Why many pregnant women aren't screened for deadly disease until it's too late
The shortage of a dermatologist in some areas makes it impossible for nearby women to get a timely diagnosis
A new report finds that swaths of pregnant women are having to wait too long for treatment of deadly melanoma. The lag puts not just one, but two lives at risk.
In
September, Women’s Health published a troubling report about the
dangerous repercussions of a nationwide shortage of dermatologists. One
in five areas of the country don’t have a single dermatologist within 50
or even 100 miles, and in these areas—which we dubbed “derm deserts”—there
are more melanoma deaths. The shortage makes it impossible for nearby
women to get a timely diagnosis, and when you have melanoma—the most
aggressive form of skin cancer—waiting a few months, or even weeks, for
an appointment can be fatal.
Now, we’re getting hit with more bad news: Pregnant women may be particularly vulnerable.
A new study published in the journal JAMA Dermatology
looked at more than 7,600 North Carolina residents who had been
diagnosed with melanoma. Researchers found that those with Medicaid
insurance—which covers around half of all pregnant women in the U.S., or
2 million pregnancies per year—were 36 percent more likely than those
on other insurance plans to experience a delay of more than six weeks
for the surgical removal of their cancer. Yet research shows that
patients should be treated within two weeks for the best chance of
survival. Six weeks is the recommended maximum wait time; once melanoma
has spread, it’s much harder to treat. And pregnant woman with melanoma
may be at greater risk for complications from the disease than
nonexpecting women. (Though the study was done only in North Carolina,
researchers say this data can be extrapolated to the entire
country—where things might be more problematic: According to our
investigation, North Carolina is far from the worst of the derm-desert
states; in contrast, the entire state of Utah is a desert.)
WHAT’S HAPPENING WITH MEDICAID
The
government-funded health insurance program is set up to help low-income
people and families, pregnant women, and those with disabilities. Many
states offer Medicaid to pregnant women with higher incomes than
nonpregnant women (even incomes that hover around the national average
for young women) because they’re considered a “needy” group by the U.S.
government. So if they’re covered, why can’t they get their melanomas
removed? Experts suggest two troubling theories:
- Many doctors aren’t taking Medicaid patients. “We have a real access-to-care issue,” says Sapna Patel, M.D., a melanoma oncologist at the MD Anderson Cancer Center in Houston. “Women who call the Medicaid community health center for a derm referral might have to wait months for an appointment and then also experience a delay in treatment.” One study found that only 32 percent of U.S. dermatologists accept new Medicaid patients. This may be because Medicaid reimburses doctors only a fraction of what private insurers do and takes longer to process those payments, studies show. Women’s Health contacted Medicaid for comment, but there was no response as of press time.
- Pregnant women on Medicaid have to jump through medical hoops. The JAMA researchers surmise that Medicaid patients could be waiting longer for surgery because of poor coordination of care. Think of it this way: Fewer derms mean you might have to get a diagnosis from a PCP. At that point, you’ve got to find a dermatologic surgeon—those, too, are few and far between on Medicaid. That person has to be able to fit you in ASAP. Yet they may not, because, as one derm told us, a diagnosing dermatologist will see her own patients more quickly than new people. All of this explains the finding of multiple studies: that when a general-care doctor or other health-care aide, versus a derm, diagnoses a melanoma, there are longer excision delays.
A SPREADING CONCERN
Almost
a third of melanoma cases are diagnosed in women during their
childbearing years. One explanation: The sun damage we acquire as kids
usually pops up 10 to 20 years later, says Patel, putting women in their
twenties and thirties at risk. Once pregnant, many women don’t
prioritize skin checks. They are likely more concerned with seeing their
ob-gyn than, say, having a new mole on their leg checked out and
subsequently getting a prompt diagnosis, says Patel. It’s true that
melanoma in pregnant women is quite uncommon, but when it happens, it
can be serious.
Biologically, pregnancy itself may trigger melanoma for some women. Pregnancy decreases the efficacy of the immune system. “This
is nature’s way of preventing the body from rejecting something
‘foreign’ and protecting the fetus—but we rely on that immune system to
protect the body from things like cancer and melanoma,” explains Patel. “In some cases, melanomas can emerge due to what we call ‘immune escape,’” meaning they sneak through the gates while the immune system is compromised.
This immune suppression can also make melanoma more dangerous. “While
there’s a lot we don’t know, we see concerning patterns with melanoma
being diagnosed at a more advanced state, and progressing faster in
pregnancy,” says Patel. A 2016 study, from the Cleveland Clinic and published in the Journal of the American Academy of Dermatology,
found that women who were diagnosed during or shortly after their
pregnancy were significantly more likely to have tumors spread to other
organs and have the cancer return after treatment.
Another hypothetical reason for melanoma growth in pregnant women: estrogen. “We’ve
had a hunch that, though melanoma is not hormonally driven like breast
cancer or ovarian cancer, there could be hormonal factors that
contribute, especially during pregnancy, to skin changes,” says Patel. It’s a fact that pregnancy can bring on melasma, dark spots on the face, so “we know that hormones are already doing things to the pigment itself in the body,”
Patel continues. Currently, there’s no data proving that extra estrogen
is causing or accelerating melanoma in pregnant women, but researchers
are interested in studying this.
TWO LIVES IN JEOPARDY
When
melanoma metastasizes, or spreads to other organs or lymph nodes, it
requires more complex treatment options. Some of them—like
immunotherapy, more effective than chemo for late-stage skin cancer
—can’t be used during pregnancy because they could put the baby at risk
for an autoimmune disease. “If a patient has metastatic melanoma and
is in her first or second trimester, it’s unlikely she’ll be able to
deliver to term without the melanoma becoming very life-threatening,”
says Patel. Earlier this year, a 30-year-old New Jersey mom died just
three days after an early delivery at six months pregnant, and three
weeks after her diagnosis, from metastatic melanoma that had spread
throughout her body while pregnant.
And though
it’s extremely rare, melanoma is one of the few cancers that can cross
over from the mother into the placenta, affecting the baby. “It’s
tragic when this happens because the baby will usually develop melanoma
within the first year of life, and because the disease is advanced, it’s
always fatal,” says Patel.
PROTECTING MOM AND BABY
If
there is good news, it’s that if caught early—and in general, most
melanomas are—cancer that’s localized to the skin doesn’t generally put a
pregnant woman or her baby at an extra risk, says Justin Ko,
M.D., director of medical dermatology at Stanford Health Care and
clinical associate professor at Stanford University School of Medicine.
Physicians (both dermatologists and many primary-care docs) can safely
perform skin biopsies with local anesthetic during pregnancy, which is
why it’s key to have regular skin cancer checks (especially if you’ve
had it in the past) and report suspicious moles to your M.D.
For
those struggling to get an appointment, it’s crucial to be specific
when calling a derm’s office. Tell the receptionist you’ve been
diagnosed with melanoma and need a removal ASAP, and if you’re pregnant,
make sure to mention the situation is particularly time-sensitive. If
that doesn’t work, demand to speak with a doctor or nurse, and be
persistent
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