Rural Residency Status in South Dakotans is Not Associated With More Advanced Stage Melanoma at Time of Diagnosis.

Previous studies have established that geographic location strongly influences health literacy, access to care, and health outcomes across all disease types. There are many well-understood risk factors for the development of melanoma, and likewise various markers of disease severity. However, few studies have been conducted to determine what role locality and access to dermatological care play in both the incidence and severity of melanoma, particularly in South Dakotans. Here, it is hypothesized that living in rural regions with less access to care increases the risk for more advanced stage melanoma at time of diagnosis. A retrospective chart review of the electronic medical records of patients with a diagnosis of melanoma from a Midwest dermatology practice in South Dakota was performed. The authors examined patients' rural vs. urban status, disease predictors, and markers of disease severity. Multivariate and descriptive statistical analysis were utilized. There were 148 unique cases identified. The average age was 62.32 (SD=16.69, min=25, max=98); 53.4% were male (n=79); 99.3% were Caucasian. Among them, 35 (23.6%) had a personal history of non-melanoma skin cancer (NMSC), 9 (6.1%) had a personal history of melanoma, and 20 (13.5%) had a family history of melanoma. Most cases (75.7%) had at least one documented visit to a primary care physician (PCP) within a year of melanoma diagnosis. When comparing geographic distance to the Breslow depth at time of biopsy, a significant negative relationship (p=0.009) resulted. However, when eliminating 3 outliers (Breslow depths of 22.2mm, 19.0 mm, and 15.0mm), this relationship was no longer significant (p=0.141). No significant findings resulted when comparing geographic distance to provider site for wide lesion excision (WLE) to post-WLE Breslow depth (p=0.778), pathological stage (p=0.079), +/- sentinel lymph node biopsy (p=0.299), or +/- chemotherapy/radiation (p=0.191). When comparing disease predictors to severity markers of disease, the only significant finding was between personal history of melanoma and post-WLE Breslow depth (p=0.026). Those without a personal history of melanoma had greater (3.08 vs 1.68) post-WLE Breslow depth. Prior studies indicate increased distance to a dermatologist and decreased density of dermatologists represent significant associations with Breslow depth and mortality. In contrast, the present data did not appear to indicate a significant difference in melanoma detection or outcomes based on geographic parameters. However, it does support that the density of dermatologists is a more appropriate proxy for melanoma outcomes than is PCP density. The lack of impact based on rural vs. urban status may suggest the current literature is not applicable to all states or populations or that some disparities in access to dermatologists and melanoma treatment may be overcome by factors not investigated presently (e.g. AI, tele-dermatology). Other limitations include analyzing patients within a single health system and a sample population consisting primarily of persons located in the Sioux Falls metropolitan area. With rural South Dakotans representing a significant portion of the population, this state presents an opportunity to identify disparities in access and treatment based on population and community resources.

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