Timely Skin Cancer Screening After Organ Transplant Still Lacking

Recent skin cancer risk stratification guidelines did not improve rates of timely dermatologic follow-up visits among solid organ transplant recipients, according to an analysis of claims data.

The rate of post-transplant dermatology encounters that met scheduling recommendations in the Skin and UV Neoplasia Transplant Risk Assessment Calculator (SUNTRAC) was no different before or after publication of that risk assessment tool (42.6% vs 42.2%), reported Mackenzie Wehner, MD, MPhil, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues.

“More very high-risk patients followed SUNTRAC than medium- and high-risk patients,” they detailed in a JAMA Dermatology research letter. Pre-transplant dermatology encounters or diagnoses of skin cancer, “factors known to raise skin cancer awareness, each increased odds of SUNTRAC adherence 3-fold.”

Skin cancers are the most common malignancy in organ transplant recipients, and SUNTRAC was released in 2019 to guide screening in this setting. Patients classified as high- or medium-risk with the tool are advised to see a dermatologist within 1 year and 2 years of their transplant, respectively, whereas very high-risk patients are advised to see a dermatologist before the transplant and within 6 months of their transplant.

In the study, transplant centers that scheduled those dermatology visits, rather than just giving a recommendation for one, had more success in meeting the guidelines.

“Enhanced multidisciplinary collaboration in patients who have never seen a dermatologist or been diagnosed with skin cancer may promote timely dermatology referrals for SOT [solid organ transplant] recipients, especially medium- and high-risk patients,” Wehner and co-authors suggested.

Using data from the Optum Clinformatics Data Mart, the researchers analyzed the timing of dermatology visits from 2011 to 2022 according to SUNTRAC recommendations. Included were 3,177 solid organ transplant recipients (average age 62 years, 67.3% men) with continuous insurance coverage 1 year before and after transplant. Kidney transplants were most common among the study population, at 48%, followed by liver (23%), heart (14%), and lung (13%) transplants.

The SUNTRAC tool classifies solid organ transplant recipients as being at medium (7-13 points), high (14-17 points), or very-high (18-22 points) risk for skin cancer. Notably, white race (9 points) alone categorized patients as medium risk on SUNTRAC. Younger age, other race and ethnicity, and female sex are assigned 0 points and people must have additional SUNTRAC risk factors to meet inclusion criteria for medium to very high risk.

Wehner’s group found that more very high-risk patients (76.6%) followed SUNTRAC, compared with the medium-risk (45.9%) and high-risk (35.5%) patients.

Among the medium-risk group, Black race and ethnicity was associated with decreased likelihood of SUNTRAC adherence (OR 0.31, 95% CI 0.13-0.70).

“This decreased adherence might be influenced by a range of factors, including disparities in access to dermatologic care, lack of skin cancer awareness in populations that traditionally have a lower baseline risk for skin cancer, or other social determinants of health that are not fully captured in the risk calculator,” commented Shoshana Marmon, MD, PhD, a dermatologist at New York Medical College in Valhalla.

“Addressing these disparities and integrating SUNTRAC more actively into care protocols could enhance post-transplant dermatologic outcomes,” she told MedPage Today. “The SUNTRAC tool itself appears useful, but its implementation could benefit from more active integration into post-transplant care protocols, especially for medium- and high-risk patients who currently exhibit lower adherence,” added Marmon, who was not involved in the study.

On multivariable analyses, Wehner’s group found that receiving a prior skin cancer diagnosis or having seen a dermatologist before transplant were each associated with an increased likelihood of SUNTRAC adherence, with respective adjusted odds ratios (aORs) of 3.06 (95% CI 2.23-4.19) and 3.38 (95% CI 2.89-3.96).

SUNTRAC adherence was also increased among women (aOR 1.57, 95% CI 1.34-1.85), those with thoracic transplant (aOR 1.22, 95% CI 1.02-1.46), and those who underwent transplant before the age of 50 (aOR 1.26, 95% CI 1.02-1.57).

Among those predictors of follow-up adherence, only thoracic transplant turned out to be a factor associated with elevated skin cancer risk, reported Wehner and colleagues.

The authors acknowledged study limitations, including use of claims data that lacked dermatology encounter details. Also, COVID disruptions may have affected adherence rates.