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Following up Transplant Patients and their Skin
Mr Per Hall
Consultant Plastic Surgeon, Addenbrooke's, also Joe Wallis and Gill Matthews
Gill Matthews, Per Hall and Joe Wallis
‘I am enormously privileged to be able to present to you work that really would not be presentable to you if it had not been for the Addenbrooke’s KPA who recognized that skin cancer was a problem for transplant patients who are immuno-compromised. They set about funding a transplant nurse to set up a skin surveillance programme – Gill, who is our second speaker here. They also funded equipment which Joe Walls, my research registrar in plastic surgery, will explain. This equipment is available for you to see on the Aston Clinica stand in the Exhibition Room. The third thing they funded was a beautiful leaflet on the importance of skin surveillance and the fourth was to organize coordination of all this and this enormous task was undertaken by Alan Craig.’
Joe Wallis
As Mr Hall said, I would like to talk about a research project that we put together using a machine called a SIA Scope and how we incorporated that into a newly set up skin surveillance clinic within the transplant service at Addenbrooke’s. Deep within the National Service Framework - that enormous document - there is a very small passage that relates to skin cancer and it effectively says that it agrees that skin cancer is a problem within immuno-compromised transplant patients, and it suggests that something should be done in some sort of a way to survey these patients from time to time. Unfortunately there is no national agreement as to how, when or where this is supposed to happen! Is it a transplant problem? Is it a dermatology problem? So with that in mind we organized a skin surveillance project within the transplant services.
Now - a little background behind skin cancers in immuno-compromisation. As Dr Tompson said earlier, there is an increase in the types of cancers in immuno-compromised patients. Skin cancers actually account for a relatively significant proportion of these and although it is not high on the agenda in terms of survival rates it does have a significant lifestyle problem for lots of people. The big problem with skin cancers in immuno-compromised patients is that they are incredibly difficult to diagnose, they are very difficult to detect and very difficult to tell what is nasty from what is friendly. Published literature actually states the diagnostic accuracy is actually about 54%. Which is pretty much a guess really!
So we introduced a machine called a SIA Scope to see if we can tip the balance slightly in our favour and see if we can pick out more of these nasty things before they get to a stage where they are a bit more difficult to manage.
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Above is the SLA Scope; a small hand held scanner. We hold this to your skin and the scan takes only a few seconds and is entirely painless. It illuminates the skin using various frequencies and these frequencies are specific to the different pigments which are associated with the skin. And where we can see that the light is bounced back or adsorbed into the body we can draw graphs to illustrate the depth of the pigment or lesions.
The SLA Scope has a 94% accuracy rate at identifying melanoma or other suspicious characteristics. What we are looking for is an area with an absence of blood or where the blood looks ‘smudgey’ and goes across the rest of the lesion. The SLA Scope will tell us if it is friendly or not!
We all know that most of our problems stem from exposure to sunshine. How big is this problem? Well we know that within 5 years of being immuno-compromised, 25% of patients will develop some sort of skin cancer, and after 20 years – which is not an unrealistic time these days – up to almost 80%. On average we are seeing changes at around the 7 or 8 year milestone and these cancers do not appear individually. Two thirds of patients will have more than one lesion at the time the first one is identified.
The problem skin cancers are the SCCs and the BCCs and these cancers do not necessarily have any pigment associated with them but they do tend to behave slightly differently within the immuno-compromised community. So we looked at about 450 patients who are being followed up by the transplant services at Addenbrooke’s and specifically the one third who have had their transplants for over 10 years as these are likely to be the population who will encounter problems. We didn’t look at the people who are already being looked at by plastic surgeons or the dermatology services because we want the new ‘skin virgins’; the people who have never had anyone look at them.
What did we find? We looked at just over half of the patients in a nine month period up ‘til April this year – although the clinic is still continuing. In that time, using the SIA Scope and looking at and examining the patients, we had identified almost 20 patients who had skin lesions which seemed to be suspicious. We did 41 biopsies of these and what we found is that all of those biopsies were abnormal. So we took these and said this just doesn’t look right. What this actually shows is, even in this small study, that the risk in the immuno-compromised community of getting a BCC is 50 times higher and for a SCC over 130 times higher. My clinical accuracy is 58% which is a bit better than was documented, but the SIA Scope completely outstripped this also – 82% accuracy in diagnosing suspicious lesions. Maybe we have finally tipped that balance for you!
And for a glimpse into the future, my project is a non contact SIA Scope – a sort of digital camera. It is a straight forward off the shelf digital camera with a very strong flash and some polarizing lenses on it. This will enable us to take pictures of larger areas which if combined with computer technology, could detect other areas of interest that we might not have thought of.
The World Health Organization predicts that in 10 years time a billion people on this planet at any one time will be affected by skin cancer – so this is something which really needs to be taken seriously and even if one person in this room goes back to their hospital and asks why they haven’t got a skin surveillance program then it has all been worth while.’
Gill Matthews
I have been in this new post since July 2005 with responsibilities for the long term follow-up of patients plus patient education in general.
The aim of our clinic is skin surveillance and to keep clinic visits to a minimum, with a one stop shop if possible. We started advertising the skin surveillance clinic using posters and through the AKPA Newsletter. Then through the usual post transplant clinic appointment I would pre-select the patients Joe mentioned: those who had been transplanted at least 5 years and ask if it was convenient for them to be seen on that clinic day. The appointment takes only half an hour or so.
At this appointment we would have a general health based discussion around the side affects of immuno-suppressants mainly. We look at risks of heart disease and stroke, cholesterol levels and make sure a lipid profile is done, and if treatment is necessary, make sure that is followed up. Also, if they are diabetic patients, we make sure this is followed up too and just generally offer help in promoting healthy living.
We then turn to skin cancer issues and do a risk assessment which involves questioning the patients on their sun history: their work, leisure activities, whether they are outdoor workers etc. Then we examine their skin from top to toe looking and feeling for lesions. If we find any suspicious lesions we scan them with the SIA Scope and you have just heard how affective that is from Joe. Our patient satisfaction survey at 6 months showed an 88% overall satisfaction rate. Other patients are now asking when is it their turn!
We still hear the most obvious complaint ‘but we don’t go out in the sun’, so we say ‘well how did you get to here from your car?’, ‘how did you put your washing out?’
Most patients are aware of the need to use sun screen, but we can only
advise, we cannot change habits!
Question 1: Do you advocate using a sun tan lotion (screen) such as P20 daily or one every hour or so?
Gill Matthews: You need to read the small print. Look for what protection is offered against UVA and this must go onto skin that is just washed and completely dry.
Question 2: Could you tell me how much the SIA Scope costs please?
Joe Wallis : The cost is currently £10,000 but over the next year or so they will probably become a little bit cheaper - £9,000. But the great thing is you don't need a great deal of training to be able to use one: look, I even managed to train Gill!
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