As the number of organ transplants continues to increase throughout the world, so too are the number of organ transplant recipients developing skin cancer. Due in large part to the immunosuppressive medications required to prevent organ rejection, skin cancer among patients receiving solid organ transplants such as kidney, heart, liver, or lung, among other organs also tends to be more aggressive and spreads more quickly than in other patients. Now, new research demonstrates the need for more comprehensive patient education and management of skin disease in transplant patients to try to reverse these rising skin cancer rates.
Speaking today at the 66th Annual Meeting of the American Academy of Dermatology, dermatologist Summer R. Youker, MD, FAAD, assistant professor of dermatology at Saint Louis University School of Medicine in St. Louis, Mo., discussed the reasons why organ transplant patients failed to see a dermatologist and did not practice proper sun protection, despite educational efforts advising these practices.
"Educating transplant patients about the risk of skin cancer is essential, but multiple studies have shown that education during their hospital stay is not retained by patients and is not enough to change patient behaviour regarding sun protection," said Dr. Youker. "Our findings confirmed that the majority of transplant patients surveyed did not know they were at risk of developing skin cancer, and many of the reasons they gave for not practicing proper sun protection or seeing a dermatologist could be remedied by developing an intensive educational approach that raises awareness of the prevalence of this real health threat."
In 2006, there were 29,000 solid organs transplanted, contributing to a total of 223,000 people living with functioning organ transplants in the United States at the end of that year. The incidence of skin cancer in solid organ transplant recipients is up to 200-fold that of age-matched controls due mostly to the required immunosuppressive medications. Dr. Youker cited studies that show that as many as 82 percent of kidney transplant recipients develop skin cancer 20 years after transplantation, and a study of Australian heart transplant recipients found that 27 percent of deaths occurring four years after transplantation were due to skin cancer.
In Dr. Youker’s study, a total of 298 solid organ transplant patients (65 percent males and 35 percent females) who attended the outpatient transplant clinics at Saint Louis University completed a two-page survey to evaluate their comprehension of skin cancer risk, their compliance with skin cancer preventive measures, and their attitudes about sunscreen use and skin screenings. Dr. Youker reported that 62 percent of respondents did not know they were at risk for skin cancer, and 73 percent of respondents stated that they were not informed about the risk of skin cancer following their organ transplant. In fact, only 21 percent of patients had seen a dermatologist since their transplant, with even less (14 percent) receiving annual skin exams.
Of the reasons respondents gave for not seeing a dermatologist, 64 percent said they "did not know about the increased risk" and 7 percent said that they "do not want to attend another doctor’s appointment." Only 28 percent of respondents reported wearing sunscreen regularly, a slight increase from 22 percent who reported wearing sunscreen regularly before transplantation.
Reasons for not wearing sunscreen varied widely among survey participants 33 percent responded "I forget to put it on," 25 percent said "I don’t think it is important to use sunscreen," 16 percent said they are "not in the sun very much," 11 percent said "I like looking tan," 8 percent said they "don’t like the way it feels," and 5 percent said it "takes too much time to put on."
"Because the time around an organ transplantation is consumed with the more pressing issues of rejection and infection, patients cannot be expected to recall information regarding the risks of sun exposure," explained Dr. Youker. "Clearly, another method of informing patients of this risk is needed preferably one involving dermatologists, who can assist the transplant team with strategies to educate and treat this high-risk patient population."
Dr. Youker cited a related study, "Educational Outcomes Regarding Skin Cancer in Organ Transplant Recipients," published in the June 2006 issue of the Archives of Dermatology, that found that the patients who received an intensive educational program in which written reminders reinforced the risk of skin cancer fared significantly better in terms of complying with the recommended sun protection tips than those patients who did not receive this education.
"Regular correspondence with transplant patients concerning the risk of skin cancer and referral to a dermatologist for initial skin screening, assessment of risk factors and detailed education about skin cancer prevention could help reduce the incidence of skin cancers in these patients," added Dr. Youker.
Sun exposure is the most preventable risk factor for skin cancer. The Academy recommends that everyone follow these sun protection guidelines:
- Generously apply a water-resistant sunscreen to all exposed skin using a Sun Protection Factor (SPF) of at least 15 that provides broad-spectrum protection from both ultraviolet A (UVA) and ultraviolet B (UVB) rays. Re-apply every two hours, even on cloudy days, and after swimming or sweating.
- Wear protective clothing, such as a long-sleeved shirt, pants, a wide-brimmed hat and sunglasses, where possible.
- Seek shade when appropriate, remembering that the sun’s rays are strongest between 10 a.m. and 4 p.m. If your shadow is shorter than you are, seek shade.
- Use extra caution near water, snow and sand as they reflect the damaging rays of the sun which can increase your chance of sunburn.
- Protect children from sun exposure by applying sunscreen.
- Get vitamin D safely through a healthy diet that may include vitamin supplements. Don’t seek the sun.
- Avoid tanning beds. Ultraviolet light from the sun and tanning beds can cause skin cancer and wrinkling. If you want to look like you’ve been in the sun, consider using a sunless self-tanning product, but continue to use sunscreen with it.
- Check your birthday suit on your birthday. If you notice anything changing, growing, or bleeding on your skin, see a dermatologist. Skin cancer is very treatable when caught early.
(Source: 66th Annual Meeting of the American Academy of Dermatology: American Academy of Dermatology: February 2008)