Malignancy and Solid Organ Transplantation: Evaluating Cancer Mortality, Pretransplant Malignancies, and Cancer Screening

This thesis explores the intersection of malignancy and solid organ transplantation. First, establishing that solid organ transplant recipients (SOTRs) are at risk of cancer mortality and cancer is the second leading cause of death in this population. Second, exploring pretransplant malignancies (PTM): our systematic review identified a lack of clear and consistent recommendations for cancer evaluation of transplant, with only one in every four clinical practice guidelines (CPGs) including recommendations for cancer evaluation. Most recommended cancer screening as per the general population, which might be not adequate to ensure transplant candidates they are free of occult neoplasms. We also found that recipients with PTM in remission are at increased risk of all-cause mortality compared to recipients without prior history of cancer, with increased risk not only of cancer-specific mortality but also non-cancer death. However, when stratified by type of PTM, only those with high-risk PTM had worse outcomes. Lastly, this dissertation explores recommendations for cancer screening in SOTRs and their uptake. A systematic review of CPGs identified several weaknesses in the available recommendations for cancer screening, including variable screening recommendations, lack of recommendations for non-kidney recipients, and paucity of involvement of relevant stakeholders. Our population-based study found that the uptake of cancer screening uptake in SOTR was low; most SOTR had periods when they were non-adherent to screening recommendations during follow-up, and in fact, many recipients were never screened. In addition, we identified that recipients with visits to primary care physicians were more likely to become up-to-date with cancer screening. Overall, the results of this thesis provide compelling evidence that SOTRs are at increased risk of dying from cancer and highlight the role of cancer evaluation of transplant candidates and cancer screening recipients as a strategy to reduce the burden of cancer in this population.Ph.D.2018-12-19 00:00:0