Skin cancer is a frequent complication of organ transplantation. Current guidelines advise specialist skin surveillance but there are limited data on how these should be implemented. This study determines overall burden of cancer and relevant intervals for strategic surveillance in an ethnically diverse transplant population. Prospective data on time to first and subsequent cancers and cumulative burden with respect to defined risk factors were analyzed in a cohort of 1010 patients in a UK center over 22 years. Among 931 individuals transplanted >6 months (mean 10.3 years), 1820 skin cancers occurred in 267 (29%) individuals and were multiple in 66%. Cumulative incidence at 5, 10, 20 and 30 years was 11%, 25%, 54% and 74%, with median time to second, third and fourth cancers of 24, 14.7 and 8.4 months, respectively. Tumors were overwhelmingly squamous and basal cell carcinomas (73% and 24%, respectively). Skin phototype, ultraviolet radiation exposure, age at transplant and duration of transplant were significant risk predictors and were used to construct clinically relevant surveillance intervals. This study provides a comprehensive, prospective analysis of skin cancer morbidity and risk in an ethnically diverse transplant population from which we derive an evidence-based skin cancer surveillance program.

SummaryBackground-Organ transplant recipients (OTRs) have 100-fold increased risk of developing squamous cell carcinomas. Cumulative exposure to ultraviolet radiation is the main risk factor and there is evidence that lack of dermatological surveillance may be responsible for poor levels of knowledge and photoprotection among OTRs.

A case-control study was conducted in 140 people with histology proven cutaneous squamous cell carcinoma (SCC) and 454 controls, nested within 2 cohorts of organ transplant recipients (OTR) recruited in London and Oxford between 2002 and 2006. All participants had a skin examination, completed a questionnaire and had serum tested for antibodies against the L1 antigen of 34 HPV types using Luminex technology. SCC was more common in men than women (odds ratio [OR] 5 1.7, 95% confidence interval [CI]: 1.1-2.8, p 5 0.02) and in people with susceptibility to burn easily (OR 5 3.0, 95%CI: 1.9-4.8; p < 0.001). The risk increased with increasing age (p-trend < 0.001), increasing time since transplant (p-trend < 0.001), increasing self-reported number of sunburns as a child (ptrend < 0.001) and with the presence of viral warts (p < 0.001). As expected, antibodies against HPV 16 were associated with a selfreported history of an abnormal cervical smear among women (OR 5.1, 95%CI: 2.6-10.2) and antibodies against HPV 6 were associated with a self-reported history of genital warts (OR 4.0, 95%CI: 2.2-7.2). However, no clear associations between any of the HPV types examined (including cutaneous betaHPVs) and SCC were identified. For example, the seroprevalence of HPV 5 was 15% among cases and 9% among controls (p 5 0.09) and the seroprevalence of HPV 8 was 23% among cases and 21% among controls (p 5 0.6). Nor was seropositivity to multiple types associated with SCC. These serological data do not provide evidence for a role for HPV in the aetiology of cutaneous SCC among OTR in two UK-based populations. ' 2009 UICC Key words: Epidemiology; human papillomavirus (HPV); serology; cutaneous squamous cell carcinoma (SCC); organ transplant recipients Immunosuppressed organ transplant recipients (OTR) have a higher risk of non-melanoma skin cancer than the general population. Furthermore, cutaneous squamous cell carcinomas (SCC) occur significantly more frequently than basal cell carcinomas (BCC), reversing the ratio usually found in the general population (4:1). 1,2 Ultraviolet radiation (UVR) is the main established risk factor both for SCC and BCC. 3 The strength of the association between SCC and immunosuppression, particularly after solid organ transplantation, parallels that seen for other virally associated posttransplant cancers; certain HPV types have long been proposed as potential candidates. 4 However, while the oncogenic mechanism of HPV in cancers of the uterine cervix is well-understood and the causative association is now established, it remains uncertain what role, if any, HPV plays in the aetiology of skin cancer.DNA of cutaneous HPV appears to be ubiquitous and persistent in the skin and hair follicles of healthy individuals. 5,6 Higher prevalence of cutaneous HPV-DNA has been found in the normal skin of immunosuppressed compared to immunocompetent people 7 and putative novel types are often detected. 5 Studies relying on HPV-DNA detection confront problems not only of contamination, a major consideration given t...

Background: Despite intensive study of high-risk mucosal human papillomaviruses (HPV), little is known of the epidemiology of cutaneous HPV. As part of a study of cutaneous squamous cell carcinoma and HPV among organ transplant recipients (OTR) from London and Oxford, we investigated the seroprevalence and risk factors for 34 HPV types (detected using Luminex technology) among 425 Caucasian OTR without skin cancer.

Background: The natural history of cutaneous HPV is unclear and in particular, seroprevalence among individuals with different levels of immune function and ethnicity is unknown. As part of a study of cutaneous squamous cell carcinoma (SCC) and HPV among organ transplant recipients (OTR) from London, we investigated the seroprevalence and risk factors for 34 HPV types (detected using Luminex technology) among 409 OTR patients without skin cancer (243 Caucasians and 166 non-Caucasians), 367 individuals with end stage renal failure on dialysis (222 Caucasians and 145 non-Caucasians) and 152 immunocompetent (IC) individuals without skin cancer (102 Caucasians and 50 non-Caucasians) to compare the HPV seroprevalence in patients with differing immune status and ethnicity. In total, seroprevalence data from 928 individuals, all from London, was available.