Missed opportunities for prevention: deficits in skin cancer and sun protection knowledge before solid organ transplantation

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Abstract
Cumulative ultraviolet radiation exposure and chronic immunosuppression are major risk factors for keratinocyte cancers. Squamous cell carcinomas, the most frequent malignancies following solid organ transplantation, show markedly increased incidence and aggressiveness in transplant recipients. While posttransplant dermatologic surveillance is well established, pretransplant skin cancer prevention remains insufficiently addressed. This monocentric cross-sectional study (August 2023 to August 2025) assessed skin cancer and sun protection knowledge in adult transplant candidates undergoing dermatologic screening at a university hospital dermatology outpatient clinic, using the validated 25-item Skin Cancer and Sun Knowledge (SCSK) Scale, supplemented by questions on immunosuppression-related risk awareness and self-perceived knowledge adequacy. Immunosuppression-naive transplant candidates constituted the primary cohort; immunosuppression-experienced transplant candidates served as reference. Descriptive and nonparametric analyses were performed. Among 154 transplant candidates (144 immunosuppression-naive and 10 immunosuppression-experienced), immunosuppression-naive (mean age: 52.2 years; 69.4% male) demonstrated significantly lower SCSK scores than immunosuppression-experienced (13.6 vs. 16.9; P = 0.018). Deficits were greatest regarding tanning behavior and prevention, while symptom recognition was poor across both groups. Only 59.0% of immunosuppression-naive transplant candidates recognized immunosuppression as major skin cancer risk factor, and 29.2% felt adequately informed. Higher knowledge was associated with personal ( P = 0.031) or family ( P < 0.001) history of skin cancer, regular screenings ( P < 0.001), and lighter Fitzpatrick skin types ( P = 0.011). Transplant candidates, particularly those without prior immunosuppression, exhibit substantial deficits in skin cancer and sun protection knowledge. The pretransplant phase represents a critical, underutilized opportunity for early, structured dermatologic education before lifelong immunosuppression and increased cancer risk.

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