Skin cancer surveillance in renal transplant recipients: questionnaire survey of current UK practice
====================================================================================================

* P N Harden
* S M Reece
* A A Fryer
* A G Smith
* H M Ramsay

The risk of non-melanoma skin cancer is increased after organ transplantation, with a prevalence and annual incidence for the United Kingdom reported at 16.5% and 7.1-10.6% respectively. 1 2 Non-melanoma skin cancer presents at an earlier age and spreads more rapidly in people who have received a transplant than in the general population, and it often occurs at more than one site. These factors result in substantial morbidity and a sevenfold increase in mortality from the disease, although absolute death rates are low.3 The high incidence, rapid growth, and increased metastatic potential of non-melanoma skin cancer in transplant recipients justifies a surveillance programme. 1 3 We did a survey to establish current practice in skin cancer surveillance in UK centres managing renal transplant recipients.

View this table:
[Table1](http://www.bmj.com/content/323/7313/600/T1)

Skin cancer surveillance and education of transplant recipients followed up in 61 surgical and nephrology centres. Values are numbers (percentages) of centres unless stated otherwise

## Methods and results

We sent a questionnaire to 65 UK centres that follow up renal transplant recipients. The questionnaire asked whether they did skin cancer surveillance, which staff did the surveillance, and what the policy was for educating patients about the risk of skin cancer.

Sixty one centres (26 surgical and 35 nephrology centres) responded, collectively managing 16 264 renal transplant recipients. Among the 61 respondents, 31 were consultant nephrologists or transplant surgeons and 24 were specialist renal transplant nurses. The table shows the results of the questionnaire. On-site dermatology facilities were available in 54 centres. Thirteen centres did annual surveillance for skin cancer—by a dermatologist (2 centres), nurse practitioner (4), nephrologist or transplant surgeon (4), and a combination of nurse and nephrologist (3). Annual full skin examination (patient undressed to their underwear) was done in 12 of these 13 centres. Patients were educated about skin cancer before transplantation in 36 centres and after transplantation in 51. The mean number of transplant recipients followed up was significantly higher in surgical centres than in nephrology centres (P<0.0001) (table). Furthermore, a higher proportion of surgical centres provided education for patients (table). We found no difference in the proportion of surgical or nephrology centres that provided skin cancer surveillance, full skin examination, or specific training for clinicians performing surveillance (table), regardless of the size of the unit (data not shown).

## Comment

Skin cancer surveillance is available only to a minority of UK renal transplant recipients. We found no difference between surveillance strategies in surgical and nephrology centres.

Surveillance of individuals with atypical mole syndrome in the general population is well established.4 Such people have an estimated cumulative 10 year risk of melanoma of 11%, compared with a 32% prevalence of non-melanoma skin cancer in transplant recipients.1 Guidelines for annual screening of renal transplant recipients for non-melanoma skin cancer were recently established in the United States.3 We previously showed the benefit of nurse led surveillance in the United Kingdom, which facilitates earlier diagnosis and treatment of non-melanoma skin cancer, with a potential reduction in morbidity and mortality.2 Clinicians doing surveillance must have adequate training to maintain clinical competence; current levels of training are inadequate. Non-melanoma skin cancer often occurs on covered body sites (20% of cases1); such lesions could be missed in centres doing only limited skin examination.

Although advice and literature on avoidance of ultraviolet light are given at the time of transplantation, only a minority of patients remain aware of the risks and adopt adequate sun protection measures long term.5 Education of patients should start as soon as transplantation is recognised as a potential treatment and should continue long term.

All transplant recipients should have skin cancer surveillance, and all clinicians (general practitioners, specialist physicians and surgeons, and nurses) caring for transplant recipients should be aware of the risks. The higher prevalence of non-melanoma skin cancer in renal transplant recipients compared with the general population is largely due to long term immunosuppression. The prevalence of skin cancer is therefore also likely to be increased in patients taking immunosuppression for a range of non-renal clinical conditions.

## Acknowledgments

We thank all of the nephrologists, transplant surgeons, specialist nurses, and transplant coordinators throughout the United Kingdom who completed and returned the questionnaires.

Contributors: PNH conceived and designed the study, wrote the draft manuscript, and is the guarantor for the paper. SMR distributed the questionnaires and liaised with individual units. AAF did the statistical analyses and collated the database. AGS advised on dermatological aspects of the study. HMR helped to design the study. AAF, AGS, and HMR reviewed the draft and final versions of the manuscript

## Footnotes

*   Funding Lord Trafford award from the Royal College of Nursing.

*   Competing interests None declared.
    
    ![Graphic][1]</img> The questionnaire is available on the BMJ's website

## References

1.  1.Ramsay HM, Fryer AA, Reece S, Smith AG, Harden PN.Clinical risk factors associated with nonmelanoma skin cancer in renal transplant recipients.Am J Kid Dis2000;36:167–176.
    
    [PubMed](http://www.bmj.com/lookup/external-ref?access_num=10873887&link_type=MED&atom=%2Fbmj%2F323%2F7313%2F600.atom) 
    
    [Web of Science](http://www.bmj.com/lookup/external-ref?access_num=000088007700023&link_type=ISI) 

2.  2.Harden PN, Fryer AA, Reece S, Smith AG, Ramsay HM.Annual incidence and predicted risk of nonmelanoma skin cancer in renal transplant recipients.Transplant Proceedings2001;33:1302–1304.
    
    

3.  3.Kasiske BL, Vazquez MA, Harmon WE, Brown RS, Danovitch GM, Gaston RS, et al.Recommendations for the outpatient surveillance of renal transplant recipients.J Am Soc Nephrol2000;11: S1–86.
    
    [Abstract/FREE Full Text](http://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiam5lcGhyb2wiO3M6NToicmVzaWQiO3M6MTM6IjExL3N1cHBsXzEvUzEiO3M6NDoiYXRvbSI7czoyMjoiL2Jtai8zMjMvNzMxMy82MDAuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

4.  4.Salopeck TG, Rigel DS, Kopf AW, Bart RS.Atypical mole syndrome: risk factor for cutaneous malignant melanoma and implications for management.J Am Acad Dermatol1995;32:479–494.
    
    [CrossRef](http://www.bmj.com/lookup/external-ref?access_num=10.1016/0190-9622(95)90073-X&link_type=DOI) 
    
    [PubMed](http://www.bmj.com/lookup/external-ref?access_num=7868720&link_type=MED&atom=%2Fbmj%2F323%2F7313%2F600.atom) 
    
    [Web of Science](http://www.bmj.com/lookup/external-ref?access_num=A1995QJ45800012&link_type=ISI) 

5.  5.Seukeran DC, Newstead CG, Cunliffe WJ.The compliance of renal transplant recipients with advice about sun protection measures.Br J Dermatol1997;138:301–303.

 [1]: /embed/inline-graphic-1.gif