ORLANDO – Annual skin exams reduced the rate of advanced keratinocyte carcinoma (KC) after solid organ transplant by 34%, according to a review of 10,198 transplant patients in Ontario, Canada.

Transplant patients have a far higher risk of KC than the general public because of immunosuppression: A quarter of patients are affected within 5 years. Transplant guidelines have recommended annual skin exams.

But just 2.1% of the patients in the review had annual exams, and less than half saw a dermatologist even once during an average of 5 years of follow-up.

Other studies have reported adherence rates of up to 50%, but the numbers were based largely on patient self-report. Instead, the Ontario study used billing codes and other administrative data to get an idea of how many patients actually followed through.

“I would be surprised if other jurisdictions have significantly better rates of adherence,” said lead investigator An-Wen Chan, MD, of the division of dermatology at the University of Toronto and director of a transplant dermatology clinic at the University Health Network.

Part of the problem is that there’s just not a lot of evidence that annual screenings improve KC outcomes, he noted.

To help plug that evidence gap, Dr. Chan and his team reviewed transplant cases in Ontario going back to the mid-1990s; 62% of the patients had kidney transplants, 24% had liver transplants, and the rest had heart or lung transplants. The patients were all aged over 18 years; 60% were white, 15% Asian, 4% black, and the rest unknown. About two-thirds were men.

Adherence to annual dermatology checkups at least 75% of the time was associated with a marked reduction in the development of advanced KC, defined as lesions greater than 2 cm and requiring reconstruction and lymphadenectomy (adjusted hazard ratio, 0.66; 95% CI, 0.48-0.92).

Increasing age at transplant, white race, male sex, and past history of skin cancer were among the factors that were associated with increased risk. There was a trend toward increased risk with liver, lung, and heart transplants, as opposed to kidney transplants. Results were adjusted for demographic, transplant, and other variables.
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In short, “adherence to annual dermatology assessments ... reduced KC-related morbidity and death. The highest risk patients were not necessarily the ones that saw their dermatologist annually,” Dr. Chan said.

Rates of adherence varied across transplant sites. It’s probably less of a problem at the University of Toronto, where Dr. Chan is embedded with the transplant team and where he can educate patients and providers on the importance of annual screening and help ensure that it’s done.

“We have a rigorous skin referral policy in place and really target transplant patients to be seen within a year. Having a dermatologist dedicated to transplant dermatology really helps,” he said. The next step is to define the optimal frequency of posttransplant skin cancer screening and to address barriers to screening.

There was no industry funding for the work, and Dr. Chan had no relevant disclosures.

aotto@frontlinemedcom.com

SOURCE: Chan A et al. IID 2018, Abstract 522.

Sheila Kredit, MD

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