Skin Cancer Screening in Inflammatory Bowel Disease Patients on Chronic Immunosuppressant Therapy: A Quality Improvement Project

Abstract

Purpose: Inflammatory bowel disease (IBD) patients on chronic immunosuppressants are at increased risk of melanoma and nonmelanoma skin cancer (NMSC). As part of an initiative to assess care in a tertiary IBD center, we undertook a quality project to assess how often IBD patients are evaluated for skin malignancies. Methods: We used DMAIC (Define, Measure, Analyze, Improve, Control) methodology to first assess the amount of screening that occurs. We retrospectively reviewed patient charts from 10/1/2011 to 11/1/2012 of adults in a single tertiary care center undergoing a first consultation in the IBD Clinic and who had been on immunosuppressive therapy for at least 6 months. Information collected included demographics, clinical status and skin care work-up launched at the time of the IBD consultation. Results: 141 patients satisfied study criteria. 71 (50%) were female and the majority (126 patients, 89%) were Caucasian. The average age was 36 years (STD 12.7 years). 93 patients (66%) had Crohn's, 37 (26%) patients had ulcerative colitis and 11 (8%) had indeterminant colitis. 73 (52%) patients were on TNFα inhibitor monotherapy, 32 (23%) patients were on combination therapy with a TNFα inhibitor and another immunomodulator (thiopurine, prednisone or methotrexate), 23 (16%) patients were on thiopurine monotherapy, 6 (4%) patients were on combination therapy not containing a TNFα inhibitor, 4 (3%) patients were on prednisone monotherapy, and 3 (2%) patients were on methotrexate monotherapy. The median duration of immunosuppression was 18 months (range, 6 mo to 31 yr). During their IBD consultation, none of the patients underwent a primary skin cancer screening, defined as discussions regarding sun avoidance, sun protection and minimization of modifiable risk factors for skin cancer. Only 3 patients were educated regarding their increased skin cancer risk. A documented recommendation to use sun screen was provided to just one patient. Eighty-three (59%) patients had a skin exam listed, which was limited in all but two patients. None of the patients were referred to dermatology for a full skin exam or skin cancer screening. Conclusion: Currently, there is a paucity of skin cancer counseling and monitoring in IBD patients. Improving clinician awareness regarding the increased risk of melanoma and NMSC in IBD patients on immunosuppressants is critical for the provision of optimal care and reduction of morbidity and mortality in this at risk population. Our next step is to share these results with clinicians, and then develop a process for identifying those at higher risk for appropriate referral.