Skin Color Matters in Everyday Cancer Care

By Stephanie DeMeyer, MA, Elaine S. DeMeyer, RN, MSN, AOCN®, BMTCN® - Last Updated: December 22, 2022

Oncology nurses must continually examine implicit biases to ensure patients receive the best care possible. Therefore, skin color matters when making decisions in cancer care. You have likely heard of racial bias and its impact on morbidity and mortality rates for patients of color. However, there is a subset of racial bias called “color bias” that nurses also need to be aware of due to its potential clinical impact.   

How Is Color Bias Different Than Racial Bias? 

Racial bias is a more significant systemic problem, and color bias is a type of racial bias. For example, racial bias affects cancer prevention and detection. Research shows that the overall cancer screening rate is lower among people of color than their White counterparts. However, color bias is more specific than racial bias. An example of color bias is that subtle graft-versus-host disease (GVHD) erythema may be challenging to assess on darker skin colors if health care professionals lack an understanding of color differences.     

Color bias reveals the inadequate education and training on darker skin tones that make it challenging to provide equitable care to all patients regardless of skin color. Clinical trials, publications, scales for grading, and normal ranges for test results mainly have been based on information from a White population. If you recognize where the science came from, you will know where it might fall short in being inclusive of your patient. For timely interventions, oncology nurses must identify and intervene in different clinical manifestations of all skin colors.  

What Are Examples of Color Bias? 

Although more effort is moving toward inclusivity, cancer care teams must realize the limitations of current information that is not color sensitive. The following are just 2 examples of color bias. 

  • Dermatology. Skin changes are a prime example of color bias in health care. Frequently, photographs of actual patients are used to help health care professionals identify skin conditions. Unfortunately, these photos overwhelmingly skew toward lighter skin colors. For example, in a 2020 study, researchers found that 92% of articles published about COVID-19–related dermatologic manifestations used pictures of the Fitzpatrick I-III skin type (ivory through light brown). In addition, even though Black people made up 13.4% of the population, more than double the COVID-19 cases (30%) occurred in Black patients at the time of publication—a clear example of racial bias.  

In an article in the New York Times, Jenna Lester, MD, director of the Skin of Color Program at the University of California, San Francisco, said, “If you’re only trained to look at something in one color, you won’t recognize it in another color.” Tools like visualDx focus on curating an image library of medical conditions on all skin types to help health care providers make better diagnoses for their patients of color.  

  • Pulse oximeters. An FDA panel discussed several studies that found pulse oximeters register higher oxygen level readings in people with darker skin tones. Unfortunately, darker skin color interferes with the light passing through the fingertip, leading to inaccurate results. Studies dating back to 1990 have tried to bring attention to this issue; the COVID-19 pandemic was a catalyst to bring it into the spotlight.  

During the pandemic, blood oxygen levels were used to make critical care decisions, and inaccurate readings could have contributed to the higher mortality rate for people of color. For example, a University of Michigan study found that patients “who received inaccurate oximeter readings posted saturation levels of 92% to 96%, when their levels were 88%, meeting the 90% or below the threshold for oxygen therapy set by the CDC.” As a result, the FDA is currently examining how to improve pulse oximeter testing, regulation, and use for care decisions.  


How Can Oncology Nurses Help Fight Color Bias?  

Take the time to educate yourself and your colleagues on color bias and its impact on patient care. Oncology nurses must be aware of the shortcomings of current medical information. For example, the science to define “normal” does not comprise America’s racial makeup. Instead, it is based on a very limited White sample. If you know this occurs, you can intervene until science catches up. Oncology nurses must be more “color aware” to close the gap toward health equity.  


Implicit Bias and Racial Disparities in Health Care 

Quality of Life in Patients With Skin of Color and Chronic Graft-vs-Host Disease 

Identifying Diagnostic Bias in Skin of Color 

Dermatology Has a Problem With Skin Color 


Pulse Oximeters Are Inaccurate in People With Darker Skin, Studies Suggest. Now the FDA Is Reviewing. 

Pulse Oximeters Are Less Accurate in Hospitalized Black Patients