By Victoria Colliver Updated 6:17 am, Wednesday, October 1, 2014
When doctors informed Darrell Johnson that his lung transplant would put him at higher risk of skin cancer, he didn’t give it a lot of thought. His concerns at the moment were bigger. A genetic disease had slowly robbed his lungs of the ability to expand and contract. He couldn’t breathe without an oxygen tank, which he carried in a backpack, and only a double lung transplant, which he received in August 2008 at UCSF, would save his life.
The higher risk for skin cancer came after surgery, with the daily regimen of medications Johnson had to take to decrease the possibility of organ rejection. The drugs would allow him to keep his new lungs, but would also weaken his body’s immune system and his ability to ward off certain cancers, skin cancer in particular.
Studies show the medications increase the odds that transplant patients will acquire skin cancer by up to 100 times compared with the general population, and their risks increase every year there on out. Twenty-five percent of them will develop the potentially fatal disease at five years, and at least half will be diagnosed with it after 10 years.
“It’s really devastating for transplant patients, given a new lease on life from their transplant, to discover they’re struggling with skin cancer,” said Dr. Sarah Arron, director of UCSF’s High Risk Skin Cancer Clinic. Monitoring risk crucial
Some patients, and even their physicians, aren’t aware of the connection between transplantation and elevated cancer risk, specifically skin. In some cases, the risk may not be monitored closely enough and the skin cancers tend to be more aggressive in transplant patients.
“It’s heartbreaking to have a functioning transplant patient die of skin cancer, and unfortunately that’s happening more than we would wish,” Arron said.
A link has also been made between transplants and certain forms of leukemias and lymphoma, as well as a cancer that appears on the skin called Kaposi’s sarcoma.
Medical researchers aren’t exactly sure what causes the elevated risks of skin cancer, but they have theories. They believe some skin cancers may actually be caused by viruses, which transplant patients have a tougher time fighting off. They are also hampered in attacking cancer cells as they form in the body.
But Arron said the fact that transplant recipients are living longer has bolstered efforts to get patients checked and treated more quickly.
For Johnson, the risk became a reality almost immediately. “They gave me the heads up, they started checking me, and they started finding things,” said the 64-year-old man, who lives in Grass Valley (Nevada County).
Johnson said he’s has lost track of how many skin cancers he’s had removed since his transplant, but he counted five surgeries this year and three the previous year. Potentially deadly
Virtually all of Johnson’s skin cancers have been what’s known as squamous cell carcinomas, the second-most-common form of skin cancer behind basal cell. Skin cancer is the most common type of cancer in the United States, with 3.5 million cases diagnosed in more than 2 million Americans each year. Squamous and basal skin cancers are generally not life-threatening for most people, but they can be deadly for transplant patients.
“Sometimes the cancers themselves are so aggressive that even the best we can do isn’t good enough,” Arron said. “These patients don’t get one squamous (skin cancer). They get five, 10 or 15 a year.”
To better understand the connection between organ transplant and skin cancer, Arron and her colleagues are collaborating with the UCSF transplant team on several research projects. UCSF will serve as the lead among 20 centers in an American Academy of Dermatology study looking at the incidence and death rates of skin cancer in transplant patients.
UCSF researchers are also involved in a National Cancer Institute study on melanoma in organ transplant patients, which includes examining how safe it would be for a patient already diagnosed with melanoma to have a transplant. They recently published a paper showing the relatively poor outcomes in transplant patients who have an even deadlier form of skin cancer than melanoma called Merkel cell carcinoma. About 250,000 organ recipients are living in the U.S., and Arron said she hopes the research will provide insight into the broader population of people who have been diagnosed with skin cancer.
“What can we learn about skin cancer in the transplant patient that can help us understand why skin cancer forms in the general population?” Arron said. “We’re learning how the immune system fails in a transplant patient and allows tumors to grow so we can identify in a non-transplant patient how that immune system can fail in the same way.”
Specimens in research David C. Brown, a UCSF heart transplant recipient from Mill Valley, has agreed to be in virtually every skin cancer study he’d been asked to participate in, a process that generally involves allowing his biopsy specimens to be used for research.
“Honestly I don’t know how many studies I’m in,” said Brown, who received his transplant in 1990 at age 36. Brown, 60, describes his post-transplant life as “reasonably smooth sailing medically,” but said he’s had about 13 skin cancers in the past decade, mostly basal cell carcinomas. The pace has quickened recently, he said. He’s had three in the past few months, including one that he had removed recently on his finger.
“I don’t really worry about it a whole lot because they seem to be caught and treated very efficiently,” he said. “I’m getting smarter about responding to them sooner. All this stuff feels petty … but if one digs deep enough, I’m going to have a real problem.”
Surgeries take toll Both Brown and Johnson know that their age, gender, and past history of sun exposure put them at higher risk of skin cancer, regardless of being transplant patients. Johnson has undergone five or six skin cancer procedures this year alone to remove cancers at the top of his head, and the surgeries are taking a toll. But, like Brown, he said he feels so grateful for the outcome of his transplant, he won’t complain.
He recently started trying an approved cream and a drug and is being treated with photodynamic therapy in hopes of reducing his incidence of cancer. Like all transplant patients, he has reduced his exposure to the sun by using sunscreen and protective clothing.
So far, it seems the increased preventive steps may be working. For the first time he can remember, Johnson said he went to UCSF a few weeks ago and his doctors did not find a new lesion.
Finally, he said, his head will be able to heal enough that he won’t feel self-conscious and cover his head indoors. “I’m going to a party and won’t be wearing a hat for the first time for at least a year and a half,” he said.
Victoria Colliver is a San Francisco Chronicle staff writer. E-mail: vcolliver@sfchronicle.com Twitter: @vcolliver
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