Skin services for solid organ transplant recipients

Skin services for solid organ transplant recipients

An audit of care in the North of England Cancer Network

Katie Blasdale September 2010

Some statistics UK 10yr incidence of NMSC in SOTRs is 13x normal

Comparison of incidence of malignancy in recipients of different types of organ: a UK registry audit . Colett D et al Am J Transplant Aug 2010

Biphasic peak in NMSC – age dependant

Direct standardization. All invasive nonmelanoma skin cancers

A population-based study of skin cancer incidence and prevalence in renal transplant recipients F.J. Moloney et al BJD 2006

NICE Guidance 2006Care of transplant patients

Transplant patients who have precancerous skin lesions or who havedeveloped a skin cancer should be seen in a dedicated ‘transplantpatient skin clinic’, either in the transplant centre or in a hospitalcloser to the patient’s home, according to the choice of the patient.

Close links should be established between the transplant centre, localphysician and dermatologist for the management of transplant patientspostoperatively.

Dermatologists managing transplant recipients with multiple and/orrecurrent skin cancers need to liaise with the transplant teamregarding reduction of immunosuppression and the use of systemicretinoids in order to reduce the risk of invasive disease.

Improving Outcomes for People with Skin Tumours including Melanoma

Skin measures 2008

The network board should agree in consultation with the NSSG and cancer lead clinicians of each trust in the network, which localities will staff and run a clinic for immunocompromised patients with skin cancer.

The network should designate at least one such clinic, and (in addition, if necessary) any locality which contains a trust which hosts a centre for renal and/or liver and/or cardiac transplants should be required by the network to run such a clinic.

Manual for Cancer Services 2008

NICE Guidance 2006Care of high risk groups

Specialised services commissioners, together with their cancer network(s), should undertake a needs assessment for these special groups of patients, plan the provision of appropriate specialist care and put in place the necessary commissioning arrangements.

Network-wide protocols should be developed that describe the pathways of care for these special groups of skin cancer patients.

Commissioners should receive results of audits of the care of these special groups.

Information provision for patients in these special groups should be tailored to their specific needs and contain information on their condition and relevant patient support groups. Links should be made to national support groups, to assure the quality of information (see chapter on ‘Patient-centred care’).

Improving Outcomes for People with Skin Tumours including Melanoma

All patients with a high risk of developing skin cancer should be counselled effectively by a dermatologist or a CNS about sun protection before they develop any skin lesions, and should have annual checks carried out thereafter.

All patients in high-risk groups with precancerous skin lesions (e.g. multiple warty lesions and/or AK) should be referred early to a dermatologist for assessment, active treatment and follow-up.

Once patients at high risk start to develop skin lesions they should be offered at least 6-monthly follow-up.

Improving Outcomes for People with Skin Tumours including Melanoma

Audit aims

To quantify roughly the numbers of transplant patients currently receiving care within Skin Cancer MDTs

To assess compliance with NICE guidance and skin measures

Audit design

Prospective data collection Standardised proforma across network Cascaded by MDT lead. Caldicott approval for each trust

Very simplified data collected 2 month data collection period

1/2/10 to 31/3/10

Audit findings

51 patient contacts reported across all sites (48 patients) 20F:28M

Equivalent to 306/year assuming no seasonal variation

10

1220

9 Newcastle

Durham

Sunderland

Middlesborough

Type of transplant

69%

21%

10%

kidney

heart

liver

Type of appointment?

new urgent 4

new routine 3

review urgent 2

review routine 41

Seen in which department?

dermatology 45

maxillofacial surgery 5

plastics 1

Appointment types

0

5

10

15

20

RVI JCUH SRH UHND

new urgent new routine review urgent review routine

Surgery required?

26/51 appointments resulted in surgery 3/4 new urgent 2/3 new routine 1/2 review urgent 20/42 review routine

0

5

10

15

20

RVI JCUH SRH UHND

general Rapid access plasics / max fax

Clinic type

Transplant patients alive with a functioning graft, May 10, in the ‘North of England’

Tx type Area 1* Area 2**

Kidney 1362 1557

Pancreas 239 115

Kidney/pancreas 399 411

Heart 13 12

Lung(s) 80 67

Heart/lungs 10 6

Liver 5 9

Liver/kidney 52 41

Heart/kidney 0 2

Liver/pancreas 0 1

Liver/lung 0 1

Total 2160 2222

* comprises postcode areas CA, DH, DL, LA, NE, SR, TS

Information from NHS Blood and Transplant June 2010

Transplant patients alive with a functioning graft, May 10, in the ‘North

of England’

Tx type / postcode area CA DH DL LA NE SR TSKidney and/or pancreas 130 119 153 107 521 101

296Heart and heart/lung 15 32 28 6 99 22

47Lung(s) 3 6 12 6 25 8

20Liver (inc. liver/kidney) 33 26 35 24 177 34

75

Total 181 183 228 143 822 165438

Information from NHS Blood and Transplant June 2010

Renal transplant patients by site of renal review

renal transplant recipients

Newcastle600

JCUH435

Sunderland / Durham280

Carlisle115

Annual transplant visitIncludes skin check

Referral links to dermatology

Seen in general clinicNo routine skin checks

Informal links with dermatology

Proposed transplant clinicCurrently no links with dermatology

Work in progress

Seen in general clinicNo routine skin checks

Informal links with dermatology

Models of care

Single regional transplant clinic

+ Specialist care+ Potential for education at time of transplant- Travelling distances may reduce accessibility and

compliance- Potentially large numbers- Loss of interface with local physicians- Loss of MDT control

Models of care 2

Local dedicated immuno-suppressed clinic

+ Opportunity for multi-disciplinary care in local setting

+ Linked with local MDT- Numbers likely to be small

Models of care 3

Protected slots within Rapid Access clinic

+ Easy access for both new and review patients+ Facilities for immediate surgery+ Close links with physicians+ MDT centred care- Busy clinic with short time slots

Summary of findings

51 patient episodes involving solid organ transplant recipients were reported within the area studied over a 2 month period.

27% of these were seen within a rapid access clinic; none in a dedicated transplant clinic.

The majority were routine review patients but 51% required surgery

Comments

These numbers are low in comparison to the local population of SOTRs ? underreporting ? Unmet need within the SOTR population

The majority are still seen in general clinics, even in those areas with rapid access clinics

Prompt access to surgery is essential for these high risk patients

Recommendations

Planning for dedicated clinics or rapid access slots essential in all parts of the network

Dialogue with physicians Skin assessment within transplant clinics

? by whom Easy access to skin cancer services Education of new transplant recipients