Expert Panel Develops Guidance to Manage Skin Cancer in Organ Transplant Patients

Jennifer DeSimone, MD, is board-certified in dermatology practicing at Inova Melanoma and Skin Cancer Center. Dr. DeSimone specializes in skin lymphomas and high-risk skin cancers. Her goal is to help educate her patients about skin cancer etiology, management and importantly, prevention.

Cutaneous squamous cell carcinoma, the second most common form of skin cancer, is a concern for solid organ transplant patients with fair skin, but guidelines are lacking on prevention and treatment.

Patients that receive solid organ transplants often take immunosuppression drugs to prevent rejection throughout their lives. Transplant patients with fair skin are also at an elevated risk for developing a very common form of skin cancer (cutaneous squamous cell carcinoma (CSCC)) than the typical population. Despite the need, dermatologists lack clear guidance on how to prevent disease in this population.

An international group of dermatology and transplant experts have reached consensus on guidelines on how to manage and treat transplant patients with CSCC. The results were published in the September issue of JAMA Dermatology.

In 2004, the International Transplant Skin Cancer Collaborative issued guidelines on the management of CSCC in patients, which focused on managing existing disease rather than prevention. To update this approach, an international group of experts assembled during the 2018 International Immunosuppression and Transplant Skin Cancer Collaborative meeting to perform a Delphi study to develop consensus-based medical management decisions in the prevention of skin cancer in transplant patients. The Delphi method is an iterative survey tool to build consensus among experts when uncertainties exist to identify the most agreed upon preventive and treatment recommendations.

As a first step, a working group was established to create an actinic keratosis (AK) damage and skin cancer index (AD-SCI). They identified six stages — Stage 1: photo damage of skin only; Stage 2: discrete AKs; Stage 3: field cancerization; Stage 4: first invasive low-risk CSCC; Stage 5: multiple invasive low-risk CSCCs; and Stage 6: high-risk CSCC. The index was presented at the Skin Care in Organ Transplant Patients Europe in 2019.

To evaluate the best guidance across the index spectrum, 74 participants from 13 countries were selected to participate in the Delphi study. The participants were board certified in dermatology, had at least five years of experience after residency in treatment of transplant patients, and maintained an active membership in an appropriate professional organization.

For the first survey, 50 respondents provided input, while 48 and 46 participants provided input for the second and third surveys respectively. A steering committee reviewed and interpreted data from each round of the Delphi process and released results after each survey.

Through the Delphi process, the expert panel produced management recommendations for five of the six AD-SCI stages.

Stage 1 recommendations included education, sun protection strategies, sunscreen, and/or skin surveillance.

Stage 2 recommendations for thin scattered AK include cryotherapy as a first-line treatment and lesion-directed therapy for thick scattered AKs. For thin, grouped AK lesions, they recommend field therapy while thick lesions should be treated with the lesion-directed therapy followed by cryotherapy and field therapy.

Stage 3 recommendations include lesion-directed therapy followed by field therapy using a fluorouracil-based modality.

Consensus was not achieved for the Stage 4, and no management recommendations were provided.

Stage 5 recommendations include oral chemoprevention followed by oral chemoprevention with acitretin. The treating physician is encouraged to coordinate with the patient’s transplant team regarding modification of immunosuppression.

Stage 6 recommendations include oral chemoprevention with acitretin. The treating physician is encouraged to coordinate with the patient’s transplant team regarding modification of immunosuppression.

By developing areas of consensus, physicians can employ best practices regarding prevention of CSCC in patients who received an organ transplant; however, the developed guidelines were based on limited and sometimes contradictory evidence in real-world clinical experience across a range of CSCC disease severity.

Future studies and clinical trials aimed at assessing optimal management are needed, which will require input from experts in transplant medicine.

Jennifer A. DeSimone, MD, in Dermatology at Inova Schar Cancer Institute, participated in this study. She was joined by colleagues from 55 institutions on the paper titled, “Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients.”