11.4 Organ transplantation and other conditions associated with immunosuppression: health system implications and discussion
Health system implications
The care and surveillance of immunosuppressed patients who develop multiple keratinocyte cancers should ideally be performed by in a multidisciplinary setting.
Multidisciplinary team care and routine dermatological surveillance require investment by the health system and coordinated delivery of health services. Currently resourcing for such care is available only in a few metropolitan centres and tertiary hospitals.
Barriers to implementation
Lack of routine skin care integrated into existing services for immunosuppressed patients, necessitating out-of-pocket payments by patients, is a major barrier to implementation of early detection for many immunosuppressed patients.
Lack of routine, ongoing patient education about the need for sun protection measures is also a barrier to implementation of primary prevention.
It remains uncertain whether biologic therapies, such as anti-tumour necrosis factor (TNF) therapies, raise the risk of keratinocyte cancer (KC) above the risk of KC in patients with immune-related disease receiving standard (non-biologic) treatment.
Studies currently underway
The Oral Nicotinamide after Transplant (ONTRANs) study is a multicentre, Australian randomised controlled trial, in which high-risk organ transplant recipients with multiple KCs are randomised to receive either nicotinamide 500 mg or placebo twice daily over a 12-month period, with the primary objective of investigating whether this treatment can reduce KCs.
Future research priorities
The role of human papillomavirus (HPV) in the development of KC and the potential for HPV vaccination in the prevention of KC, particularly in the organ transplant population.
- Australian and New Zealand Clinical Trials Registry. Effect of oral nicotinamide (vitamin B3) on skin cancer incidence and actinic keratoses in kidney, liver, heart and lung transplant recipients: a randomised controlled Phase 3 trial. ANZCTR; Available from: URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372709 Trial/Registration/TrialReview.aspx?id=372709.