Dr Rajiv Nijhawan: Immunosuppression Increases Skin Cancer Risk Among Transplant Patients

With immunosuppression, self-regulatory mechanisms may start to decrease, and these are the patients who develop skin cancers more frequently, said Rajiv Nijhawan, MD, associate professor of dermatology and Mohs surgeon at UT Southwestern (UTSW) Medical Center and director of the UTSW High Risk Skin Cancer Transplant Clinic, in Dallas, Texas.

Nijhawan is one of several clinicians presenting “Pearls for Surveillance and Management of High Risk Skin Cancer Patients,” which addresses skin cancer risk among organ transplant recipients, at the American Academy of Dermatology Virtual Meeting Experience.

Transcript

Why are organ transplant patients at higher risk for skin cancers?

A lot of it is driven by the immunosuppression. When patients are starting on immunosuppressive medications—and this isn’t necessarily just purely related to transplant, we just happen to see this in transplants—sometimes patients are on the same medications for other disease processes, other inflammatory disease processes. But we definitely see it at an increased level within the transplant population.

These medications prevent them from rejecting their new heart, their new lungs, because in a way that's foreign to them. It's not their native heart, their native lung. It's kind of a balancing act, where the transplant teams want to make sure that the body doesn't reject these new organs that are really meant to prolong their life. But with that comes immunosuppression, and immunosuppression means it suppresses their immune system so they're not necessarily able to fight infections as well. But also, our bodies also take care of skin cancers and precancers, let's say, and sometimes we're able to have this regulatory mechanism where if some cells start to go awry, our body can keep it in check and make sure they don't get worse in any way.

But with the immunosuppression, unfortunately, our checking mechanisms, our self-regulatory mechanisms start to sometimes decrease in capacity. And so patients who are on these medications, unfortunately, are developing more skin cancers at an increased frequency, because their self-checking mechanisms start to not be at the same level they were pretransplant, let's say. And it’s in the context of their other risk factors, their skin type. If they're fair-skinned individuals, they're at higher risk. If they are out in the sun, they're more likely to burn rather than get a tan, they're at increased risk.

If they have genetic susceptibility, a family history of skin cancer and melanomas; if they’ve had a lot of sun exposure, both chronically throughout life [and] if they're outdoor workers and farmers, and just spend a lot of time outdoors or just tanning in their youth even, that sun exposure history just adds up, unfortunately, and cumulatively puts them at increased risk. Also, if they've had sunburns as a kid or teenagers or in their 20s, you know, blistering sunburns, that increases their risk.

So it's kind of in that patient context of their history, their genetics. But when you add on another level of immunosuppression, it just unfortunately can propel these skin cancers forming more quickly, more rapidly, and, unfortunately, more aggressively as well.