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Original Investigation
March 2017

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States

Giorgia L. Garrett, MD1; Paul D. Blanc, MD, MSPH1; John Boscardin, PhD1; et al Amanda Abramson Lloyd, MD2; Rehana L. Ahmed, MD, PhD3; Tiffany Anthony, MD4; Kristin Bibee, MD, PhD5; Andrew Breithaupt, MD6; Jennifer Cannon7; Amy Chen, MD8; Joyce Y. Cheng9; Zelma Chiesa-Fuxench, MD, MSCE10; Oscar R Colegio, MD, PhD9; Clara Curiel-Lewandrowski, MD11; Christina A. Del Guzzo, MD12; Max Disse3; Margaret Dowd, MD12; Robert Eilers Jr, MD13; Arisa Elena Ortiz, MD13; Caroline Morris, BA14; Spring K. Golden, MD15; Michael S. Graves, MD2; John R. Griffin, MD4; R. Samuel Hopkins, MD15; Conway C. Huang, MD16; Gordon Hyeonjin Bae, MD4; Anokhi Jambusaria, MD7; Thomas A. Jennings, MD, PhD16; Shang I. Brian Jiang, MD13; Pritesh S. Karia, MPH17; Shilpi Khetarpal, MD18; Changhyun Kim, MD19; Goran Klintmalm, MD, PhD4; Kathryn Konicke, BS20; Shlomo A. Koyfman, MD18; Charlene Lam, MD, MPH18; Peter Lee, MD, PhD3; Justin J. Leitenberger, MD15; Tiffany Loh13; Stefan Lowenstein1; Reshmi Madankumar21; Jacqueline F. Moreau, MD, MS17; Rajiv I. Nijhawan, MD22; Shari Ochoa, MD, MS23; Edit B. Olasz, MD, PhD20; Elaine Otchere, BS2; Clark Otley, MD19; Jeremy Oulton, MS11; Parth H. Patel, BS5; Vishal Anil Patel, MD12; Arpan V. Prabhu, BS5; Melissa Pugliano-Mauro, MD5; Chrysalyne D. Schmults, MD, MSCE17; Sarah Schram, MD3; Allen F. Shih, AB, AM9; Thuzar Shin, MD, PhD10; Seaver Soon, MD2; Teresa Soriano, MD6; Divya Srivastava, MD15; Jennifer A. Stein, MD, PhD21; Kara Sternhell-Blackwell, MD14; Stan Taylor, MD22; Allison Vidimos, MD18; Peggy Wu, MD8; Nicholas Zajdel, BS20; Daniel Zelac, MD2; Sarah T. Arron, MD, PhD1
Author Affiliations
  • 1University of California-San Francisco Medical Center, San Francisco
  • 2Scripps Green Hospital, La Jolla, California
  • 3University of Minnesota Medical Center, Minneapolis
  • 4Baylor All Saints and Baylor University Medical Center, Dallas, Texas
  • 5University of Pittsburgh, Pittsburgh, Pennsylvania
  • 6University of California-Los Angeles Medical Center, Los Angeles
  • 7Mayo Clinic Florida, Jacksonville
  • 8Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 9Yale New Haven Hospital, New Haven, Connecticut
  • 10University of Pennsylvania, Philadelphia
  • 11University of Arizona Medical Center, Tucson
  • 12New York Presbyterian/Columbia University Medical Center, New York
  • 13University of California-San Diego Medical Center, San Diego
  • 14Barnes-Jewish Hospital, St Louis, Missouri
  • 15Oregon Health and Science University, Portland
  • 16University of Alabama Hospital, Birmingham
  • 17Brigham and Women's Hospital, Boston, Massachusetts
  • 18Cleveland Clinic Foundation, Cleveland, Ohio
  • 19Mayo Clinic Rochester, Rochester, Minnesota
  • 20Medical College of Wisconsin, Milwaukee
  • 21New York University Langone Medical Center, New York
  • 22University of Texas Southwestern Medical Center, Parkland Memorial Hospital, Dallas
  • 23Mayo Clinic Arizona, Phoenix
JAMA Dermatol. 2017;153(3):296-303. doi:10.1001/jamadermatol.2016.4920
Key Points

Question  What is the population-based incidence of posttransplant skin cancer in the United States?

Findings  In this population-based cohort study of 10 649 organ transplant recipients, the incidence ratio for posttransplant skin cancer overall was 1437 per 100 000 person-years. The specific subtype rates for squamous cell carcinoma, malignant melanoma, and Merkel cell carcinoma were 812, 75, and 2 per 100 000 person-years, respectively.

Meaning  Posttransplant skin cancer is common, with elevated risk imparted by specific risk factors.


Importance  Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population–based incidence in the United States.

Objective  To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008.

Design, Setting, and Participants  This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years.

Main Outcomes and Measures  Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR).

Results  Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94).

Conclusions and Relevance  Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.