Serious skin cancers recognized for 30 years as a problem for organ transplant recipients might be prevented by reducing the immunosuppressive drugs transplant patients take, or by eliminating them altogether over time, according to Thomas Starzl, M.D., Ph.D., director of the Thomas E. Starzl Transplantation Institute at the University of Pittsburgh, and a pioneer in the transplantation field.
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George Mazariegos, M.D., and other members of Starzl's Pittsburgh institute reported in 1997 that a study of 59 liver transplant patients concluded that "long-surviving liver transplant recipients are systematically overimmunosuppressed," but that slow drug weaning was possible for many.
Patients with heart transplants may be a different story, however, because rejection can be fatal. "People don't dare cut their drugs," Starzl said.
Alarming Numbers
A skin cancer problem has long been recognized in sunny northern Australia; but even in England, the incidence of squamous cell cancers, in particular, has grown to alarming proportions in organ transplant patients. After 9 years about 40% of 291 patients in a study reported from the Royal London Hospital NHS Trust in London had developed these highly metastatic cancers.
Jan N. Bouwes Bavinck, M.D., reported that the risk of developing skin cancer in renal transplant recipients in Queensland, Australia, was 7% in the year after transplant, 45% after 10 years, and 70% after 20 years of immunosuppression.
In the United States, the overall risk is probably around 35%, according to Starzl, who said that the risk might be slightly lower with patients taking the newer immunosuppressive drug tacrolimus "because it's possible to use much lower doses of steroids," than with azathioprine or cyclosporin.
Clark Otley, M.D., a dermatologist at the Mayo Clinic, said from 35% to 70% of patients who have lived with their organ transplants for 20 years will have developed skin cancers. Otley noted that the rate depends to some extent on patients' geographic location, as well as on the amount of previous sun exposure, whether they have had any skin cancers previously, and on the fairness of their skin.
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Overall, Otley said 6% to 8% of a group of organ transplant patients will have metastatic squamous cell cancer, and from 5% to 7% will die from these cancers. He agreed that the amount of immunosuppression required is probably an important factor in the development of skin cancers.
Such skin cancers, which typically begin on sun-exposed areas like the back of the hand, may be difficult to diagnosis, and skin inspections should be made at least monthly, Otley advised during the annual meeting of the American Academy of Dermatology in New Orleans, where he gave an update on the subject.
"The skin has a very long memory," he added, noting that organ transplant patients must do everything now, including putting sunscreen on all exposed areas, and wearing broad-brimmed hats and other sun protective clothing, to reduce their risk of skin cancers.
He also views the typical 2-year wait for a transplant as "an opportunity for patients to start protecting their skin before they go on immunosuppressive medication."
There is considerable morbidity as well as mortality associated with the non-melanoma skin cancers, whose order of prevalence is reversed in the transplant patients. In these patients, squamous cell, with its potential for metastasis, is the dominant form of non-melanoma skin cancer, whereas the basal cell cancers are more common in the non-transplant population.
Transplant patients also can minimize the skin cancer problem by limiting outdoor activities, according to Otley.
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