Skin cancer surveillance in renal transplant recipients

P N Harden, S M Reece, A A Fryer, A G Smith, H M Ramsay

The risk of non-melanoma skin cancer is increased after organ transplantation, with a prevalence and annual incidence for the United Kingdom reported at 16.5% and 7.1?10.6% respectively.^{1 2} Non-melanoma skin cancer presents at an earlier age and spreads more rapidly in people who have received a transplant than in the general population, and it often occurs at more than one site. These factors result in substantial morbidity and a sevenfold increase in mortality from the disease, although absolute death rates are low.³ The high incidence, rapid growth, and increased metastatic potential of non?melanoma skin cancer in transplant recipients justifies a surveillance programme.^{1 3} We did a survey to establish current practice in skin cancer surveillance in UK centres managing renal transplant recipients.

Methods and results

We sent a questionnaire to 65 UK centres that follow up renal transplant recipients. The questionnaire asked whether they did skin cancer surveillance, which staff did the surveillance, and what the policy was for educating patients about the risk of skin cancer.

Sixty one centres (26 surgical and 35 nephrology centres) responded, collectively managing 16 264 renal transplant recipients. Among the 61 respondents, 31 were consultant nephrologists or transplant surgeons and 24 were specialist renal transplant nurses. The table shows the results of the questionnaire. On?site dermatology facilities were available in 54 centres. Thir? teen centres did annual surveillance for skin cancer—by a dermatologist (2 centres), nurse practitioner (4), neph? rologist or transplant surgeon (4), and a combination of nurse and nephrologist (3). Annual full skin examina? tion (patient undressed to their underwear) was done in 12 of these 13 centres. Patients were educated about skin cancer before transplantation in 36 centres and after transplantation in 51. The mean number of transplant recipients followed up was significantly higher in surgical centres than in nephrology centres (P < 0.0001) (table). Furthermore, a higher proportion of surgical centres provided education for patients (table). We found no difference in the proportion of surgical or nephrology centres that provided skin cancer surveil? lance, full skin examination, or specific training for clini? cians performing surveillance (table), regardless of the size of the unit (data not shown).

Comment

Skin cancer surveillance is available to only a minority of UK renal transplant recipients. We found no differ? ence between surveillance strategies in surgical and nephrology centres.

Guidelines for annual screening of renal trans? plant recipients for non?melanoma skin cancer were recently established in the United States.³ Clinicians doing surveillance must have adequate training to maintain clinical competence; current levels of training are inadequate. Non?melanoma skin cancer often occurs on covered body sites (20% of cases¹ ); such lesions could be missed in centres doing only limited skin examination.

Although advice and literature on avoidance of ultraviolet light are given at the time of transplantation, only a minority of patients remain aware of the risks and adopt adequate sun protection measures long term.⁵ Education of patients should start as soon as transplantation is recognised as a potential treatment and should continue long term.

All transplant recipients should have skin cancer surveillance, and all clinicians (general practitioners, specialist physicians and surgeons, and nurses) caring for transplant recipients should be aware of the risks. The higher prevalence of non?melanoma skin cancer in renal transplant recipients compared with the gen? eral population is largely due to long term immunosuppression. The prevalence of skin cancer is therefore also likely to be increased in patients taking immunosuppression for a range of non?renal clinical conditions.

P N Harden, nephrologist,
Email: pnharden@netscape.net

S M Reece, research nurse, Department of Nephrology, North Staffordshire Hospital, Stoke on Trent ST4 7LN

A A Fryer, biochemist, Department of Biochemistry, North Staffordshire Hospital

G Smith, dermatologist,

H M Ramsay, dermatologist, Department of Dermatology, North Staffordshire Hospital


studentBMJ 2001;09:399-442 November ISSN 0966-6494

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3. Kasiske BL, Vazquez MA, Harmon WE, Brown RS, Danovitch GM, Gaston RS, et al. Recommendations for the outpatient surveillance of renal transplant recipients. J Am Soc Nephrol 2000;11:S1?86.
4. Seukeran DC, Newstead CG, Cunliffe WJ. The compliance of renal trans? plant recipients with advice about sun protection measures. Br J Dermatol 1997;138:301?3.