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Cancer Incidence Before and After Kidney Transplantation
Claire M. Vajdic, PhD;
Stephen P. McDonald, PhD;
Margaret R. E. McCredie, PhD;
Marina T. van Leeuwen, MPH;
John H. Stewart, MB, ChB;
Matthew Law, PhD;
Jeremy R. Chapman, MD;
Angela C. Webster, PhD;
John M. Kaldor, PhD;
Andrew E. Grulich, PhD
JAMA. 2006;296:2823-2831.
Context Immune suppression after organ transplantation is associated with a markedly increased risk of nonmelanoma skin cancer and a few virus-associated cancers. Although it is generally accepted that other cancers do not occur at increased rates, there have been few long-term population-based cohort studies performed.
Objective To compare the incidence of cancer in patients receiving immune suppression after kidney transplantation with incidence in the same population in 2 periods before receipt of immune suppression: during dialysis and during end-stage kidney disease before renal replacement therapy (RRT).
Design, Setting, and Participants A population-based cohort study of 28 855 patients with end-stage kidney disease who received RRT, with 273 407 person-years of follow-up. Incident cancers (1982-2003) were ascertained by record linkage between the Australia and New Zealand Dialysis and Transplant Registry and the Australian National Cancer Statistics Clearing House.
Main Outcome Measure Standardized incidence ratios (SIRs) of cancer, using age-specific, sex-specific, calendar year–specific, and state/territory–specific population cancer incidence rates.
Results The overall incidence of cancer, excluding nonmelanoma skin cancer and those cancers known to frequently cause end-stage kidney disease, was markedly increased after transplantation (n = 1236; SIR, 3.27; 95% confidence interval [CI], 3.09-3.46). In contrast, cancer incidence was only slightly increased during dialysis (n = 870; SIR, 1.35; 95% CI, 1.27-1.45) and before RRT (n = 689; SIR, 1.16; 95% CI, 1.08-1.25). After transplantation, cancer occurred at significantly increased incidence at 25 sites, and risk exceeded 3-fold at 18 of these sites. Most of these cancers were of known or suspected viral etiology.
Conclusions Kidney transplantation is associated with a marked increase in cancer risk at a wide variety of sites. Because SIRs for most types of cancer were not increased before transplantation, immune suppression may be responsible for the increased risk. These data suggest a broader than previously appreciated role of the interaction between the immune system and common viral infections in the etiology of cancer.
Author Affiliations: National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia (Drs Vajdic, Law, Kaldor, and Grulich, and Ms van Leeuwen); Australia and New Zealand Dialysis and Transplant Registry, Queen Elizabeth Hospital, Adelaide, Australia (Drs McDonald, Chapman, and Webster); Disciplines of Medicine and Public Health, University of Adelaide, Adelaide, Australia (Dr McDonald); Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand (Drs McCredie and Stewart); and Centre for Transplant and Renal Research, Millennium Institute, Westmead Hospital, University of Sydney, Sydney, Australia (Drs Chapman and Webster).
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