SkinCancerNet Article
Organ Transplant Increases Risk of Skin Cancer
Sun protection, close follow-up, and early intervention vital

In study after study, the finding is the same. Organ-transplant recipients have an increased risk of developing skin cancer, and with each passing year, this risk grows. Some dermatologists report that these patients tend to develop their first skin cancer 2 to 4 years after the transplant operation.

Why Organ Transplant Increases Risk
The medication taken to prevent organ rejection plays a key role, but it is not the only reason for this increased risk. Unprotected sun exposure, which allows ultraviolet (UV) rays to harm the skin, also affects a person’s risk. The more lifetime sun exposure, the greater the risk. Research shows that 20 years after receiving an organ, recipients who live in a temperate climate have a 40% overall increased risk of developing skin cancer. This risk exceeds 80% in sun-intense areas such as Australia.

Having naturally pale to olive skin and contracting an infection caused by a human papillomavirus (HPV) also seem to increase the risk of an organ-transplant recipient developing skin cancer.

When skin cancer develops in an organ-transplant recipient, multiple skin cancers may appear and the cancer can be more aggressive. An aggressive cancer has greater potential to recur (return after treatment) and to metastasize (spread). Being aware of this and learning what can reduce the risk are likely to improve one’s quality of life.

What Dermatologists Recommend
Since the risk of getting skin cancer jumps significantly after an organ-transplant operation, dermatologists recommend the following:

1. Get a full-body examination before the transplant operation. The purpose of this exam is to detect existing skin cancer and actinic keratoses (AKs), lesions that can progress to squamous cell carcinoma (a type of skin cancer). Skin cancers and AKs are best treated before the transplant operation. Once the person starts taking anti-rejection medication, the body’s immune system cannot work as effectively. This means that existing skin cancer can grow rapidly, making treatment more difficult. With a weakened immune system, skin cancer also may become more aggressive.

2. Wear sun-protective clothing. Organ-transplant patients must take anti-rejection medication for life. This medication suppresses the body’s immune system, so exposure to UV rays significantly increases the risk of developing nonmelanoma skin cancer (any skin cancer excluding melanoma).

   Before going outdoors, dermatologists recommend that people who are organ-transplant recipients put on:

   • A wide-brimmed hat. The brim should encircle the entire hat and be wide enough to shade the face, back of the head, and neck.

   • Long pants

   • Long sleeves

   • Sunglasses

   It is important to wear clothing that effectively blocks harmful UV rays. Several factors affect clothing’s effectiveness, including the weave, color, and fabric. To illustrate, a white cotton T-shirt provides only moderate protection, with an average SPF of 7. At the other end of the spectrum, a long-sleeve dark denim shirt offers excellent sun protection — an estimated SPF of 1,700. In general, the tighter the weave, the more sun protection.
   
   Color also plays a key role. Darker colors offer more protection than lighter colors. While a white cotton T-shirt has an SPF of 7, a green cotton T-shirt provides an SPF of 10. A thicker fabric such as velvet in black, blue, or dark green has an approximate SPF of 50.
   
   An easy way to find out how much sun protection clothing offers is to hold up the garment to a light or sun-filled window. If plenty of light passes through, the clothing does not offer adequate sun protection. Before heading outdoors during the day, be sure to wear clothing that does not let much light through.

3. Apply sunscreen daily. All skin must be protected from harmful UV rays. Before going outdoors, be sure to apply sunscreen to all skin that is not covered by sun-protective clothing.
   
   According to one research study, daily sunscreen use may help prevent skin cancer in organ-transplant recipients. This study suggests that when organ-transplant recipients apply sunscreen every day to all skin that receives any sun exposure such as the face, neck, and forearms, the sunscreen helps prevent and even reduce the incidence of nonmelanoma skin cancer and AKs.
   
   In this study, organ-transplant recipeints freely applied a sunscreen with a sun protection factor (SPF) of 50 to all skin that would receive sun exposure. With daily use, these patients had either: 1) no further progression of skin cancer or 2) a decrease in the number of AKs and invasive nonmelanoma skin cancer.
   
   Dermatologists recommend that organ-transplant recipients apply a sunscreen that provides:

   • UVA and UVB protection (label may say broad-spectrum)

   • An SPF of 30

   • Water resistance (label may say waterproof)

   To be effective, the sunscreen must be applied:

   • 20 minutes before going outdoors

   • Liberally enough to coat the skin. Be sure to cover all exposed areas completely. Pay close attention to the face, ears, hands, and arms.

   • Every two hours when outdoors — even on cloudy days, and after swimming or sweating
      

4. Avoid direct sun exposure. In addition to wearing sun-protective clothing and sunscreen, it is essential that organ-transplant recipients avoid direct sun exposure. With a weakened immune system, the body may not be able to repair damage caused by this exposure, which greatly increases the risk of developing skin cancer.
   
