Getting the word out: Derms must educate organ transplant patients, physicians about skin cancer risks

September 1, 2008

Organ transplant patients are at risk for developing skin cancer from immunosuppressive medications given to prevent organ rejection. Better education is needed for both patients and organ transplant teams to encourage compliance with sun-protective measures.

Key Points

St. Louis - Organ transplant patients are at risk for developing skin cancer - up to 65-fold over the general population - yet most of these patients are not using necessary sun protection.

In fact, most patients seem unaware of the increased risk brought on by the immunosuppressive drugs required to prevent organ rejection.

Skin cancer rates are rising in this population, partially because more people are living with functioning organ transplants than ever before. In June 2006, 223,000 people in the United States were living with transplanted organs.

"These days, survival is significantly better," she says.

"The reason they're doing so much better is because of these really wonderful immunosuppressive drugs that we have."

However, these same drugs that allow patients to live after transplantation can lead to skin cancer.

The further out patients get from transplantation, and the higher the dose of medication, the greater the risk for skin cancer. Over time, the immunosuppressive drugs can build up and make cancer.

"Skin cancer is the most common malignancy in organ transplants," Dr. Youker tells Dermatology Times.

Lack of education

The greatest barrier to skin cancer prevention in organ transplant patients is education.

"We need to educate people. This is the problem. We're not educating them well enough. Not only patients and their families, but transplant coordinators - the entire transplant team needs to be educated; primary care physicians as well.

"We need to educate them on how to prevent skin cancers, early detection and aggressively managing them," Dr. Youker says.

Dr. Youker's research shows that most patients do not retain education at the time of transplant. Therefore, dermatologists generally see a small percentage of this population.

The top reason for not seeing a dermatologist is not knowing about the increased risk. In very few cases, patients simply don't want to see yet another doctor.

Verbal information imparted to patients while in the hospital is not enough.

"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 behavior regarding sun protection," Dr. Youker says.

Study results

In a study conducted by Dr. Youker and colleagues, 62 percent of the respondents state that they did not know they were at risk for skin cancer.

Of the 298 patients responding to the survey, 73 percent assert that they were not told about skin cancer risk after transplant.

Therefore, significantly few transplant patients - 21 percent - consult dermatologists following surgery, and only 14 percent receive annual skin exams.

It is no surprise, then, that 28 percent reported wearing sunscreen regularly after transplantation, compared to 22 percent who reported wearing sunscreen before surgery.

Patients give many reasons for not using sunscreen. "I forgot to put it on" and "I don't think it is important to use sunscreen" are most common.

Timing

Patients cannot be expected to recall information about skin cancer risks given at the time of surgery, when immediate concerns take precedence over long-term safety, Dr. Youker says.

"They don't care about skin cancer. They're just trying to get through the day," she says.

However, this information is equally vital, as "skin cancer in transplant patients tends to be more aggressive and metastasize more quickly" than in the general population, she says.

"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 population," she says.

A better approach, she says, is "intensive, repetitive, written education," which can increase compliance with dermatologic follow-up.

Dr. Youker suggests "all transplant patients be referred to dermatology for initial skin screening, assessment of risk factors, and detailed education."

Dr. Youker also urges physicians to learn more about skin cancer risks from the AT-RISC (After Transplant Reduce the Risk of Skin Cancer) Alliance, a collaborative effort of the International Transplant Skin Cancer Collaborative, the International Transplant Nurses Society and the Transplant Recipients International Organization, which provides free educational materials to healthcare workers and patients.

Disclosure: Dr. Youker reports no relevant financial disclosures.

For more information: http://www.at-risc.org/