African-American organ transplant recipients at risk for skin cancer
A new study from Drexel University College of Medicine suggests all organ transplant recipients, regardless of race, should receive routine, total-body screenings for skin cancer.
Out of 259 nonwhite transplant recipients who were evaluated in the study, 19 skin cancer lesions were identified in 6 percent of the patients. The research was published recently in JAMA Dermatology.
Further, the study shows risk factors for nonwhite transplant recipients likely differ between races/ethnicities — which represents an important shift in how dermatologists approach minority patients. Doctors should keep these unique characteristics in mind when examining and counseling nonwhite patients about prevention strategies, said Christina Lee Chung, MD, associate professor of dermatology in the College of Medicine and director of the Drexel Dermatology Center for Transplant Patients.
"Once physicians began to realize there was a significant number of transplant patients dying from skin cancer, there was a push to prevent it. But much of the field has focused on trying to decrease the morbidity of the Caucasian transplant population, which is more susceptible to skin cancer overall," said Chung, the study's principal investigator. "This is the first research of its kind to look at a diverse population of nonwhite transplant recipients and how skin cancer affects them."
Squamous-cell carcinoma of the skin is 65- to 250-times more frequent in patients who have received an organ transplant, due to the side effects of the anti-rejection medications they are prescribed. Skin cancers in transplant patients also tend to be more aggressive and more deadly.
There are currently no guidelines that require transplant patients to be screened for skin cancer pre- and post-operation. At some centers, Chung said, fair-skinned patients are encouraged to receive a full-body evaluation from a dermatologist. While black transplant patients, on the other hand, may only be sent to a specialist if a suspicious lesion is identified. And while a white patient may be screened yearly, a black patient is likelier to either never or only be evaluated one time post-transplant.
"Overall, people tend to believe that dark-skinned patients can't get skin cancer," Chung said. "But they are taking the same immunosuppressant drugs as their white counterparts."
The Drexel Dermatology Center for Transplant Patients — which opened in 2011 — is uniquely positioned to track the rates of skin cancer in nonwhite patients. As one of the only models of its kind, the center provides coordinated, post-transplant dermatological care to every single patient who receives a transplant at Hahnemann University Hospital or who is managed by the Drexel transplant program. That means each patient, regardless of race, is screened annually for skin cancer.
With a large African-American, Asian and Hispanic patient population, Drexel researchers were able to perform a retrospective medical record review of 259 nonwhite transplant recipients who had visited the center between 2011 and 2016.
They found six black patients, five Asian patients and four Hispanic patients presented with 19 different cancerous lesions. Interestingly, the predominant type of skin cancer diagnosed within the group was in the "in situ" stage, which means it was caught in its earliest form. No black patients were diagnosed with a late-stage skin cancer.
This suggests that screening for skin cancer early and often can prevent it from becoming more aggressive, which touts the Drexel Dermatology Center for Transplant Patients as a successful model that Chung hopes can be replicated throughout the country.
Finally, the researchers found that the majority of skin cancers in black transplant patients were found in the groin-genital area, and most of those lesions tested positive for high-risk human papillomavirus (HPV). For the Asian population, sun exposure appeared to be the most significant risk factor for skin cancer.
The potential association between HPV and squamous-cell carcinoma warrants careful examination of the groin, genitalia and perianal area in search of early lesions, the study authors write. The finding also suggests there may be significant differences in risk factors pertaining to the development of skin cancer between white and black organ transplant recipients.
"If you're spending all of your time counseling your black patients about sunscreen, you're probably missing more important aspects of skin cancer prevention," Chung said.
Instead, she added, consideration should be given to administering the HPV vaccine to all patients prior to transplantation. In addition, black patients, and especially those with a history of HPV, should be taught how to identify potential cancerous lesions in their groin areas.
"The ultimate takeaway is that though people of color are at decreased risk for skin cancer, but they're not not at risk. And those people have different risk factors," Chung said. "So when you see a person of color who is a transplant patient, you need to approach them differently, depending on their skin type and tone, where they are from and their medical history."