Heart Transplant Recipients are More Susceptible to Skin Cancer

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New methodological data presents the frequency, incidence, and prevalence of skin cancer in patients who have undergone heart transplantation.¹ Skin cancer, including squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), is the most prevalent non-lymphoid malignancy occurring during heart transplantation follow-up.²

Investigators analyzed literature from EMBASE and PubMed databases published between 1974 and 2015. They focused on retrospective and prospective cohort studies from 19 different countries. Studies were evaluated for characteristics including sample size and study design, casuistic of patients, and overall epidemiologic analysis.

The authors used the Newcastle Ottawa Scale Quality Assessment Form to review each article’s relevance. Using this scale, 62% were classified as good quality. Out of the initial 2589 studies found, 37 were eligible and included in the study after the screening and exclusion process.

The incidence of non-melanoma skin cancer ranged from 0.97% to 52.8%. The highest incidence came from an Italian study with a good sample size and long-term follow-up. These numbers could also be attributed to factors such as UV light exposure and high immunosuppression prescription use among transplant patients. The lowest incidence occurred in Taiwan, which could be influenced by genetic factors that lower the prevalence of such cancer in the Asian population.

Additionally, the incidence of SCC ranged from 1.19% (Canada) to 89% (United States) and the incidence of BCC ranged from 2% (Germany) to 63% (Austria). More specifically, SCC appeared to be more aggressive in solid organ recipient transplants (SORTs), with an average 10 times greater risk of metastasis. This aligns with existing research, confirming that SCC occurs more frequently than BCC in patients receiving organs.

In malignant melanoma, the incidence ranged from 0.94% to 4.6% in studies from the United States and Australia, respectively. This confirms the connection between skin cancer and HLA antigens among heart transplant patients. The likelihood of developing melanoma after the procedure is also higher in SORTs.

Factors such as older age and intensity of required immunosuppression may make heart transplant patients particularly susceptible to developing skin cancer. A lower number of immunosuppression medications may be associated with a decreased incidence of skin cancer, but the investigators hope to better characterize this complex correlation in future research.

“Associated with this fact, among solid organ transplants, patients with heart transplants are considered a vulnerable population because they need intense and strong immunosuppressive therapy,” the authors wrote. “Since the risk of rejection of the transplanted organ can be fatal, these patients usually receive 3 different types of immunosuppressive drugs. This fact can be one of the main reasons why these patients have even higher rates of skin cancer, as this study suggests.”

Heterogeneity among the studies as well as variations in follow-up periods may have limited the statistical analysis of the literature. Currently, there are few studies focused specifically on patients with heart transplants and the development of skin tumors.This is the first systematic review focusing specifically on the frequency of skin cancer in this specific population of patients.

Dermatologists play an important role of regular skin examinations in the short and long-term follow-up of heart transplant patients, especially with the increased number of procedures performed in recent years. Researchers hope to emphasize a multidisciplinary approach when caring for this patient population. Future research is needed to analyze environmental, immunosuppressive, and other individual risk factors exclusively in heart transplant patients and the outcome of skin cancer.

“The authors reinforce the importance of focusing on each population of organ transplant, each immunosuppression therapy, and each malignancy, separately, providing the statistical analysis in a more precise and less generalized way,” the investigators wrote. “A more homogenous methodology will be helpful to understand the complexity of this cohort of patients.”

References

1. Aguzzoli NHG, Bueno AL, Halezeroğlu Y, Bonamigo RR. Skin cancer after heart transplantation: a systematic review. An Bras Dermatol. Published online November 16, 2024. doi:10.1016/j.abd.2024.05.004

2. Shiba N, Chan MC, Kwok BW, Valantine HA, Robbins RC, Hunt SA. Analysis of survivors more than 10 years after heart transplantation in the cyclosporine era: Stanford experience. J Heart Lung Transplant. 2004;23(2):155-164. doi:10.1016/S1053-2498(03)00147-5