title: Reduction of immunosuppression for transplant-associated skin cancer: expert consensus survey.
abstract: BACKGROUND
  Reduction of immunosuppression is considered a reasonable adjuvant therapeutic strategy in solid-organ transplant recipients experiencing multiple or high-risk skin cancers. However, the literature provides no guidance about what threshold of cancer development would warrant initiation of reduction of immunosuppression.
  
  
  OBJECTIVE
  To develop expert consensus guidelines for initiation of reduction of transplant-associated immunosuppression for solid-organ transplant recipients with severe skin cancer.
  
  
  METHODS
  An expert consensus panel was convened by the International Transplant Skin Cancer Collaborative and Skin Care for Organ Transplant Patients Europe Reduction of Immunosuppression Task Force. Thirteen hypothetical patient scenarios with graduated morbidity and mortality risks were presented and mean and mode expert opinions about appropriate level of reduction of systemic immunosuppression (mild, moderate, severe) were generated.
  
  
  RESULTS
  Mild reduction of transplant-associated immunosuppression was considered warranted once multiple skin cancers per year developed or with individual high-risk skin cancers. Moderate reduction was considered appropriate when patients experienced > 25 skin cancers per year or for skin cancers with a 10% 3-year risk of mortality. Severe reduction was considered warranted only for life-threatening skin cancers.
  
  
  CONCLUSIONS
  Reduction of immunosuppression is considered a reasonable adjuvant management strategy for transplant recipients with numerous or life-threatening skin cancers. Proposed guidelines are presented for the graduated reduction of immunosuppression coincident with the increasing skin cancer risks.
authors.affiliation: Department of Dermatology, University of Washington, Seattle, USA. otley.clark@mayo.edu
authors.forename: C C
authors.initials: CC
authors.lastname: Otley
authors.forename: D
authors.initials: D
authors.lastname: Berg
authors.forename: C
authors.initials: C
authors.lastname: Ulrich
authors.forename: T
authors.initials: T
authors.lastname: Stasko
authors.forename: G M
authors.initials: GM
authors.lastname: Murphy
authors.forename: S J
authors.initials: SJ
authors.lastname: Salasche
authors.forename: L J
authors.initials: LJ
authors.lastname: Christenson
authors.forename: R
authors.initials: R
authors.lastname: Sengelmann
authors.forename: G E
authors.initials: GE
authors.lastname: Loss
authors.forename: J
authors.initials: J
authors.lastname: Garces
mesh_terms: D004334:Drug Administration Schedule; D006801:Humans; D016867:Immunocompromised Host; D007165:Immunosuppression Therapy / Q000009:adverse effects* / Q000379:methods; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D016377:Organ Transplantation; D012878:Skin Neoplasms / Q000209:etiology / Q000276:immunology / Q000517:prevention & control*
chemical_list: D007166:Immunosuppressive Agents