What can dermatologists do to prevent squamous cell carcinoma in solid organ transplant recipients?
Dr. Schwarzenberger is the physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, FAAD, January 1, 2023
In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with Anokhi Jambusaria, MD, FAAD, associate professor and section chief of general dermatology in the Department of Internal Medicine at Dell Medical School, about her JAMA Derm paper, ‘Consensus-based recommendations on the prevention of squamous cell carcinoma in solid organ transplant recipients. A Delphi consensus statement.’
DermWorld: Those of us who manage solid organ transplant recipients recognize the need for skin cancer prevention strategies and very much appreciate your efforts to provide recommendations in this arena! You chose to do this using the Delphi process. For those who may not be familiar with this concept, can you briefly explain the process and tell us why you chose to approach the problem this way?
Dr. Jambusaria: The Delphi method is an iterative process that can be utilized to achieve consensus regarding a clinical question. It is employed when there is no high-level evidence to guide physicians.
During the Delphi process, a group of experts anonymously answer questions regarding how they would manage a particular clinical question. After each respondent completes the questionnaire, the results are tabulated and shared with the Delphi panel for feedback. Utilizing the results from the previous round and feedback from the panelists, follow-up questions are formulated and sent to the panelists again. Typically, most Delphi studies have about three to five rounds of questions. A Delphi process allows for self-reflection from each panelist as to how their response compares to their peers, and allows them to modify their responses based on how their peers are responding. Since the process is anonymous, everyone on the panel has an equal voice. Over time, the group “moves” toward a consensus. Typically, most Delphi panels identify 80% agreement as a threshold for consensus.
In this study, a Delphi process was chosen given the limited data in the literature surrounding the medical management of solid organ transplant recipients (SOTR) to prevent skin cancer.
DermWorld: What prompted this study, and did you accomplish what you hoped to when you designed the study?
Dr. Jambusaria: Despite being the most common long-term complication in SOTR, there is very little information in the literature to guide dermatologists as to what they can do medically to prevent skin cancer. While we have options such as field therapy and lesion-directed therapy for actinic keratoses, oral nicotinamide and acitretin for CSCC chemoprevention, reduction of immunosuppression, or modification of immunosuppression to mTOR inhibitors, there is little known about the optimal time to employ these strategies.
For the most part, we were able to identify optimal skin cancer prevention strategies for patients with actinic keratoses, field cancerization, patients who develop a “high-rate” of cSCC (>10/year), or when patients develop their 1st high-risk (> BWH T2b or > AJCC T3) cSCC. We were not able to identify optimal cSCC prevention strategies for SOTR who develop their 1st cSCC.
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DermWorld: Are there any major limitations of the process we should be aware of? Did we miss anything in this study?
Dr. Jambusaria: The major limitation of this study is that the results are based on expert consensus, and there are patient-level data to date to support many of the interventions recommended in the study. However, these results can be very helpful until high-level evidence can be obtained regarding strategies for skin cancer prevention in SOTR.
DermWorld: Were you or the other members of the panel surprised by any of the results?
Dr. Jambusaria: As mentioned above, we were unable to achieve consensus regarding the optimal medical management for cSCC prevention after 1st cSCC development. This was rather surprising to us given there is randomized data showing conversion to sirolimus-based immunosuppression after 1st cSCC reduces subsequent risk of cSCC (PMID 30016177).
DermWorld: Will the results of this study change your management of solid organ transplant recipients?
Dr. Jambusaria: While the results of the study were more or less what I expected as a transplant dermatologist, it helps to affirm that our current management strategies are appropriate. Importantly, the process identified that we really need to answer the question about what to do after a SOTR develops their 1st low-risk (BWH T1/T2a or AJCC T1/2) cSCC.
Anokhi Jambusaria, MD, FAAD, is an associate professor and section chief of general dermatology in the Department of Internal Medicine at Dell Medical School, and deputy service lead for adult general dermatology at Ascension Medical Group. She is on the advisory board for Regeneron Pharmaceuticals, Inc. Her paper appeared in JAMA Derm.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.