Highlight
- Solid organ transplant recipients face a markedly increased risk of skin cancer due to chronic immunosuppression.
- The KP-SUNTRAC program stratifies patients based on clinical risk factors, enabling targeted surveillance.
- Implementation of KP-SUNTRAC significantly improved screening rates and detection of skin cancer in high- and very high-risk groups.
- The enhanced surveillance did not increase short-term dermatology or pathology resource utilization, supporting its feasibility.
Study Background
Solid organ transplant (SOT) recipients require lifelong immunosuppressive therapy to prevent graft rejection, which unfortunately predisposes them to multiple complications, including a markedly elevated risk of cutaneous malignancies. Skin cancers, particularly basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC), cutaneous melanoma, and Merkel cell carcinoma, occur at much higher rates in this population than in the general public. This increased risk is heterogeneous, influenced by factors such as patient age, transplant type, cumulative immunosuppression, prior skin cancer history, and ultraviolet (UV) light exposure.
Current guidelines emphasize routine skin cancer surveillance in SOT recipients, but resource constraints and patient heterogeneity complicate uniform screening strategies. Therefore, a risk stratification approach is critical to optimize detection without overwhelming clinical systems. The Skin and Ultraviolet Neoplasia Transplant Risk Assessment Calculator (SUNTRAC) integrates established clinical risk factors to categorize SOT recipients into various risk strata to guide surveillance intensity.
Study Design
This retrospective cohort study was conducted within Kaiser Permanente Northern California (KPNC), an integrated healthcare system serving over 4.5 million members. Adult patients (≥18 years) who underwent SOT between January 1, 2016, and March 31, 2023, were included. SOT recipients were matched 1:20 by sex, race and ethnicity, and medical facility with nontransplanted controls to evaluate relative skin cancer risk.
The study period was divided into two phases: preimplementation of the modified SUNTRAC (KP-SUNTRAC) program from 2016-2021, and postimplementation from 2022-2024. KP-SUNTRAC utilizes SUNTRAC clinical risk factors to stratify patients into low, medium, high, and very high risk for developing posttransplant skin cancer, thereby tailoring surveillance frequency accordingly.
Primary endpoints included the number of skin cancer screenings, incident rates of skin cancer subtypes (BCC, cSCC, melanoma, Merkel cell carcinoma), and healthcare resource utilization metrics such as dermatology visits, nondermatology encounters, and number of pathology specimens examined.
Key Findings
A total of 2,083 SOT recipients were matched to 26,199 nonrecipients. The analysis revealed a striking 7.8-fold increased risk of skin cancer posttransplant compared with controls (hazard ratio [HR] 7.78; 95% CI, 5.97-10.10), affirming the heightened vulnerability of this population.
Following implementation of KP-SUNTRAC, the risk of first detected skin cancer was significantly higher in the postimplementation cohort compared to preimplementation (HR 2.57; 95% CI, 1.76-3.73). This likely reflects improved detection rather than increased incidence per se.
Notably, screening rates improved significantly during the postimplementation period in both the high-risk (HR 1.98; 95% CI, 1.39-2.82) and very high-risk groups (HR 2.17; 95% CI, 1.21-3.86), indicating effective risk-based targeting by KP-SUNTRAC. Conversely, screening among low- and medium-risk groups was appropriately lower, demonstrating resource-conservative surveillance.
Importantly, despite increased screening and detection, short-term healthcare utilization, measured by dermatology visits, nondermatology encounters, and pathology specimen counts, did not increase post-KP-SUNTRAC implementation. This suggests that risk-stratified screening can be integrated without overwhelming clinical services.
Expert Commentary
The findings from Lee et al. provide compelling evidence that incorporating a validated risk stratification tool like KP-SUNTRAC into routine clinical care enhances early skin cancer detection among solid organ transplant recipients who are at greatest risk. Given the aggressive nature and higher metastatic potential of skin cancers in immunosuppressed patients, early diagnosis is paramount in reducing morbidity.
Moreover, the absence of increased healthcare utilization suggests efficient targeting, which is critical in healthcare systems with constrained dermatology resources. This risk-adaptive approach aligns with precision medicine principles, balancing patient benefit and system sustainability.
Limitations of this retrospective analysis include potential residual confounding inherent to observational designs and a relatively short postimplementation follow-up period. Additionally, longer-term outcomes such as skin cancer morbidity, mortality, and cost-effectiveness were not assessed but represent important future directions.
Conclusion
This large retrospective cohort study within an integrated health system demonstrates that KP-SUNTRAC, a modified SUNTRAC-based risk stratification program, significantly improves targeted skin cancer screening and detection among solid organ transplant recipients at high risk, without increasing short-term healthcare burden. These findings support wider adoption of risk-adapted surveillance protocols to facilitate timely diagnosis, reduce morbidity, and potentially lower long-term healthcare costs related to skin cancer management in this vulnerable population.
Ongoing efforts should focus on validating KP-SUNTRAC across diverse populations, evaluating long-term clinical and economic outcomes, and integrating this tool into transplant follow-up care pathways to optimize skin cancer prevention strategies.
Funding and ClinicalTrials.gov
The study was conducted within Kaiser Permanente Northern California and did not indicate external funding. No ClinicalTrials.gov registration was cited.
References
Lee DS, Gigoyan L, Sells RE, Nugent JR, Goes NB, Harris HR, Nishime EO, Rihal GK, Conant DL, Pham N, Kwan ML. Skin Cancer Surveillance Program for Solid Organ Transplant Recipients. JAMA Dermatol. 2025 Oct 15. doi:10.1001/jamadermatol.2025.3890. Epub ahead of print. PMID: 41091513.
Additional references on skin cancer risk posttransplant and surveillance guidelines can be found in current dermatology and transplant literature, including practice guidelines from the American Academy of Dermatology and the American Society of Transplantation.