# Skin cancer after an organ transplant

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## TL;DR

The drugs that keep a transplanted organ alive let skin cancers grow, and they grow differently: faster, in numbers, and far more likely to spread. This group is large, it is getting larger as transplant recipients live longer, and almost every trial of the drugs that would help them has excluded them.

## Summary

A solid organ transplant recipient has something like 65 to 100 times the general risk of cutaneous squamous cell carcinoma, and the ratio in the other direction is also reversed: in the general population basal cell carcinoma outnumbers squamous cell carcinoma about four to one, and after a transplant squamous cell carcinoma dominates. The tumours are multiple, recur, and metastasise at rates that would be extraordinary in an immunocompetent person. Chronic lymphocytic leukaemia and other causes of immune suppression produce a milder version of the same picture.

Three levers exist and each has a cost.

The first is the immunosuppression itself. TUMORAPA randomised 120 kidney transplant recipients who had already had one cutaneous squamous cell carcinoma to switch from a calcineurin inhibitor to sirolimus or to carry on: new squamous cell carcinomas occurred in 22 per cent against 39 per cent, relative risk 0.56 (0.32 to 0.98), with the median time to a new cancer moving from 7 to 15 months. The cost was 60 serious adverse events against 14, and 23 per cent stopped the drug. Switching rapidly caused twice as many serious events as switching gradually.

The second is chemoprevention, which belongs to the prevention layer of this site but has a transplant-specific complication: the effect of nicotinamide, established in immunocompetent people with a history of keratinocyte cancer, has not been reproduced in transplant recipients, and a large matched cohort of 33,822 patients found no overall significant risk reduction in the 1,334 transplant recipients within it, although early use was associated with reduced squamous cell carcinoma incidence. Acitretin is used and is hard to tolerate.

The third is immunotherapy for advanced disease, and until recently it was simply refused, because PD-1 blockade can cause the graft to be rejected. A phase 1 study at Dana-Farber treated twelve kidney transplant recipients with advanced cutaneous squamous cell carcinoma after cross-tapering immunosuppression to a mammalian target of rapamycin inhibitor and pulsing prednisone around each cycle: no rejection and no graft loss occurred, and five of eleven evaluable patients responded (46 per cent, 90 per cent confidence interval 22 to 73). One patient died of angioedema and anaphylaxis attributed to the immunosuppressive cross-taper rather than to the cemiplimab.

Twelve patients and one randomised trial of 120 is the whole prospective evidence base for the group at highest risk of this cancer. Everything else is case series. That is the gap, and it is a consequence of an eligibility criterion rather than of biology.

## Fields

- Kind: Term
- Last checked: 2026-09-25
- Also known as: skin cancer in transplant recipients; immunosuppressed skin cancer; solid organ transplant recipient skin cancer; post-transplant squamous cell carcinoma

## Notes

- What the scale of it looks like from the patient leaflet. The British Association of Dermatologists and the British Society for Skin Care in Immunosuppressed Individuals say squamous cell carcinoma is 150 times more common in transplant recipients than in the general population and is the most frequent skin cancer in this group, basal cell carcinoma is up to 10 times more common, in a UK study one in three people who had had a transplant for more than 10 years had developed a skin cancer, and by about 20 years after transplantation about half will have had one. Two in three transplant recipients who have had one skin cancer are likely to have several over their lifetime. The population studies agree on the direction: in 10,476 Swedish recipients followed over 93,432 person-years the standardised incidence ratio for squamous cell carcinoma was 121 (95 percent confidence interval 116 to 127) and 198 for heart or lung recipients, and in 10,649 American recipients the incidence of squamous cell carcinoma was 812 per 100,000 person-years.
- Three things the leaflet asks of a transplant recipient that it does not ask of anyone else. What counts as suspicious is different: pain in a growing skin lump is specifically flagged as suspicious for a squamous cell carcinoma. Sun protection is stricter, SPF 50 with five UVA stars applied daily to all exposed skin all year round, and it applies to people with brown and black skin on immunosuppressants, where routine sun protection would otherwise rarely be needed in the UK. And the treatment itself can change: where someone has multiple or more serious skin cancers, the dermatologist may discuss with the transplant physicians whether reducing or switching the immunosuppression would reduce the number of future cancers, and preventive medicines, the vitamin A derivative acitretin and vitamin B3 as nicotinamide, may be added.

## Sources

- TUMORAPA (New England Journal of Medicine 2012): https://doi.org/10.1056/NEJMoa1204166
- Cemiplimab in kidney transplant recipients (Journal of Clinical Oncology 2024): https://doi.org/10.1200/JCO.23.01498
- Nicotinamide in 33,822 patients including 1,334 transplant recipients (JAMA Dermatology 2025): https://doi.org/10.1001/jamadermatol.2025.3238
- British Association of Dermatologists and BSSCII: skin cancer advice for organ transplant recipients, patient information leaflet (June 2024): https://www.skinhealthinfo.org.uk/condition/skin-cancer-in-organ-transplant-recipients/
- Krynitz et al., risk of skin cancer and other malignancies in kidney, liver, heart and lung transplant recipients 1970 to 2008, Swedish population-based study of 10,476 recipients (Int J Cancer 2013): https://doi.org/10.1002/ijc.27765
- Garrett et al., incidence of and risk factors for skin cancer in organ transplant recipients in the United States, 10,649 recipients (JAMA Dermatology 2017): https://doi.org/10.1001/jamadermatol.2016.4920
- Brantsch et al., analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: prospective study of 615 patients (Lancet Oncology 2008): https://doi.org/10.1016/S1470-2045(08)70178-5

## Connected records

- terms: [Immune-related adverse events (irAEs)](https://onco.cc/terms/irae/), [Sun protection after a skin cancer diagnosis](https://onco.cc/terms/sun-protection-after-skin-cancer/), [The next skin cancer: second primaries after a keratinocyte cancer](https://onco.cc/terms/second-primary-skin-cancer/)
- technologies: [Chemoprevention & risk-reducing surgery](https://onco.cc/technologies/chemoprevention/), [Immune checkpoint inhibitors](https://onco.cc/technologies/checkpoint-inhibitor/)
- pathways: [Field cancerisation](https://onco.cc/pathways/field-cancerisation/)
- cancers: [Advanced cutaneous squamous cell carcinoma](https://onco.cc/cancers/advanced-cutaneous-scc/), [Basal cell carcinoma](https://onco.cc/cancers/basal-cell-carcinoma/), [Cutaneous squamous cell carcinoma](https://onco.cc/cancers/cutaneous-scc/), [Merkel cell carcinoma](https://onco.cc/cancers/merkel-cell-carcinoma/), [Skin cancer (all types)](https://onco.cc/cancers/skin-cancer/)
- fronts: [Early Detection & Screening](https://onco.cc/fronts/early-detection/), [Prevention & Risk](https://onco.cc/fronts/prevention/)
- drugs: [Acitretin](https://onco.cc/drugs/acitretin/), [Cemiplimab](https://onco.cc/drugs/cemiplimab/), [Nicotinamide](https://onco.cc/drugs/nicotinamide/), [Sirolimus](https://onco.cc/drugs/sirolimus/)
- trials: [Cemiplimab for kidney transplant recipients with advanced skin squamous cell carcinoma](https://onco.cc/trials/cemiplimab-kidney-transplant-cscc/), [EMPOWER-CSCC-1](https://onco.cc/trials/empower-cscc-1/), [TUMORAPA (switching from a calcineurin inhibitor to sirolimus after a transplant skin cancer)](https://onco.cc/trials/tumorapa/)

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