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Table 1.  Sociodemographic and Phenotype Characteristics at Baseline
Sociodemographic and Phenotype Characteristics at Baseline
Table 2.  Change in the Use of Sun Protection Measures for the Majority of Time When Outdoors
Change in the Use of Sun Protection Measures for the Majority of Time When Outdoors
1.
Euvrard  S, Kanitakis  J, Claudy  A.  Skin cancers after organ transplantation.  N Engl J Med. 2003;348(17):1681-1691. doi:10.1056/NEJMra022137PubMedGoogle ScholarCrossref
2.
Garrett  GL, Lowenstein  SE, Singer  JP, He  SY, Arron  ST.  Trends of skin cancer mortality after transplantation in the United States: 1987 to 2013.  J Am Acad Dermatol. 2016;75(1):106-112. doi:10.1016/j.jaad.2016.02.1155PubMedGoogle ScholarCrossref
3.
Iannacone  MR, Pandeya  N, Isbel  N,  et al; STAR Study.  Sun protection behavior in organ transplant recipients in Queensland, Australia.  Dermatology. 2015;231(4):360-366. doi:10.1159/000439428PubMedGoogle ScholarCrossref
4.
Wu  SZ, Jiang  P, DeCaro  JE, Bordeaux  JS.  A qualitative systematic review of the efficacy of sun protection education in organ transplant recipients.  J Am Acad Dermatol. 2016;75(6):1238-1244.e5. doi:10.1016/j.jaad.2016.06.031PubMedGoogle ScholarCrossref
Research Letter
July 2018

Sun Protection Among Organ Transplant Recipients After Participation in a Skin Cancer Research Study

Rebecca I. Hartman, MD, MPH1; Adele C. Green, MBBS, PhD2,3; Louisa G. Gordon, PhD2; et al for the Skin Tumours and Allograft Recipients (STAR) Study
Author Affiliations
  • 1Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Australia
  • 3Cancer Research UK Manchester and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
JAMA Dermatol. 2018;154(7):842-844. doi:10.1001/jamadermatol.2018.1164

Because of long-term immunosuppressive therapy, organ transplant recipients experience significantly elevated skin cancer risk1 and mortality.2 Because of increasing rates of transplantation and improved survival among organ transplant recipients, primary skin cancer prevention is essential for organ transplant recipients to reduce their skin cancer burden.

Elsewhere we reported the sun protection behaviors among a subset of organ transplant recipients who were at especially high risk of skin cancer because of a history of actinic skin lesions. We found that approximately 50% of the study participants regularly practiced multiple sun protection measures.3 It has been shown elsewhere that specific educational interventions can improve the use of sun protection measures among organ transplant recipients.4 Here we report a significant increase in the number of organ transplant recipients who practiced multiple sun protection behaviors after participation in a skin cancer research study for at least 1 year without any specific educational intervention.

Methods

This was a retrospective cohort study among kidney and liver transplant recipients at high risk of skin cancer conducted at Princess Alexandra Hospital in Brisbane, Australia, a tertiary referral center. Patients were enrolled at baseline in the Skin Tumours and Allograft Recipients (STAR) study from November 2012 to May 2016, and the methodology has been published elsewhere.3 At study enrollment, annually, and at study exit, we surveyed, in routine transplant clinics, organ transplant recipients’ use of sunscreen, hats, and/or long sleeves when outdoors. Use of multiple sun protection measures was defined as use of at least 2 of these practices more than 50% of the time when outdoors. Dermatologists performed initial total body skin cancer examination of participants and arranged clinical care and follow-up. Human research ethics committees of Metro South Hospital and Health Service and QIMR Berghofer Medical Research Institute (Brisbane, Australia) approved study procedures, and all study subjects provided written informed consent.

Results

A total of 248 organ transplant recipients provided initial survey data, and 23 patients (9%) who did not provide follow-up data were excluded, leaving 225 study participants. Almost all organ transplant recipients (224 patients) were followed up for at least 15 months after enrollment; mean (SD) follow-up time was 36 (5) months.

Patients who used multiple sun protection measures at baseline were significantly more likely than those who did not use multiple measures to have fair complexions (82 [68] vs 51 [50]), to have been born in Australia (102 [84] vs 74 [72]), and to have undergone annual skin cancer screening during the past 5 years (78 [64] vs 40 [39]); they were also more likely to have undergone prior skin cancer excision (84 [69] vs 56 [54]) (Table 1). After adjustment for these variables, the odds of using multiple sun protection measures increased more than 4-fold between study enrollment and exit (odds ratio, 4.4; 95% CI, 2.3-8.5) (Table 2). The odds of wearing long sleeves and hats increased more than the odds of applying sunscreen (3.3 [95% CI, 1.8-6.0] vs 3.6 [95% CI, 1.9-6.7] vs 1.7 [95% CI, 1.0-2.8]) (Table 2).

