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Cancer screening guidelines ‘largely inconsistent’ for solid-organ transplant recipients
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Cancer screening recommendations for recipients of solid-organ transplants varied widely based on the transplanted organ and issuing organization, according to the results of a systematic review.
“The majority of cancer screening recommendations were targeted toward kidney recipients, and fewer recommendations exist for other solid-organ transplant recipients,” Nancy N. Baxter, MD, PhD, FRCSC, FACS, chief of the division of general surgery at St. Michael’s Hospital and professor of surgery at University of Toronto, told HemOnc Today. “Moreover, the available screening guidelines are largely inconsistent.”
Transplant recipients face a higher risk for cancer than the general population, and cancers diagnosed in this patient population often have poor prognoses. Malignancy is the leading cause of death after a solid-organ transplant.
Although early cancer diagnosis would improve outcomes for these patients, screening has remained controversial due to comorbidities and reduced life expectancy of this population. No randomized controlled trials of cancer screening have been conducted in transplant recipients.
Baxter and colleagues sought to identify cancer screening recommendations in clinical practice guidelines for the long-term care of transplant recipients, and to determine the quality and consistency of these recommendations.
The researchers searched publication databases, bibliographies and grey literature to identify guidelines that included a recommendation for malignancy screening in solid-organ transplant recipients. Search terms included “cancer,” “screening” and “recommendation.”
The systematic review included 13 clinical practice guidelines. Five clinical practice guidelines
focused specifically on recipients of kidney transplants and three additional guidelines fully endorsed recommendations for cancer screenings presented in the Kidney Disease: Improving Global Outcomes clinical practice guidelines.
Three guidelines focused exclusively on liver transplant recipients. One guideline focused on heart and lung transplant recipients, and one guideline was not limited to organ transplant type.
Guideline development sites included the United States (n = 5), Europe (n = 2), Australia, Canada, Switzerland and the United Kingdom (n = 1 for each). The remaining two guidelines were developed by international organizations.
No clinical practice guidelines included specific recommendations for surveillance of pretransplant malignancies.
Ten clinical practice guidelines offered specific recommendations on skin and lip cancer screening, nine of which recommended annual clinical examinations. Four guidelines recommended skin screening by a primary care physician and five recommended screening by a dermatologist or skin specialist.
The recommendation offered by the American Society for Transplantation recommended risk stratification for skin cancer screening, based on susceptible skin type, history of sun exposure or history of skin health problems.
Eight guidelines recommended cervical cancer screening. American Society of Transplantation and Renal Association recommended that kidney transplant recipients undergo Pap testing with pelvic exam every 3 years, which is consistent with the recommendation for the general population. However, other clinical practice guidelines recommended more frequent screening, including annual Pap tests and pelvic examinations.
Six guidelines recommended breast cancer screening, four of which recommended the same guidelines as those used for the general public.
Seven guidelines made recommendations on prostate cancer screening, including four guidelines that recommended against screening.
American Society of Transplantation and Renal Association recommended against kidney and bladder cancer screening in kidney transplant recipients, whereas the European Renal Best Practice Advisory Board recommended ultrasound screening for native kidney cancer.
Six guidelines recommended screening for liver malignancies in kidney transplant recipients, especially those with cirrhosis, liver disease, or hepatitis B or C.
Seven guidelines offered recommendations on colorectal cancer screening, five of which mirrored general population guidelines.
American Society of Transplantation recommended against lung cancer screening in kidney transplant recipients; however, this subgroup is recommended to undergo a physical examination for lymphoma every 3 months the year following transplantation.
Level of evidence and strength of recommendation varied. Six clinical practice guidelines did not evaluate level of evidence or strength of recommendation. The majority of skin cancer screenings included level of evidence and strength of recommendation; however, ratings mostly consisted of “low” or “very low” quality of evidence.
“Clinical practice guidelines are cautious in not making strong recommendations for cancer screening in solid-organ transplant recipients due to the lack of evidence from randomized clinical trials,” Sergio A. Acuna, MD, PhD candidate in the department of epidemiology and clinical research at University of Toronto’s Institute of Health Policy and Management, told HemOnc Today. “However, this situation is unlikely to change given that clinical trials require large numbers of people to provide accurate data and the transplant population is relatively small. Involvement of relevant stakeholders such as oncologists, primary care physicians, public health officials and patients could lead to changes in the strength of these recommendations and may help improve screening practices.”
The researchers acknowledged study limitations. Their systematic review only included clinical practice guidelines published in English, and they acknowledged that some potentially relevant guidelines may have been excluded due to a lack of information included in the literature search criteria.
“More guidance for transplant specialist and primary care physicians taking care of transplant recipients is required for improved decision-making,” Baxter said. – by Cameron Kelsall
For more information:
Sergio A. Acuna, MD, can be reached at sergio.acuna@utoronto.ca.
Nancy N. Baxter, MD, PhD, FRCSC, FACS, can be reached at baxtern@smh.ca.
Disclosure: The researchers report no relevant financial disclosures.
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