Systemic Chemoprevention for Skin Cancer in Transplant Recipients

The talk reviewed systemic chemoprevention options for skin cancer in transplant recipients, focusing on nicotinamide, acitretin, and capecitabine. Nicotinamide was described as promising but controversial: while an initial trial showed benefit, a later transplant-recipient trial was negative and likely underpowered, biased toward higher-risk patients already on the drug, and possibly enrolled patients too late in their disease course. The speaker emphasized that benefit may be greatest when nicotinamide is started earlier, after only one or two prior skin cancers, and cited additional data suggesting an inverse association with new keratinocyte cancers. Acitretin also appeared effective across several studies in transplant recipients, with roughly 50% reductions in skin cancers, but the benefit seems to disappear after stopping therapy and is mainly supported by smaller or underpowered studies. Capecitabine was presented as a true systemic chemotherapy option with evidence limited to case reports and case series; it may reduce actinic damage and skin cancers but has substantial toxicity, requires careful monitoring, and should include testing for DPD deficiency because severe toxicity can be fatal. Overall, the speaker concluded that nicotinamide and acitretin may help when used consistently, larger randomized trials are needed, and capecitabine should be reserved for refractory cases because of tolerability concerns.