2023-08-21 09:08:39
Hungarian-born dermatologist Dr. Emöke Rácz, who is currently working at the University Medical Center Groningen (UMCG), is passionate about tackling complex problems in dermatology. One such issue that she focuses on is skin cancer in transplant patients. Dr. Rácz sheds light on when, where, and why this type of cancer occurs in transplant patients, its impact on patients, how the risk can be minimized, and the research she is conducting in this field.
Born in Budapest, Dr. Rácz spent two years researching rare hereditary skin diseases in her home country. However, she felt uncomfortable within the strict hierarchical structure of the Hungarian healthcare system. Seeking new experiences, she worked in the United States for one year before coming to the Netherlands. She decided to pursue dermatology training in the Netherlands, partly because her boyfriend, now husband, is Dutch. Dr. Rácz speaks highly of the healthcare system in the Netherlands, particularly the low-threshold collaboration and communication among healthcare professionals.
At the UMCG Transplantation Center, Dr. Rácz emphasizes the importance of informing transplant patients about the risks of skin cancer and prevention strategies. Regular visits to the dermatologist for screening are recommended for transplant patients. Dr. Rácz has encountered numerous transplant patients with skin cancer, particularly those who have undergone kidney and lung transplants. These patients face unique challenges, with higher rates of cancer recurrence, metastasis, and the need for multidisciplinary care. Dr. Rácz aims to find better ways to help this patient population.
The increased life expectancy after organ transplantation, attributable to improved immunosuppressive therapy, has also led to an increased risk of cancer in transplant patients. The type of transplant plays a significant role in determining the risk of skin cancer. Lung and heart transplant patients, who require higher levels of immunosuppressants, face the highest risk of skin cancer. Kidney transplant patients, who have longer survival rates, also exhibit a high incidence of skin cancer. Dr. Rácz’s own study revealed that skin cancer typically develops around seven years after transplantation. The risk of cutaneous squamous cell carcinoma (cSCC) is at least 50 times higher in transplant patients, and the likelihood of developing melanoma is three to four times higher than that of the general population. These cancers tend to be more aggressive and metastasize more quickly. Sun-exposed areas such as the head, neck, hands, forearms, lower legs, and feet are often affected.
Dr. Rácz stresses the importance of transplant patients being cautious in the sun. Studies have shown that many patients do not adequately consider this risk. However, she also emphasizes the need for a healthy balance between sun protection and maintaining an active lifestyle.
Treating skin cancer in transplant patients poses unique challenges, as the cancer often recurs. Having to undergo excisions once or twice a year can be burdensome for patients. When the cancer recurs deeply, grows significantly, or metastasizes to the lymph nodes, treatment becomes more difficult, and larger operations may be necessary, or in some cases, no longer feasible. Dr. Rácz’s research has shown that the quality of life of transplant patients with skin cancer is not significantly impacted. However, disfiguring scars and recurring skin cancer can have negative effects on patients’ well-being. Transplant patients tend to view skin cancer procedures relatively positively compared to their previous medical experiences.
Not all immunosuppressive medications carry the same risk of skin cancer. Individuals with a history of skin cancer or its precursors may be prescribed medications with a lower risk of skin cancer, such as mycophenolate mofetil. However, the choice of medication depends on multiple factors.
The question of whether transplant patients should undergo more frequent screening for skin cancer is currently under discussion in the Netherlands. Dr. Rácz explains that the Netherlands takes a reserved approach to this, with dermatologist screening typically initiated when there is already a skin problem. However, other countries like Germany and the US adopt a more proactive stance. Dr. Rácz believes that screening for high-risk individuals is meaningful but does not necessarily have to be conducted by dermatologists.
Dr. Rácz is involved in two research studies focusing on cancer in transplant patients. One study, called TransplantLines, examines the outcomes of transplant patients at UMCG, including quality of life, physical functioning, and cognitive functioning. Skin cancer data collected in this study is currently being analyzed to identify new risk factors. Dr. Rácz also conducts research on vulnerable elderly individuals with skin cancer, exploring how healthcare providers manage their vulnerability. The aim is to strike a balance between avoiding excessive burdensome treatments that could worsen the patients’ condition and providing necessary treatments to address cancer effectively. Dr. Rácz expects to publish the results of this research in one to two years.
Collaboration between centers is crucial in the relatively small field of research focused on skin cancer in transplant patients. Dr. Rácz is participating in the SCOPE-ITSCC Metastases Study, a large study initiated in Leiden that evaluates the risk of cSCC metastasis in transplant patients. The results of this study will be presented in 2022 and are eagerly awaited. Initial findings from the study suggest an association between treatment with tacrolimus and cSCC metastasis, while conversion to mTOR inhibitors does not reduce the risk. However, further research is needed to confirm these findings.
By conducting research, raising awareness of the risks of skin cancer in transplant patients, and collaborating with other centers, Dr. Rácz is dedicated to improving the care and outcomes for this vulnerable patient population.]
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