Recommendations on Preventing SCC in Solid Organ Transplant Recipients JAMA Dermatology

TAKE-HOME MESSAGE

• The authors undertook this Delphi process in an effort to provide guidance for the treatment and prevention of cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients.

• The Delphi panel, which consisted of 48 dermatologists, concluded that (1) oral chemoprevention with acitretin and (2) discussion with the transplant team about modification of the immunosuppression regimen are recommended when solid organ transplant recipients develop more than 10 CSCC tumors per year or develop a high-risk CSCC (defined as nodal metastasis risk of 20% or greater).

–  Caroline K. Crabtree, MD

Abstract

Importance

There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs).

Objective

To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs.

Evidence Review

Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses.

Findings

The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC.

Conclusions and Relevance

Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

JAMA Dermatology

Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients: A Delphi Consensus Statement

JAMA Dermatol 2021 Sep 01;[EPub Ahead of Print], PR Massey, CD Schmults, SJ Li, ST Arron, MM Asgari, JN Bouwes Bavinck, E Billingsley, TW Blalock, K Blasdale, BT Carroll, JA Carucci, AH Chong, SR Christensen, CL Chung, JA DeSimone, E Ducroux, B Escutia-Muñoz, C Ferrándiz-Pulido, MC Fox, RE Genders, A Geusau, P Gjersvik, AM Hanlon, EB Olasz Harken, GFL Hofbauer, RS Hopkins, JJ Leitenberger, MJ Loss, V Del Marmol, JM Mascaró, SA Myers, BT Nguyen, WRP Oliveira, CC Otley, CM Proby, E Rácz, V Ruiz-Salas, FH Samie, D Seçkin, SN Shah, TM Shin, SP Shumack, SL Soon, T Stasko, E Zavattaro, NC Zeitouni, FO Zwald, CA Harwood, A Jambusaria-Pahlajani