   To prevent direct sun exposure, avoid being outdoors when the sun’s rays are strongest between 10 a.m. and 4 p.m. It also is important to know that extra caution is needed near water, snow, and sand. These reflect the damaging rays of the sun.

5. Avoid tanning beds, sunlamps, and other indoor tanning devices. Indoor tanning is not a safe alternative to the sun. Tanning beds, sun lamps, and other indoor tanning devices emit dangerous UV radiation. Research has found that tanning lamps emit UV rays that can be up to 15 times stronger than the sun. Both UVA and UVB rays have been shown to cause skin cancer.
   
   If looking tan is important, apply a self-tanning lotion or cream that darkens skin without exposure to UV rays.

6. Perform regular self-exams. Learning how to perform this simple exam can be life-saving. Treatment for skin cancer is most effective when begun early. As organ-transplant recipients have an increased risk of developing skin cancer and the skin cancer is more likely to recur or spread, detecting skin cancer in its earliest stage is vital. An organ-transplant recipient is typically shown how to perform this self-exam during the first appointment with a dermatologist.
   
   It is important that patients perform these exams as recommended by the dermatologist and contact the dermatologist’s office immediately if a suspicious lesion is detected.

7. Get regular dermatologic check-ups. In addition to performing regular self-exams, it is vital that organ-transplant recipients have regular dermatologic screenings. The sooner skin cancer can be detected and treated, the better the prognosis.

Preventive Care and Treatment for High-Risk Patients
Some organ-transplant recipients will develop multiple skin cancers. A few will see more than 100 nonmelanoma skin cancers in a year. For these high-risk patients, dermatologists can prescribe medication to help reduce the number of skin cancers and actinic keratoses (AKs) that form. Topical retinoids can reduce AKs and may help prevent skin cancers. Researchers continue to look at the effectiveness and safety of a number of other therapies, including topical chemotherapy, photodynamic therapy, and oral retinoids.

Multi-faceted Approach Improves Quality of Life
While some patients find daily sun protection, regular self-exams, and frequent follow-up frustrating, these remain essential for controlling skin cancer. Organ-transplant recipients often develop particularly aggressive skin cancer. If skin cancer spreads, it can be lethal. Lessening the likelihood of developing skin cancer along with early detection and treatment can greatly improve an organ-transplant recipient’s quality of life.

References:
1 American Academy of Dermatology. Innovative Public Service Advertisement Campaign Sends Strong Message to Teens About Dangers of Indoor Tanning. News release issued October 18, 2006. Last accessed August 16, 2007 at www.aad.org/public/News/NewsReleases/PSA.htm.

2 American Academy of Dermatology. Dermatologists Encourage Consumers to be "Clothes" Minded When It Comes to Selecting Summer Wardrobe. News release issued May 2, 2005. Last accessed August 16, 2007 at www.aad.org/public/News/NewsReleases/Press+Release+Archives
/Skin+Cancer+and+Sun+Safety/Sun+Protective+Clothing.htm

3 American Academy of Dermatology. The Truth About Sunscreens. News release issued October 22, 2003. Last accessed August 23, 2007 at www.aad.org/public/News/NewsReleases/
Press+Release+Archives/Skin+Cancer+and+Sun+Safety/PhotoProtectionRigel.htm

4 Berg D, Otley CC. Skin cancer in organ transplant recipients: Epidemiology, pathogenesis, and management. Journal of the American Academy of Dermatology 2002; 47: 1-17; quiz 8-20.

5 Carucci, JA. Update on Transplant Related Skin Cancer. Presented during a surgical symposium (SYM 308) at the Summer Academy Meeting of the American Academy of Dermatology, August 2007; New York City.

6 Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. The New England Journal of Medicine 2003; 348: 1681-91.

7 Harwood CA, Leedham-Green M, Leigh IM et al. Low-dose retinoids in the prevention of cutaneous squamous cell carcinomas in organ transplant recipients: a 16-year retrospective study. Archives of Dermatology 2005; 141: 456-64.

8 Harwood CA, Proby CM, McGregor JM et al. Clinicopathologic features of skin cancer in organ transplant recipients: a retrospective case-control series. Journal of the American Academy of Dermatology 2006; 54: 290-300.

9 Martinez JC, Otley CC, Stasko T et al. Defining the clinical course of metastatic skin cancer in organ transplant recipients: a multicenter collaborative study. Archives of Dermatology 2003; 139: 301-6.

10 Ong CS, Keogh AM, Kossard S et al. Skin cancer in Australian heart transplant recipients. Journal of the American Academy of Dermatology 1999; 40: 27-34.

11 Ulrich C, Stockfleth E. Prevention and reduction of non-melanoma skin cancer through regular application of sunscreen (SPF 50) in organ transplant recipients. Presented as a poster (P2308) at the 65th Annual Meeting of the American Academy of Dermatology, February 2007; Washington, DC. (Commercial support: None identified.).

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