Research Questions Inequality Of Skin Cancer Monitoring For Transplant Patients

Main Category: Transplants / Organ Donations
Also Included In: Dermatology;  Cancer / Oncology
Article Date: 05 Sep 2008 - 0:00 PDT

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Kidney transplant patients, one of the most at-risk groups for skin cancer, are not being sufficiently educated or monitored for the disease, according to new research.

Kidney transplant recipients are three times more likely to develop skin cancer than people who have not received a transplant. 30 percent of UK renal (kidney) transplant recipients (RTRs) will go on to develop non-melanoma skin cancer, the most common type, within 10 years. This is because immunosuppressive drugs that prevent the body rejecting the transplanted organ, also increase the risk of skin cancer.

A study due to be released in the British Journal of Dermatology next month surveyed 56 UK centres, treating 82 percent of the population's kidney transplant recipients, to see how many offered routine screening for skin cancer and what level of education was provided to patients about the disease. The same survey was conducted in Australia to compare procedures in both countries.

The researchers, based in Sheffield and Oxford in the UK and Melbourne in Australia, found that in the UK only 66 percent of centres managing RTRs provide annual skin cancer surveillance. In contrast, 97 percent of centres in Australia offer skin cancer screening.

Of UK centres offering surveillance, only 59 percent provide full skin examination (39 percent of all centres). According to the researchers, 20 percent of non-melanoma skin cancers in UK kidney transplant patients arise on body sites covered by clothes.

81 percent of the UK staff conducting the skin checks are not dermatologists, and less that a third (30%) of these non-dermatologists have received any formal training for the role. Training ranged from just one day to six months. In comparison, only 40 percent of staff in Australia conducting the checks are non-dermatologists.

One possible explanation provided by the researchers is the higher availability of dermatology services in Australia, which is likely to account for the greater involvement of dermatologists in the screening process; there are approximately 53 kidney transplant recipients per Consultant Dermatologist in the UK, compared to just 22 in Australia.

According to NICE guidance on skin cancer*, "patients should be educated about primary prevention of skin cancers", however five percent of UK centres are failing to provide pre-transplant or post-transplant education on skin cancer risk and prevention.

The majority of education was delivered verbally - only 46 percent offered written information before and 66 percent after transplantation. Ideally all patients should be provided with written information, as verbal education at a stressful time, when so much other medical information is supplied, can be forgotten.

However, the study found significant improvements in services when compared to the results of the same survey carried out six years previously. While 66 percent of UK centres offered annual skin cancer surveillance in the latest survey (2006), this is a three-fold increase from 2000, when just 21 percent did so. And 39 percent now provide full skin examinations, compared to just 20 percent in 2000.

This improvement may be in part due to the inclusion of skin cancer services for transplant patients in the 2006 NICE guidance on skin cancer*, which states: "At present there is a paucity of services at regional and supraregional level that specialise in the care of high-risk or special groups, for example transplant patients… A survey of transplant physicians reported that closely integrated and well-coordinated specialist clinics for dermatological management of transplant patients are highly effective…. It is likely that there will be a need for a transplant patient skin clinic to be established in each of the existing 28 transplant units in England and Wales."

Dr Seema Garg, Dermatology Registrar at Royal Hallamshire Hospital in Sheffield and one of the researchers, said: "Current guidance recognises the need for non-melanoma skin cancer surveillance and education for organ transplant recipients and recommends the development of dedicated services.

"This survey suggests that there has been a substantial increase in the access to skin cancer surveillance since 2000. It is of concern, however, that one third of UK centres who took part in the survey still do not offer skin reviews routinely and that screening is often done by individuals with no specific training for the role. Training in full skin examinations should be provided. "A range of indices have been created to define those at highest risk, including previous history of skin cancer, duration of immunosuppression, eye colour and skin type. The development and application of these could allow for targeting of surveillance programmes to those at highest risk. This may prove more acceptable and affordable than offering routine surveillance to all."

Nina Goad of the British Association of Dermatologists said: "There appears to be something of a 'postcode lottery' regarding whether or not transplant patients receive screening for skin cancer.

"Routine screening should either be undertaken by or supervised by a dermatologist, ideally in a special transplant patient skin clinic. The current lack of training for this role is of concern.

"All screening should be of the whole body - partial skin checks of visible skin could miss areas that patients find hard to check themselves, for example the back.

"While costs and staffing are obvious factors in the availability of screening services, and resources are needed to implement NICE guidance, education can be provided with very little expense. For example, the British Association of Dermatologists produces information leaflets about skin cancer for transplant patients, which are available free of charge. It would be helpful to patients if more centres took advantage of this.

"It is, however, encouraging that there has been a significant improvement in the availability of these services, and hopefully this expansion will continue."
Matthew Patey, 39, received a kidney transplant in London in 2000. He said: "My treatment was second to none, and I received excellent care throughout. I have never been checked for skin cancer though, and I don't recall receiving any leaflets about my increased risk and how to protect myself. There is some sound advice available on the websites of medical associations, but you do need to know to look for it in the first place. Printed information is helpful as you can review it at a later date, rather than trying to remember everything you're told at an incredibly stressful time."

Key findings:

- Only 66% of centres managing RTRs provide annual skin cancer surveillance, In contrast, 97% of centres in Australia offer skin cancer screening.
- Of centres offering surveillance, only 59% offer full skin examination (39% overall). However, 20% of non-melanoma in UK RTR's arise on body sites covered by clothes.
- 81% of the UK staff conducting the skin checks are not dermatologists, and less that a third (30%) of these non-dermatologists have received any formal training for the role. In contrast, only 40% of staff in Australia conducting the checks are non-dermatologists.
- 5% of centres are failing to provide pre-transplant or post-transplant education on skin cancer risk and prevention.
- The majority of education was delivered verbally - only 46% offered written information before and 66% after transplantation.
- The study's positive findings are that 66% of UK centres offer annual skin cancer surveillance, compared to just 21% in 2000. 39% provide full skin examinations, compared to just 20% in 2000.

Notes

*National Institute for Health and Clinical Excellence "Improving Outcomes for People with Skin Tumours including Melanoma", February 2006.

If using this information, please ensure you mention that the study is being released in the British Journal of Dermatology, the official publication of the British Association of Dermatologists.

For more information please contact: Nina Goad, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355, Email: nina@bad.org.uk, Website: http://www.bad.org.uk

Articles in the BJD can be viewed online: http://www.blackwell-synergy.com/loi/BJD Study details: British Journal of Dermatology, estimated publication date October 2008, "Skin cancer surveillance in renal transplant recipients: re-evaluation of UK practice and comparison with Australian experience." S.Garg, R.P. Carroll*, R.G.Walker*, H.M. Ramsay and P.N. Harden¹; Dept of Dermatology, Royal Hallamshire Hospital, Sheffield, UK; *Department of Nephrology, Royal Melbourne Hospital, Australia; ¹Oxford Kidney Unit, Churchill Hospital, Oxford, UK; DOI: 10.1111/j.1365-2133.2008.08837.x

The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease.

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