Rajiv Nijhawan, MD, is associate professor of dermatology and Mohs surgeon at UT Southwestern (UTSW) Medical Center and director of the UTSW High Risk Skin Cancer Transplant Clinic, both in Dallas, Texas.
Rajiv Nijhawan, MD, is associate professor of dermatology and Mohs surgeon at UT Southwestern (UTSW) Medical Center and director of the UTSW High Risk Skin Cancer Transplant Clinic, in Dallas, Texas. He is one of several clinicians who will be presenting “Pearls for Surveillance and Management of High-Risk Skin Cancer Patients” at this year's American Academy of Dermatology Virtual Meeting Experience (AAD VMX). The session will focus on the greater skin cancer risk that organ transplant recipients face, as well as discuss results Nijhawan and colleagues have seen at their clinic dedicated to these patients.
What developments are you especially looking forward to hearing about at AAD VMX?
Because my subspecialty is surgery, a skin cancer oncology focus, those are all the talks that I always look forward to hearing about just because they're most related to my daily practice. There's some great surgical talks, some great oncology-related talks. Those are the sessions I'm most looking forward to.
Can you tell us about your presentation at this year’s meeting?
What we try to do in this talk is break it down into like what's been the most helpful as we implement [our transplant] clinic, in terms of how can we improve our patient outcomes as much as possible. It's really just high-yield pearls that we're hoping other practitioners [and] other physicians across the country can use in the information we present and apply it to their daily practice.
It's very much a clinically high-yield type of talk, where we review simple things like which medications are at higher risk. One, for example, is azathioprine. Azathioprine historically was used a lot in transplant patient populations. But we know that, unfortunately, it's one of the drugs that has an even higher risk compared to other immunosuppressant medications. Not every immunosuppressive medication is built the same. Some actually predispose [patients] to higher rates of skin cancer compared to others.
So one pearl, for example, is looking at medications closely, having a conversation with the transplant teams or the transplant doctor, [saying], “Hey, can we switch this medication to this alternative?” Sometimes something as simple as that can really make a difference in terms of decreasing rates of skin cancer. Sometimes a patient’s on a medication at 50 mg once a day, so can we see if they can tolerate 25 mg a day without rejecting their organ?
On the transplant side of things, they're so focused on, “Let's not change what's not broken.” From their perspective, their organ’s working well, they don't have signs of rejection, they can breathe better. But there are obviously downstream side effects with these medications. So sometimes we just kind of make the transplant teams reflect on that, asking, “Hey, this patient's developed 6 skin cancers in 6 months. What wiggle room do we have for decreasing this dose maybe or changing this dose?” They're very receptive to that. And I think it was early on seeing the impact we had and seeing the positive change we're having for our patients who were a lot more open to having those conversations.
Another pearl is, there's medication called voriconazole. Initially, our lung transplant patients were on that prophylactically to prevent fungal infections, just without any end in sight. But the problem with that medication was it’s phototoxic. Meaning if you're on the medication, you go out in the sun, you just can get a sunburn almost immediately—and that obviously puts them at a higher risk for skin cancer development. And while, yes, the prophylaxis, meaning preventing fungal infections, is important, it's kind of a balance: Is that that important to have every day for the rest of your life vs now they're developing dozens of skin cancers a year?
So having those conversations allowed us to say which patients surely need that medication, whereas which patients may forego that medication, or now that there's newer alternatives, should we consider an alternative medication to that early on? For so many years, it was kind of the only great option. But now that we've had more recently, in the last 4 or 5 years, alternatives, [we can ask], “Hey, can we consider this incentive there?
So that's really the focus of our talk: What can you take home to your patients when you're telling them what to look for? And it's just simple pearls, and then we kind of review some cases. At the end of our talk, my colleague, Dr. Srivastava [Divya Srivastava, MD], really highlights some of our own personal patients and the simple changes we made that we hope will benefit them long term.