Abstract
This study investigates the use of sun protection among organ transplant recipients after participation in a skin cancer research study.
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).
Table 1. Sociodemographic and Phenotype Characteristics at Baseline.
| Variable | Participants Using Multiple Measures of Sun Protection at Baseline, No. (%)a | P Valueb | |
|---|---|---|---|
| No (n = 103) | Yes (n = 122) | ||
| Age, mean (SD), y | 53.6 (12.4) | 55.6 (10.5) | .37 |
| Sex | |||
| Male | 69 (67) | 80 (66) | .82 |
| Female | 34 (33) | 42 (34) | |
| Born in Australia | |||
| Yes | 74 (72) | 102 (84) | .03 |
| No | 29 (28) | 20 (16) | |
| Health status | |||
| Excellent or very good | 39 (38) | 57 (47) | .40 |
| Good | 42 (41) | 44 (36) | |
| Fair or poor | 22 (21) | 21 (17) | |
| Natural complexionc | |||
| Fair | 51 (50) | 82 (68) | .01 |
| Medium/Olive | 52 (50) | 39 (32) | |
| Type of transplant | |||
| Renal | 63 (61) | 83 (68) | .28 |
| Liver | 40 (39) | 39 (32) | |
| Time since transplant, y | |||
| 1-5 | 39 (38) | 39 (32) | .28 |
| >5 to 10 | 24 (23) | 40 (33) | |
| >10 | 40 (39) | 43 (35) | |
| Prior surgical removal of skin cancer | |||
| No | 47 (46) | 38 (31) | .03 |
| Yes | 56 (54) | 84 (69) | |
| Frequency of skin cancer screening over the past 5 y | |||
| Less than annually | 63 (61) | 44 (36) | <.001 |
| Annually or more | 40 (39) | 78 (64) | |
Use of multiple measures of sun protection was defined as use of at least 2 of the following for the majority of time when outdoors: sunscreen, hat, and/or long sleeves.
Analysis of variance was used to determine the P value for age, and χ2 tests were used to determine the remaining P values.
Complexion type was recorded in lieu of ethnicity. Eligibility criteria excluded those individuals with dark brown or black innate skin color.3
Table 2. Change in the Use of Sun Protection Measures for the Majority of Time When Outdoors.
| Sun Protection Measure | Participants, No. (%) | Adjusted Odds Ratio (95% CI)a | |
|---|---|---|---|
| Study Enrollment (n = 225) | Study Exit (n = 225) | ||
| Multiple sun protection measuresb | 122 (54) | 159 (71) | 4.4 (2.3-8.5) |
| Long sleeves | 91 (40) | 123 (55) | 3.3 (1.8-6.0) |
| Hat | 146 (65) | 176 (78) | 3.6 (1.9-6.7) |
| Sunscreen | 117 (52) | 133 (59) | 1.7 (1.0-2.8) |
Mixed-effects logistic regression was used to determine odds ratios adjusted for birth in Australia, complexion, prior surgical removal of skin cancer, and frequency of skin cancer screening.
The net increase in the number of patients who used multiple sun protection measures (37 patients) encompasses 48 patients who adopted this behavior and 11 others who discontinued it.
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.
References
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