Duke researchers published a study last month analyzing the potential relationship between reported cases of skin cancers in tattooed skin over time, which opened up opportunities for future research to improve patient health outcomes.
The study was conducted by Jamie Lebhar, now a preliminary intern at the Duke School of Medicine hoping to specialize in dermatology, but then a third-year medical student when she began researching the subject in 2022.
Lebhar’s interest in the topic was sparked by an interesting patient case encountered by her research advisor, Paul Mosca, associate professor of surgery at the School of Medicine and surgical oncologist at the Duke Cancer Center. The patient had developed a “rather large” squamous cell carcinoma — a type of epidermal cancer — around 14 centimeters in diameter within their tattoo.
“Is there an association between skin cancer and tattoos? Ha[ve] there been studies on this?” Lebhar recalled asking. “… There hasn't been a very recent systematic review that’s been investigating the question … so I thought it would be a good time to look into [the topic].”
Although the study revealed an increased frequency of published cases of skin cancers within tattoos over time, the findings do not necessarily point to a causal relationship between skin cancer and tattoos.
Mosca underscored the importance of not overinterpreting or misinterpreting the study’s conclusions.
“[Tattoos are] like all other personal choices,” he said. “I think it's important for people to educate themselves about all the potential options, as well as the positives and potential downsides and just be sure they go to a safe, reputable place.”
The systematic review sheds light on critical issues and questions related to the diagnosis of skin cancer in tattooed skin, and Mosca identified several areas of interest for future study.
“One of the most obvious questions … is whether tattoos may impact the ability to reliably and consistently diagnose skin cancers at the earliest possible stage … in light of the concern that tattoo pigment could potentially mask abnormal skin lesions from clinical detection,” Mosca said.
He added that the presence of tattoo ink could also affect the ability of doctors and patients to monitor skin cancers and pointed to improved surveillance and lesion diagnostic techniques as possible areas for future study.
Mosca also advocated for a “high-quality, large-scale, epidemiologic study” to examine the possible correlation between different subtypes of skin cancer and certain tattoo inks.
Both Mosca and Lebhar emphasized that more research is needed to understand the full relationship between tattoo ink and skin cancer.
Mosca noted that one of the study’s limitations was publication bias. The report identified just 160 cases of skin cancer arising within tattoos published in the scientific literature since 1938. In contrast, more than 5 million new cases of basal and squamous skin cancer — which account for the vast majority of all skin cancers — are diagnosed every year.
This disparity presents challenges for researchers like Lebhar, who faced difficulties in obtaining a comprehensive dataset. She also pointed to other challenges, including language barriers, which forced her “to exclude [the papers] from the study.”
Looking forward, Lebhar hopes the study demonstrates the need for further investigation.
“This paper is a call to attention on this topic, so that if these cases do arise, people do report it … so that someone can perform a review and compile all the information to investigate the patient and tumor characteristics to see if there’s a difference,” she said.
Mosca echoed the sentiment, calling for additional research motivated by “empathy.”
“Patient stories like this I think certainly should elicit, at a minimum, empathy and a desire to strive to learn to understand more and think about whether there are ways of improving care of patients,” he said.
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