Screening of Renal Transplant Patients for Skin Cancer 2008 Report

Gillian M Murphy MD FRCPI FRCP Edin Consultant Dermatologist
Dermatology Department Beaumont Hospital, Dublin 9

Over the past year, the programme to screen renal transplant patients for skin cancer has continued. We have divided patients into risk categories to enable appropriate screening and patient education. The transplant programme for renal transplants continues to expand, and each year, 100–150 additional patients are added to the transplant population. Now more than 3000 patients are enjoying the benefits of transplantation. With long term immuno-suppression and advancing age, skin cancer becomes increasingly common. With early detection such skin cancers are cured by simple surgical removal. For those who are recently transplanted we provide education for all aspects of cancer prevention.

Risk categories include the low risk recently transplanted young patients with no visible sun-induced damage. Such patients are instructed regarding safe behaviour in the sun, appropriate clothing, use of sunscreens and eradication of viral warts. Low risk patients are followed up by the renal physicians and only seen annually by dermatology unless other skin problems occur.

Medium risk patients include those with sun-induced change on the skin indicating high levels of sun exposure, such as actinic keratoses, (scaly spots caused by the sun). Other risk factors might include one skin cancer such as a basal cell carcinoma or well differentiated squamous cell carcinoma. Medium risk patients are usually seen every 6 months and any premalignant lesion are eradicated. Preventative measure for such patients may include the use of various creams used to treat recurring sun-damage. Sun protection as above is encouraged on an ongoing basis.

High risk patients are those who have had 2 or more skin cancers, these patients are surveyed carefully to detect any new skin cancers, field change is vigorously treated. Preventative measures such as reduction of immunosuppressive drugs where possible is actively examined. Use of retinoids to halve the numbers of skin cancers is considered, and the possibility of switching to a new class of immunosuppressive drug, mTOR inhibitors is considered. These patients are reviewed every 3–6 months depending on tumour type.

Very high risk patients enter an exponential phase of tumour development, or have aggressive deeply invasive or metastatic disease. Such patients require careful multidisciplinary management which may require total cessation of immunosuppressive drugs and reversion to dialysis.

Thankfully most patients are in the first two categories with only some in the high and very high risk categories. Our screening programme is an essential part of the management of renal transplant patients and we are very grateful for the ongoing support from The Punchestown Charitable Trust which supports the ongoing programme. Currently Mary Laing is supported by this research grant and apart from the screening of patients her work is looking at genetic changes, which contribute to risk for individual patients. Depending on the outcome of this research it may be possible to prevent some risk by taking folic acid as a supplement. However, this has to be proven in clinical studies before we can recommend it.