Skin cancer awareness efforts should target transplant recipients with skin of color

Skin cancer is the most prevalent cancer in the United States, with an estimated 97,610 new cases of invasive melanoma, 89,070 cases of in situ melanoma and about 7,990 deaths from the disease in 2023.

The most common risk factors for skin cancer are a history of excessive sun exposure, including sunburns, tanning bed use, a weakened immune system and a history of skin cancer. Although skin cancer risk is higher in patients who are white, patients with skin of color (SoC) diagnosed with melanoma experience higher rates of mortality. This is attributed to delayed detection and other treatment disparities.

It is important to note the term SoC encompasses a broad group, including Black, Asian, Latino and mixed race and ethnicity communities.

Rucha Janodia

Ileana Gonzalez

There has been an increase in efforts to improve skin cancer treatment among patients with SoC, yet there are still long-standing misconceptions, such as the belief that people of color cannot get sunburn or do not need sun protection. This misinformation contributes to a lack of preventive behaviors for skin cancer in people of color.

Many patients with SoC believe they are at lower risk for developing skin cancer, that engaging in preventive behaviors would not affect their risk, and they are uncertain about which prevention efforts to follow. This may be attributed to a disproportionately low allocation of skin cancer prevention efforts targeted toward patients with SoC.

Carolyn J. Heckman

Educational interventions have shown promise in reducing the knowledge gap about melanomas for these patients, but further representation in research and education are needed for both patients and clinicians. We write this commentary in the hopes of increasing awareness about the need for more education among patients with SoC regarding skin cancer risks, including awareness of the significant differences of knowledge, attitude and behavior in different racial groups, which may partially contribute to different skin cancer outcomes.

Skin cancer risk in organ transplant recipients

Importantly, individuals with SoC make up more than half of the organ transplant waiting list. Organ transplant recipients have a heightened susceptibility to developing skin cancer due to their weakened immune systems. In terms of prevalence, almost half of recipients are diagnosed with skin cancer within 11 years of transplant, more than 90% of which are squamous cell and basal cell carcinomas, whereas 6.2% are melanomas.

With the heightened risk for skin cancer in organ transplant recipients and the disparities faced by patients with SoC, Jennifer Wang, BS, BA, a research assistant at the University of Texas Southwestern Medical Center, and colleagues conducted a survey to compare skin cancer knowledge, attitudes and behaviors between 219 organ transplant recipients with and without SoC.

Wang and colleagues found that recipients with SoC were significantly less likely to believe they were at risk for skin cancer, significantly less likely to be concerned about getting skin cancer and significantly less likely to use sunscreen compared with their non-SoC counterparts. While these beliefs and behaviors may be appropriate based on the lower likelihood of skin cancer in patients with SoC, all patients who were surveyed were immunosuppressed and therefore considered at high risk for developing skin cancer due to their organ transplant recipient status.

Notably, all organ transplant recipients in the study were referred to a dermatologist for a skin cancer prevention screening in accordance with guideline-recommended protocols. However, 37.8% of those with SoC who received a transplant at least 1 year ago had never seen a dermatologist, compared with only 6.1% of those without SoC.

Risk for HPV-associated skin cancer

Immunosuppression among transplant recipients increases their risk for infections that may lead to conditions such as cancer. For example, HPV is a risk factor for cancers, including skin cancers.

Wang and colleagues found that a high proportion of recipients with SoC had HPV: 66.7% of genital skin cancer found in those with SoC tested positive for HPV.

In the general population, people with SoC have higher incidence rates of many HPV-associated cancers compared with those without SoC. Organ transplant recipients also have a higher risk for HPV infection than people who have not had a transplant. Data show that recipients with SoC were more likely to recognize HPV as a risk factor for skin cancer vs. those without SoC. Still, most recipients with SoC (61.9%) did not recognize this risk factor, and upon evaluating their behavior post-transplant, most of them (66.9%) did not self-examine their genital and pelvic area.

Considering squamous cell carcinomas have an association with HPV, we encourage providers to talk to patients about HPV as a risk for skin cancer and encourage them to examine their pelvic and genital areas during self-skin exams. We also suggest that future research analyze how accurately transplant recipients perform self-skin exams and whether they are prone to overlook their genital areas as in other populations. Poorer skin cancer outcomes in patients with SoC can be partially attributed to detection at later stages. Provider and patient awareness and skin self-exams may promote earlier detection, which could lead to a decrease in morbidity and mortality from skin cancer in patients with SoC.

A call to action

Wang and colleagues’ analysis highlighted the discrepancies of health-related beliefs and behaviors in organ transplant recipients, underscoring the need for educational resources geared toward recipients with SoC. A limitation to the study is that it was restricted to one academic institution. Future research should include a larger and broader sample, create an educational intervention such as a video or pamphlet, and survey health-related behaviors before and after interventions.

To support better health outcomes for patients with SoC, a multifaceted approach is recommended.

First, academic institutions should expand their curriculum and promote equity in educational resources at an early stage in medical education to increase provider confidence in identifying skin lesions in patients of color. For example, this could include improving visual equity in lectures and highlighting how different skin lesions can appear in different skin tones.

It is necessary to be aware of the differences in prevalence, risks and locations of skin cancer for each racial and ethnic population. For example, skin cancer tends to develop in sun-exposed areas for Asian populations, partially sun-exposed areas for Latinos and areas that are typically not sun-exposed for Black populations. UV exposure affects populations and individuals differently, with lighter skin tones being at the greatest risk. Further research assessing different communities’ perception of skin cancer risk is needed to target educational efforts.

Primary care providers as well as dermatologists should encourage behaviors to help prevent skin cancer, inform patients on how to perform skin self-exams, especially among those who are immunocompromised, such as organ transplant recipients. We hope this information will help lead to better provider preparation for counseling patients with SoC and organ transplant recipients on skin cancer prevention, decrease the knowledge gap of skin cancer education, and help improve the health literacy of patients with SoC.

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