To the editor:
Solid organ transplant recipients (SOTRs) have an increased risk of developing skin cancers, in particular SCCs, which exhibit higher aggressiveness in SOTRs.1,2 Immunosuppression regimen, transplant type, age at transplant, race, and sex are associated with an increased risk of non-melanoma skin cancer (NMSCs) in SOTRs.3 Analysis of racial differences in SOTR skin cancer development has shown that nearly 42% of white patients and 6% of nonwhite patients were diagnosed with skin cancer over a 5 year period.4 A skin cancer risk-prediction tool, SUNTRAC, has identified white race as the highest individual risk factor.5 While race is an important risk factor in the development of post-transplantation keratinocyte carcinomas (KCs), we sought to understand the temporality of skin cancer development based on racial differences.
We leveraged a diverse cohort of 10,767 SOTR patients from the Mount Sinai Health System in New York City. We grouped the patients by race as white (n=3,715) and non-white (i.e. Hispanic, Black, Asian, other) (n=7,052) [Supplementary Table 1]. Demographics were consistent with those from prior literature. In our cohort, 248 patients had a first-time diagnosis of SCC and 229 for BCC. Median follow-up duration for patients with and without KC diagnosis was 7.54 years and 4.44 years, respectively.
Consistent with prior studies, we found an increased risk of both SCC and BCC in white vs. non-white SOTR patients at all age groups [Table 1]. The incidence of SCC was 5.14% in whites and 0.808% in non-whites, while for BCC, it was 5.22% and 0.496%, respectively. White patients had increased odds of developing both SCC (OR = 5.75, 95% CI: 4.21–7.79, p < 0.001) and BCC (OR = 10.16, 95% CI: 7.09–15.01, p < 0.001) compared to non-whites when controlling for age at transplant, sex, transplant type, and HIV status. Smoking status was excluded since most patients had not reported their status.
Table 1.
Rates of SCC and BCC in White vs. Non-White patients by age group
| Age Groups | White | Non-White | P-value | OR [95% CI] | |
|---|---|---|---|---|---|
| SCC | Overall | 5.14% | 0.808% | <0.001 | 6.64 [4.96 – 9.02] |
| <40 | 1.12% | 0.256% | 0.013 | 4.56 [1.33–18.13] | |
| 40–50 | 3.35% | 0.602% | <0.001 | 5.65 [2.34–15.07] | |
| 50–60 | 5.42% | 1.32% | <0.001 | 4.26 [2.67–7.00] | |
| 60–70 | 5.12% | 0.731% | <0.001 | 7.27 [4.01–14.14] | |
| >70 | 9.24% | 1.09% | <0.001 | 9.05 [4.54–20.81] | |
| BCC | Overall | 5.22% | 0.496% | <0.001 | 11.00 [7.76 – 16.07] |
| <40 | 1.51% | 0 | - | - | |
| 40–50 | 4.69% | 0.258% | <0.001 | 18.17 [6.18–80.38] | |
| 50–60 | 5.78% | 0.883% | <0.001 | 6.83 [4.03–12.29] | |
| 60–70 | 5.57% | 0.394% | <0.001 | 14.63 [7.04–35.80] | |
| >70 | 7.32% | 0.955% | <0.001 | 8.03 [3.83–19.78] |
The average time from transplant to SCC or BCC diagnosis was 4.97 years (SD 5.93) or 4.13 years (SD 6.05), respectively. However, we found that diagnosis of KCs occurred at an overlapping time frame for white and non-white patients when conducting survival analyses adjusted for age at transplant, sex, and HIV status. Median KC-free survival time for whites vs. non-whites was 4.66 vs. 4.54 (p=0.67) [Figure 1], with no significant difference when examining SCC-free survival time (p=0.58) and BCC-free survival time (p=0.74) [Supplementary Figure 1].
Figure 1.
Kaplan-Meier Curve for Time to Keratinocyte Carcinoma (KC) diagnosis after solid organ transplant
Survival Analysis for time from transplantation to KC diagnosis (SCC or BCC diagnosis). The curve has been adjusted for age at transplant, sex, transplant type, and HIV status. No significant differences are observed in the survival time curves between white and non-white patients.
Our findings suggest that although non-white patients had decreased risk of developing KC, they developed them within a similar timeframe as their white counterparts. Thus, these patients should not necessarily undergo different onset or frequency of skin cancer screenings. Early detection of SCCs is critical for SOTRS of all races given their aggressiveness in this population. This study is limited by its retrospective nature and single-institution cohort; however, we have leveraged a large database to show the timeline of skin cancer diagnosis post transplantation. Future work on understanding intrinsic factors relating to the time course of skin cancer development will help elucidate the frequency and timing of skin cancer screenings.
Supplementary Material
Funding sources:
This study was funded by the National Institutes of Health K08CA263187 (A.L.J), Damon Runyon Cancer Research Foundation 121–23 (A.L.J), and the Kimberly and Eric J. Waldman Melanoma and Skin Cancer Center at Mount Sinai.
Footnotes
Conflicts of Interest: None declared.
Supplemental Material: https://data.mendeley.com/datasets/n2mbx77bkv/1
IRB approval status: Institutional Review Board of the Mount Sinai School of Medicine, in accordance with Mount Sinai’s Federal Wide Assurances (FWA#00005656, FWA#00005651) to the Department of Health and Human Services approved the following human subject research.
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References
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