Stanford Medicine Newsletter Updates For the Local Community

 

Advanced care for high-risk skin cancer patients

Stephen Hudson was treated at the new Stanford High-Risk Skin Cancer Clinic after a lung transplant made him more susceptible to aggressive skin cancer.

   

Shortly after he turned 60, Stephen Hudson received a single new lung to replace the one destroyed by his exposure to asbestos. He was happy to be alive, but it is never easy to adjust to post-transplant life. Among all the other new health habits required of him, Hudson had to take immune-suppressing medications to lower his body’s natural reaction to attack the new lung, and those medications boosted his risk of skin cancer.

By the time Hudson’s skin cancer was diagnosed, it had invaded his lower lip. It wasn’t a complete surprise. “I just forgot over the years that I was going to have this problem,” he said.

Increased cancer risk

For people lucky enough to have received a life-saving kidney, heart, lung, liver, pancreas or bone marrow transplant, that luck comes with a caveat: a 60-fold increase in the risk of developing squamous cell skin cancer. Squamous cell skin cancer tends to be more likely to invade deeper into tissue and to spread elsewhere in the body. Immunosuppressant medications also multiply the risk of basal cell carcinoma by 10-fold and of melanoma by three-fold.

Hudson, 76, was so engaged in his post-transplant adjustment that he overlooked these potential complications. “I just let it go longer than I should have,” he said.

Stanford Medicine dermatologist Carolyn Lee, MD, PhD, is trying to head off these problems through the new Stanford High-Risk Skin Cancer Clinic, which serves as an early-warning system, a frontline defense and, if need be, an all-hands-on-board diagnosis and treatment center for patients like Hudson.

Clinic physicians also see patients who develop skin cancer at a faster rate than average because they have very fair skin or a family history of skin cancer. Other people at higher risk for skin cancers are those with conditions that produce chronically inflamed skin, as well as the millions of Americans who take immunosuppressant medications for chronic autoimmune disorders, such as celiac disease, Crohn’s disease, Graves’ disease, lupus and rheumatoid arthritis.

Careful monitoring

“The good news about skin cancer is that unlike many internal cancers, you almost always see it coming,” said Lee, a clinical instructor of dermatology at Stanford University School of Medicine. “Careful surveillance is the best defense. What I hate to see is someone who’s been waiting for a transplant, then finally get it, only to be felled by skin cancer, which is fairly preventable.”

That’s why she encourages people who are waiting for a transplant to be seen as soon as possible before a transplant surgery. “It’s much better to take care of any precancerous lesions or skin cancer before that surgery,” Lee said.

Treatment and monitoring may depend in part on the age of the person with a transplanted organ. “Someone who is young, who has not sustained a great deal of sun damage, who has no precancers or active skin cancers at the first visit can probably be seen every six months to every one year,” Lee said. Transplant patients older than 50 usually have accumulated a certain amount of sun damage that can predispose them to skin cancer and so may require more frequent monitoring.

Expanded options

Treatment options for patients at the clinic include special techniques that can remove cancer from large areas, such as topical chemotherapy, photodynamic therapy and chemo wraps. Clinic specialists include dermatologic and head and neck surgeons with experience removing skin cancers that can sometimes cover entire body parts, as well as plastic surgeons who can help repair the affected areas.

Patients also may participate in clinical trials of biologics that are targeted at certain newly identified skin cancer drivers and mutations. “Many of our doctors in the clinic also spend a significant amount of their time in research to advance our field,” Lee said. “This is particularly true in the study of basal cell carcinoma. We are pushing the boundaries on what is known and what can be done to treat it.”

She and a colleague are also investigating a phenomenon they have observed—that post-transplant patients who do develop skin cancers tend to develop more aggressive malignant cancers.

Hudson had to have his entire lower lip reconstructed after doctors removed the cancerous tissue, but the repair was done so well that it is nearly undetectable. Lee continues to treat him for small surface cancers on his head, nose, face and ears. Hudson has become conscientious about using sunscreen and wearing a hat with a brim large enough to shade his ears when he is outdoors.

And he doesn’t miss his appointments. “I have renewed confidence. You’re going in knowing that they are going to take care of you,” Hudson said, “and that they are doing all they can do.’’

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