Download Skin cancer in immunosuppressed patients

Skin services for solid organ
transplant recipients
An audit of care in the North of England
Cancer Network
Katie Blasdale
September 2010
Some statistics

UK 10yr incidence of NMSC in SOTRs is 13x normal
Comparison of incidence of malignancy in recipients of different types of organ: a UK
registry audit . Colett D et al Am J Transplant Aug 2010

Biphasic peak in NMSC – age dependant
Direct standardization. All invasive nonmelanoma skin cancers
A population-based study of skin cancer incidence and prevalence in renal transplant recipients F.J.
Moloney et al BJD 2006
NICE Guidance 2006
Care of transplant patients

Transplant patients who have precancerous skin lesions or who have
developed a skin cancer should be seen in a dedicated ‘transplant
patient skin clinic’, either in the transplant centre or in a hospital
closer to the patient’s home, according to the choice of the patient.

Close links should be established between the transplant centre, local
physician and dermatologist for the management of transplant patients
postoperatively.

Dermatologists managing transplant recipients with multiple and/or
recurrent skin cancers need to liaise with the transplant team
regarding reduction of immunosuppression and the use of systemic
retinoids in order to reduce the risk of invasive disease.

Improving Outcomes for People with Skin Tumours including Melanoma
Skin measures 2008

The network board should agree in consultation with the NSSG and cancer lead
clinicians of each trust in the network, which localities will staff and run a clinic
for immunocompromised patients with skin cancer.

The network should designate at least one such clinic, and (in addition, if
necessary) any locality which contains a trust which hosts a centre for renal
and/or liver and/or cardiac transplants should be required by the network to run
such a clinic.
Manual for Cancer Services 2008
NICE Guidance 2006
Care of high risk groups




Specialised services commissioners, together with their cancer network(s),
should undertake a needs assessment for these special groups of patients, plan
the provision of appropriate specialist care and put in place the necessary
commissioning arrangements.
Network-wide protocols should be developed that describe the pathways of
care for these special groups of skin cancer patients.
Commissioners should receive results of audits of the care of these special
groups.
Information provision for patients in these special groups should be tailored to
their specific needs and contain information on their condition and relevant
patient support groups. Links should be made to national support groups, to
assure the quality of information (see chapter on ‘Patient-centred care’).
Improving Outcomes for People with Skin Tumours including Melanoma



All patients with a high risk of developing skin cancer should be counselled
effectively by a dermatologist or a CNS about sun protection before they
develop any skin lesions, and should have annual checks carried out thereafter.
All patients in high-risk groups with precancerous skin lesions (e.g. multiple
warty lesions and/or AK) should be referred early to a dermatologist for
assessment, active treatment and follow-up.
Once patients at high risk start to develop skin lesions they should be offered at
least 6-monthly follow-up.
Improving Outcomes for People with Skin Tumours including Melanoma
Audit aims


To quantify roughly the numbers of transplant
patients currently receiving care within Skin
Cancer MDTs
To assess compliance with NICE guidance
and skin measures
Audit design



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Prospective data collection
Standardised proforma across network
Cascaded by MDT lead.
Caldicott approval for each trust


Very simplified data collected
2 month data collection period

1/2/10 to 31/3/10
Audit findings


51 patient contacts reported across all sites
(48 patients) 20F:28M
Equivalent to 306/year assuming no seasonal
variation
9
10
Newcastle
Durham
20
12
Sunderland
Middlesborough
Type of transplant
10%
21%
kidney
heart
69%
liver
Type of appointment?
new urgent
4
new routine
3
review urgent
2
review routine
41
Seen in which department?
dermatology
45
maxillofacial surgery
5
plastics
1
Appointment types
20
15
10
5
0
RVI
new urgent
JCUH
new routine
SRH
UHND
review urgent
review routine
Surgery required?

26/51 appointments resulted in surgery




3/4 new urgent
2/3 new routine
1/2 review urgent
20/42 review routine
Clinic type
20
15
10
5
0
RVI
general
JCUH
SRH
Rapid access
UHND
plasics / max fax
Transplant patients alive with a functioning graft, May 10,
in the ‘North of England’
Tx type
Area 1*
Area 2**
Kidney
1362
1557
Pancreas
239
115
Kidney/pancreas
399
411
Heart
13
12
Lung(s)
80
67
Heart/lungs
10
6
Liver
5
9
Liver/kidney
52
41
Heart/kidney
0
2
Liver/pancreas
0
1
Liver/lung
0
1
2160
2222
Total
* comprises postcode areas CA, DH, DL, LA, NE, SR, TS
Information from NHS Blood and Transplant June 2010
Transplant patients alive with a
functioning graft, May 10, in the ‘North
of England’
Tx type / postcode area
CA
DH
DL
LA
NE
SR
TS
Kidney and/or pancreas
130
119
153
107
521
101
296
Heart and heart/lung
15
32
28
6
99
22
47
Lung(s)
3
6
12
6
25
8
20
Liver (inc. liver/kidney)
33
26
35
24
177
34
75
Total
181
183
228
143
822
165
438
Information from NHS Blood and Transplant June 2010
Renal transplant patients by site of renal
review
renal
transplant
recipients
Newcastle
600
Annual transplant visit
Includes skin check
Referral links to dermatology
JCUH
435
Seen in general clinic
No routine skin checks
Informal links with dermatology
Sunderland / Durham
280
Proposed transplant clinic
Currently no links with dermatology
Work in progress
Carlisle
115
Seen in general clinic
No routine skin checks
Informal links with dermatology
Models of care

Single regional transplant clinic
+
+
-
-
Specialist care
Potential for education at time of transplant
Travelling distances may reduce accessibility and
compliance
Potentially large numbers
Loss of interface with local physicians
Loss of MDT control
Models of care 2

Local dedicated immuno-suppressed clinic
+
+
-
Opportunity for multi-disciplinary care in local
setting
Linked with local MDT
Numbers likely to be small
Models of care 3

Protected slots within Rapid Access clinic
+
+
+
+
-
Easy access for both new and review patients
Facilities for immediate surgery
Close links with physicians
MDT centred care
Busy clinic with short time slots
Summary of findings



51 patient episodes involving solid organ
transplant recipients were reported within the
area studied over a 2 month period.
27% of these were seen within a rapid
access clinic; none in a dedicated transplant
clinic.
The majority were routine review patients but
51% required surgery
Comments

These numbers are low in comparison to the
local population of SOTRs



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? underreporting
? Unmet need within the SOTR population
The majority are still seen in general clinics,
even in those areas with rapid access clinics
Prompt access to surgery is essential for
these high risk patients
Recommendations

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Planning for dedicated clinics or rapid access
slots essential in all parts of the network
Dialogue with physicians

Skin assessment within transplant clinics
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
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? by whom
Easy access to skin cancer services
Education of new transplant recipients