (6)  21 (34)  28 (15) 
Nevi: predominant dermoscopic pattern
Reticular diffuse  78 (62)  24 (38)  102 (54) 
Reticular patchy  4 (3)  0 (0)  4 (2) 
Peripheral reticular pattern with central hypopigmentation  0 (0)  0 (0)  0 (0) 
Peripheral reticular pattern with central hyperpigmentation  0 (0)  1 (2)  1 (1) 
Peripheral reticular pattern with central hypopigmentation  0(0)  0 (0)  0 (0) 
Homogenous pattern  2 (2)  0 (0)  2 (1) 
Peripheral globules  1 (1)  0 (0)  1 (1) 
Globular  1 (1)  0 (0)  1 (1) 
Two components  7 (6)  5 (8)  12 (6) 
Multiple components  0 (0)  1 (2)  1 (1) 
Not described  32 (26)  31 (50)  63 (33) 
Congenital melanocytic nevus
None  117 (93)  59 (96)  176 (94) 
Small (< 1.5 cm)  8 (6)  0 (0)  8 (4) 
Median (1.6-19.9 cm)  0 (0)  2 (3)  2 (1) 
Large (> 20 cm)  0 (0)  1 (1)  1 (1) 
Solar lentigines
In 1 area  66 (53)  32 (52)  98 (52) 
In 2 areas  44 (35)  21 (34)  65 (35) 
In ≥ 3 areas  15 (12)  8 (13)  23 (12) 
Not described  0 (0)  1 (1)  1 (1) 
Actinic keratosis
None  104 (83)  47 (76)  151 (81) 
< 10  17 (14)  7 (11)  24 (13) 
> 10  4 (3)  8 (13)  12 (6) 
History of another cancer
No  119 (95)  61 (99)  180 (96) 
Yes  6 (5)  1 (1)  7 (4) 
Chronic immunosuppression
No  125 (100)  62 (100)  187 (100) 
Yes  0 (0)  0 (0)  0 (0) 
Genodermatosis
No  125 (100)  62 (100)  187 (100) 
Yes  0(0)  0 (0)  0 (0) 
Parkinson disease
No  124 (99)  62 (100)  186 (99) 
Yes  1 (1)  0 (0)  1 (1) 
UV radiation exposure
Skin reaction to sunlight
No effect  0 (0)  0 (0)  0 (0) 
Tan  17 (14)  12 (19)  29 (16) 
Mild sunburn then tan  75 (60)  30 (48)  105 (56) 
Sunburn without blisters  29 (23)  13 (21)  42 (22) 
Sunburn with blisters  3 (2)  1 (2)  4 (2) 
Not described  1 (1)  6 (10)  7 (4) 
Lifetime history of sunburn
No episodes  68 (54)  13 (21)  81 (43) 
< 3 episodes  34 (28)  25 (40)  59 (32) 
> 3 episodes  22 (17)  6 (10)  28 (15) 
  1 (1)  18 (29)  19 (10) 
Sunburn before age of 20 years
No  74 (59)  16 (26)  90 (48) 
Yes  50 (40)  29 (47)  79 (42) 
Not described  1 (1)  17 (27)  18 (10) 
Frequency of sunscreen use
Never  17 (13)  7 (11)  24 (13) 
Only during intense sun exposure  14 (11)  3 (5)  17 (9) 
Occasional  22 (18)  11 (18)  33 (17) 
Once a week  1 (1)  0 (0)  1 (1) 
Once a day  66 (53)  29 (47)  95 (51) 
At least twice a day  5 (4)  0 (0)  5 (3) 
Not described  0 (0)  12 (19)  12 (6) 
Frequency of use of other sun protection measures
Never  13 (11)  8 (13)  21 (12) 
Sometimes  53 (42)  25 (40)  78 (42) 
Often  56 (45)  13 (21)  69 (37) 
Always  3 (2)  0 (0)  0 (0) 
Not described  0 (0)  16 (26)  16 (9) 
Lifetime use of physical sun protection measures
1 method  24 (19)  19 (31)  43 (23) 
2 methods  89 (71)  27 (43)  116 (62) 
3 or more methods  12 (10)  0 (0)  12 (6) 
Not described  0 (0)  16 (26)  16 (9) 
Use of sunscreen before age of 18 years
Never  47 (38)  20 (32)  67 (36) 
Sometimes  65 (52)  24 (39)  89 (47) 
Often  1 (1)  0 (0)  1 (1) 
Always  0 (0)  0 (0)  0 (0) 
Not described  12 (9)  18 (29)  30 (16) 
Use of tanning booths
Never  111 (89)  39 (63)  150 (80) 
Yes, before age of 25 years  6 (5)  3 (5)  9 (5) 
Yes, after age of 25 years  8 (6)  4 (6)  12 (6) 
Not described  16 (26)  16 (9) 
History of sunburn
None  84 (67)  17 (28)  101 (54) 
Intermittent  31 (25)  31 (50)  62 (33) 
Chronic  9 (7)  2 (3)  11 (6) 
Not described  1 (1)  12 (19)  13 (7) 
At least 1 modifiable factorb      101 (54) 
At least 1 nonmodifiable factorb      48 (26) 
a

Interquartile range: minimum, 18 years; maximum, 88 years.

b

Nonmodifiable factors refer to phenotypic characteristics.

Table 2.

Characteristics of Patients With Melanoma (n = 62).

