Overview 2/11/18. Skin cancer surveillance after cancer therapy: When to worry. Skin cancer risk factors and types. Time to onset

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1 Skin cancer surveillance after cancer therapy: When to worry Carrie C. Coughlin, MD Assistant Professor, Dermatology Washington University School of Medicine F072 - The Big C's: Children, Cancer, and Cutaneous Complications AAD Annual Meeting, 2/17/2018 Division of Dermatology DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Carrie C. Coughlin, MD F072 - The Big C's: Children, Cancer, and Cutaneous Complications DISCLOSURES I do not have any relevant relationships with industry. Division of Dermatology Overview Skin cancer risk factors and types Time to onset Education and screening recommendations 1

2 Patients acquire several risk factors for skin cancer during cancer therapy Chemotherapies Radiation Hematopoietic stem cell transplant GvHD Antifungal therapy (voriconazole) Sun exposure Time Gathering data Childhood Cancer Survivor Study (US and Canada, diagnosed at <21yo) BCC, SCC, melanoma rates increased in cancer survivors Over 40% of patients with NMSC had >1 Turcotte. JAMA. 2017;317(8): Perkins. J Clin Oncol. 2005;23(16): Incidence of skin cancer in pediatric cancer survivors NMSC and MM seen in 1.6% (213/13,132) (2005) Most common sites: Head and neck > back > others 90% occurred within a radiation field, in patients with known radiation fields Perkins. J Clin Oncol. 2005;23(16):

3 Chemotherapies increase skin cancer risk, but radiation therapy is a bigger risk factor Radiation with or without chemotherapy: risk increases with each Gray of radiation exposure Decreased radiation doses à decreased risk for NMSC Cavalier. BMT. 2006;37: Watt. J Natl Cancer Inst. 2012;104(16): Turcotte. JAMA. 2017;317(8): Neoplasms after cancer therapy are declining Age at primary diagnosis, mean (SD), y Subsequent neoplasms, n Subsequent malignant neoplasm, n (%) Overall N= n= n= n= (6.0) 8.4 (5.8) 7.6 (5.8) 7.4 (6.2) (34.0) 523 (25.9) 364 (41.6) 139 (72.0) NMSC, n (%) 1856 (58.5) 1349 (66.8) 470 (50.6) 37 (18.8) Turcotte. JAMA. 2017;317(8): Radiation note: Patients with basal cell nevus syndrome are high risk Obtain old xrays instead of getting new ones Image as little as possible going forward Protect from UV radiation, as well 3

4 Patients have more time to develop skin cancer More years post-treatment France: survival increased from 25% in the 1970s to 75% in 2000 United States: 5-year survival increased from 58% in the 1970s to 80% in the 2000s Pediatric cancer incidence increasing by about 0.6% per year in the US Casagranda Ped Hematol Oncol. 30: Cancer.org Acco.org Risk for skin cancer increases with duration and dose of voriconazole *Verdú-Amarós years of tx Sheu. JAAD. 2105;72(2): *Verdú-Amarós. Pediatr Blood Cancer. 2017;64(4). Mechanism of increased phototoxicity and SCC with voriconazole is unclear Theory: risk with ultrarapid drug metabolism (CYP2C19*17/*17) risk in adults with exposure after allogeneic, but not autologous, HSCT Theory: Drug affects gene expression related to cell-cycle and terminal differentiation in keratinocytes Williams. JAMA Dermatol. 2016;152(6): Kuklinski. JAAD. 2017;77(4): Mansh. Br J Dermatol. 2017;176(3):

5 Skin cancer typically occurs many years after pediatric cancer therapy Increased risk jumps at age 30 (age-adjusted RR 22.9; RR 6.0 in multiple regression analysis) In a CCSS cohort of patients who developed BCC, 83% occurred from the ages of Perkins. J Clin Oncol. 2005;23(16): Watt. J Natl Cancer Inst. 2012;104(16): Patients, parents, and providers need education about risk, recognition, and prevention Rutgers long-term follow-up care program studied pediatric cancer survivors N=94 (60.6% completion rate) Average age: 24.6 (cancer before age 20) Performed skin selfexam % yes 47.9% Physician skin exam 30.9% Prior discussion about skin cancer 60.3% Stapleton. Ped Blood Cancer. 2016;63(3):

6 Cancer survivors are in the sun Israel; 143 pediatric patients with h/o cancer (3.5 ± 3.2 years from treatment) and 150 controls Patients more likely to wear hats (34.5% vs. 20.7%; P=0.009) No difference in wearing sunglasses, covering shoulders, frequency of using sunscreen, staying in the shade Levy-Shraga. PLoS One. 2015;10(9):e The ASK study investigates education and screening Advancing Survivors Knowledge (ASK) about skin cancer study: study protocol for a randomized controlled trial Patient Patient + MD Patient + MD + teledermoscopy Clinicaltrials.gov: NCT ; Registration date: 22 January

7 ealthlinks/english/skin_health_eng.pdf Technology in the mix* UV index apps (examples) Sunscreen reminder apps (examples) UVLens QSun EPA SunWise UV Index Sunscreen reminder *Examples, not endorsements Provider education: Late effects surveillance recommendations among survivors of childhood hematopoietic cell transplantation: A Children s Oncology Group report Biol Blood Marrow Transplant. 2016;22(5):

8 Provider education: New text Provider education: BCC and SCC treatment Newly released guidelines for care of BCC, SCC (JAAD in press) Que et al. Cutaneous squamous cell carcinoma: Management of advanced and high-stage tumors. JAAD. 2018;78(2): Take-home points Radiation and voriconazole are big risk factors for skin cancer in pediatric cancer survivors Onset can be decades after therapy Use your online patient and provider educational resources! 8

9 Acknowledgements Jennifer Huang, MD PeDRA (Pediatric Dermatology Research Alliance) Division of Hematology & Oncology, Department of Pediatrics, Washington University School of Medicine in St. Louis Questions? courthouse-gateway-arch-st-louis- missouri-usa-2 9

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