Skin services for solid organ transplant recipients

1. Skin services for solid organ transplant recipients An audit of care in the North of England Cancer Network Katie Blasdale September 2010

2. 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

3. 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

4. NICE Guidance 2006Care 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

5. 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

6. NICE Guidance 2006Care 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

7. 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

8. 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

9. Audit design • 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

10. Audit findings • 51 patient contacts reported across all sites (48 patients) 20F:28M • Equivalent to 306/year assuming no seasonal variation

11. Type of transplant

12. Type of appointment?

13. Seen in which department?

14. Appointment types

15. Surgery required? • 26/51 appointments resulted in surgery • 3/4 new urgent • 2/3 new routine • 1/2 review urgent • 20/42 review routine

16. Clinic type

17. Transplant patients alive with a functioning graft, May 10, in the ‘North of England’ * comprises postcode areas CA, DH, DL, LA, NE, SR, TS Information from NHS Blood and Transplant June 2010

18. 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 Transplant patients alive with a functioning graft, May 10, in the ‘North of England’ Information from NHS Blood and Transplant June 2010

19. Renal transplant patients by site of renal review Annual transplant visit Includes skin check Referral links to dermatology Newcastle 600 Seen in general clinic No routine skin checks Informal links with dermatology JCUH 435 renal transplant recipients 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

20. 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

21. 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

22. 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

23. 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

24. Comments • These numbers are low in comparison to the local population of SOTRs • ? 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

25. Recommendations • Planning for dedicated clinics or rapid access slots essential in all parts of the network • Dialogue with physicians • Skin assessment within transplant clinics • ? by whom • Easy access to skin cancer services • Education of new transplant recipients