Variable  N = 62 (%) 
Person who detected the melanoma
Patient  5 (8) 
Dermatologist  56 (90) 
Other physician  1 (2) 
Tumor site
Extremities  24 (39) 
Trunk  21 (34) 
Head and neck  13 (21) 
Abdomen  4 (6) 
Dermoscopic features
Atypical network  22 (35) 
Atypical globules  15 (24) 
Atypical vessels  9 (15) 
Regression  7 (11) 
Crystalline structures  6 (10) 
Multicomponent  31 (50) 
Not described  13 (21) 
Histologic features
Melanoma in situ  41 (66) 
Invasive  21 (34) 
Breslow thickness < 0.8 mm  15 (24) 
Breslow thickness > 0.8 mm  6 (10) 
Ulceration  1 (2) 
Regression  5 (8) 
Perineural invasion  1 (2) 
Lymphovascular invasion 
Microsatellites 
Histologic subtype
Superficial spreading  21 (34) 
Nodular  6 (10) 
Lentigo maligna  8 (13) 
Acral lentiginous  2 (3) 
Other: blue nevus–like  1 (2) 
Mitoses/mm2
Not applicable  39 (63) 
< 1  11 (18) 
> 1  12 (19) 
Growth phase
Radial  53 (85) 
Vertical  9 (15) 
Staging
In situ  41 (66) 
16 (26) 
II  2 (3) 
III  2 (3) 
IV  1 (2) 
Table 3.

Bivariate and Multivariate Analysis of Risk Factors for Melanoma.

Bivariate analysis  P Value  Odds Ratio (95% CI) 
Hair color
Blonde/red  .802  1 (0.4-3.1) 
Light Fitzpatrick skin type  .279  1 (0.5-2.5) 
Eye color
Blue/green/gray  .547  1.3 (0.6-2.8) 
Personal history of squamous cell carcinoma  .733  1.3 (0.4-5.0) 
Use of tanning booths  .779  1.4 (0.3-5.9) 
Frequency of tanning booth use  .567  1.42 (0.5-4.9) 
Presence of actinic keratosis  .242  1.5 (0.7-3.3) 
No. of common nevi  .085  1.7 (0.6-4.8) 
History of melanoma in a first- to third-degree relative  .767  1.7 (0.5-6.1) 
Personal history of melanoma  .245  2.1 (0.6-7.5) 
Number of nevi on trunk and upper extremities  .158  2.1 (0.8-5.7) 
Dysplastic nevus  .022  2.5 (1.1-5.7) 
Sunburn before age of 20 years  .005  2.6 (1.3-5.4) 
≥ 1 predominant dermoscopic pattern  .06  2.9 (0.9-9.6) 
Lifetime history of sunburn  .003  3.8 (1.7-8.4) 
Recreational sun exposure  < .001  4.9 (2.4-10.1) 
Presence of sun-damaged skin  .246  0.6 (0.3-1.3) 
Personal history of basal cell carcinoma  .037  0.2 (0.0-0.9) 
Congenital nevus  .502  0.4 (0.1-2.4) 
Use of sun protection methods  .978  0.9 (0.4-1.9) 
Physical sun protection  .040  0.3 (0.2-0.8) 
Sun protection before age of 18 years  .660  1.1 (0.6-2.4) 
Multivariate analysisa  OR (95% CI) 
History of sunburn  5.63 (2.2-14.6) 
History of reactive sun exposure  4.17 (1.8-9.6) 
Use of 2 or more physical sun protection measures  0.19 (0.1-0.5) 

χ2 test or Fisher exact test for counts below 5. Logistic regression was used for polytomous variables. Variables with a P value < .25 (Hosmer-Lemeshow goodness of fit test) were entered into the multivariate analysis.

a

Logistic regression analysis was applied using a variable selection method evaluated using the omnibus test (< .001), R-squared (.285), and Hosmer-Lemeshow test (.055), with a correct classification percentage of 76.4%; 95% CI.

Similarly to previous reports in the literature,5–7 our multivariate analysis showed that patients with melanoma were more likely to have a history of recreational or intermittent sun exposure (OR = 4.2; 95% CI, 1.8-9.6) and a lifetime history of sunburn (OR = 5.6; 95% CI, 2.2-14.6), suggesting that these patterns of exposure are risk factors for melanoma in our study population. In contrast, the use of 2 or more sun protection measures exerted a protective effect (OR = 0.2; 95% CI, 0.1-0.5). Unlike other studies, we did not observe an association between number of common or atypical nevi and melanoma risk.5,8 We observed a protective effect for a personal history of basal cell carcinoma, possibly because the control population was selected from a specialized center where patients with skin cancer predominate and basal cell carcinoma would be expected to be relatively common.

Our study has some limitations. First, the controls were selected from a referral center for patients with skin cancer and their exposure habits may not be representative of the general population in the area, possibly resulting in an overestimation of the proportion of patients with a history of skin cancer and creating a bias in our results for use of sun protection measures, access to health care, and level of education. Second, recall bias may have affected the accuracy or completeness of important data for our analyses, as some of the information was based on subjective perceptions of past events.

In conclusion, recreational or intermittent sun exposure and a lifetime history of sunburn were risk factors for melanoma in our study population, while use of 2 or more sun protection measures exerted a protective effect. Our findings are consistent with reports from different regions in the world, indicating that UV radiation plays an important role in populations other than Whites and that primary prevention efforts are also essential for preventing skin cancer in mestizo populations such as those in Colombia.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Appendix A
Supplementary data

The following is Supplementary data to this article:

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Please cite this article as: Aguirre LM, Muñoz AM, Aluma-Tenorio MS, Jaimes N. Factores de riesgo para melanoma en una población latinoamericana: estudio de casos y controles. Actas Dermosifiliogr. 2021;112:943–949.

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