There was no difference in keratinocyte carcinoma development between those who adopted multiple sun protection measures and those who did not (21 of 48 patients [44%] vs 26 of 55 patients [47%]; P = .72). Compared with those who adopted multiple sun protection measures, those who did not were more likely to have already undergone annual skin cancer screening before study enrollment; this difference approached statistical significance (26 of 55 patients [47%] vs 14 of 48 patients [29%]; P = .06).

Discussion

These results suggest that research clinics that conduct skin cancer surveillance among organ transplant recipients offer additional educational and primary prevention advantages beyond improved access to care. Possible explanations for these findings include preventative education by specialists as well as increased patient awareness of skin cancer risk; the latter is suggested by the finding that, at baseline, organ transplant recipients with annual skin cancer screening were significantly more likely to practice sun protection.

Our findings must be interpreted in the context of the tertiary hospital study setting; participants may not be representative of organ transplant recipients living in remote areas. The surveys were also subject to patient recall and response biases.

In conclusion, we found that use of multiple sun protection behaviors increased among organ transplant recipients after participation in a skin cancer research study. Future research is needed to quantify the longer-term clinical consequences of skin cancer–focused clinics on skin cancer–associated morbidity and mortality among organ transplant recipients.

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Article Information

Accepted for Publication: March 26, 2018.

Corresponding Author: Rebecca I. Hartman, MD, MPH, Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA 02115 (rhartman@bwh.harvard.edu).

Published Online: June 6, 2018. doi:10.1001/jamadermatol.2018.1164

Author Contributions: Drs Hartman and Gordon had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Hartman, Gordon.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hartman, Gordon.

Obtained funding: Green.

Administrative, technical, or material support: All authors.

Study Supervision: All authors.

Conflict of Interest Disclosures: None reported.

Funding/Support: The Skin Tumours and Allograft Recipients (STAR) Study was supported by program grants from the National Health and Medical Research Council of Australia (grants 552429, 1073898).

Role of the Funder/Sponsor: The National Health and Medical Research Council of Australia had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The STAR Study investigators are Adele C. Green, MBBS, PhD, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Nicole Isbel, FRACP, PhD, Princess Alexandra Hospital, Woolloongabba, Australia; Scott Campbell, FRACP, MBBS, PhD, Princess Alexandra Hospital, Woolloongabba, Australia; H. Peter Soyer, FACD, MD, University of Queensland and Princess Alexandra Hospital, Woolloongabba, Australia; Jonathan Fawcett, FRCS, MBBS, PhD, University of Queensland and Princess Alexandra Hospital, Woolloongabba, Australia; Daniel Chambers, FRACP, MBBS, MD, Prince Charles Hospital, Chermside, Australia; Peter Hopkins, FRACP, MBBS, Prince Charles Hospital, Chermside, Australia; David C. Whiteman, MBBS, PhD, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Louisa Gordon, PhD, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Louise Marquart, PhD, QIMR Berghofer Medical Research Institute, Brisbane, Australia; and Peter O’Rourke, PhD, QIMR Berghofer Medical Research Institute, Brisbane, Australia. The STAR Study team are Lisa Ferguson, MSPath, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Marcia Davis, MD, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Mandy Way, MBiostats, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Michelle R. Iannacone, PhD, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Therese Lawton, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Michelle Grant, BNurs, Prince Charles Hospital, Chermside, Australia; Zainab Jiyad, MBBS, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Elsemieke Plasmeijer, MD, PhD, QIMR Berghofer Medical Research Institute, Brisbane, Australia; and Kiyoko Miura, PhD, QIMR Berghofer Medical Research Institute, Brisbane, Australia.

References
1.
Euvrard  S, Kanitakis  J, Claudy  A.  Skin cancers after organ transplantation.  N Engl J Med. 2003;348(17):1681-1691. doi:10.1056/NEJMra022137PubMedGoogle ScholarCrossref
2.
Garrett  GL, Lowenstein  SE, Singer  JP, He  SY, Arron  ST.  Trends of skin cancer mortality after transplantation in the United States: 1987 to 2013.  J Am Acad Dermatol. 2016;75(1):106-112. doi:10.1016/j.jaad.2016.02.1155PubMedGoogle ScholarCrossref
3.
Iannacone  MR, Pandeya  N, Isbel  N,  et al; STAR Study.  Sun protection behavior in organ transplant recipients in Queensland, Australia.  Dermatology. 2015;231(4):360-366. doi:10.1159/000439428PubMedGoogle ScholarCrossref
4.
Wu  SZ, Jiang  P, DeCaro  JE, Bordeaux  JS.  A qualitative systematic review of the efficacy of sun protection education in organ transplant recipients.  J Am Acad Dermatol. 2016;75(6):1238-1244.e5. doi:10.1016/j.jaad.2016.06.031PubMedGoogle ScholarCrossref
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