Skin Cancer in Renal Transplant Patients 2009

Screening of Renal Transplant Patients for Skin Cancer
2009 Report

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

In the year 2009 our ongoing screening programme for renal transplant patients has gone from strength to strength. The programme to screen renal transplant patients for skin cancer has been greatly assisted by the decision in 2008 to divide 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.

More than 3200 patients are enjoying the benefits of transplantation. Most newly transplanted patients have excellent quality of life and few complications. We have new renal physicians now in Beaumont Hospital all very aware of the need for patient surveillance and are seeing patients earlier in their transplant lives to educate them on the need for protection from the sun. With early detection skin cancers are cured by simple surgical removal. For those who are recently transplanted we provide education for all aspects of cancer prevention. My experience is that patients are now much better informed about safe behaviour.

As in the previous report, 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.

In the last year a new multidisciplinary group has been convened to discuss optimal management for patients with complicated skin cancers. Thus patients get world class management with all relevant doctors meeting together to discuss how best to treat such patients. New treatments are also on the horizon and studies continue to ensure Irish transplant patients receive the best treatment.

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 now 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. Mary Laing, who has been very helpful in screening transplant patients in the last year will return to do this again this coming year enabling us to continue to offer Beaumont patients the best of care from a dermatology point of view.