Hematopoietic cell transplantation (HCT) has been established as a life-saving treatment for several cancers, but as the median survival for these patients has improved, physicians are becoming more aware of the long-term issues that follow these patients for the rest of their lives, including the difficult concept of being at greater risk of developing other cancers.
Knowing the risks makes screening and prevention efforts crucial. A study published in the Journal of the National Comprehensive Cancer Network showcased the efforts from City of Hope in Los Angeles, California, to focus on this area of key need in cancer survivors. The randomized TEACH study (NCT04358276), in which over 700 patients and their primary care physicians received communications and materials encouraging regular monitoring and screening for skin cancers, led to a near-tripling of self-exams and annual physician skin examinations from 15.8% at baseline to above 47.5% at 12 months.1
The outreach to the patients themselves proved especially effective in motivating survivors to pursue preventive care for secondary malignancies. “Never underestimate the power of patient and survivor engagement. When they understand what is at stake and feel empowered to protect their health, they can take a much more active role in their care,” said Saro H. Armenian, DO, MPH, first author of the study, in an interview with Targeted OncologyTM.
Armenian, who is chair of the Department of Pediatrics and director of the Division of Outcomes Research in the Department of Population Sciences at City of Hope, explained the goals of the study and its implications for the long-term care of transplant survivors. He emphasized that empowering patients to take an active role in their health can make educational materials, text messages, and other outreach from a cancer center more effective, particularly given the constraints facing modern primary care.
Targeted Oncology: What led you to look more into how you can detect these secondary skin cancers in patients who received a hematopoietic cell transplant?
Saro H. Armenian, DO, MPH: Hematopoietic cell transplantation has emerged as a curative therapy for many patients with hematologic malignancies and other serious conditions. The field began to focus more deliberately on survivorship approximately 20 years ago, as increasing numbers of transplant recipients were cured and lived for years after treatment. We recognized that they were at risk for unique long-term health issues, or late effects, related to the primary disease, prior therapies, and the transplant itself.
Recognizing these risks was the first step. The next was identifying ways to mitigate them, whether by changing therapy or developing strategies for early screening and detection.
What makes skin cancer risk an area of special concern when following these patients?
Skin cancer may receive less attention as a long-term health burden than other health conditions, but it is especially important among transplant survivors. Large cohort studies indicate that it is one of the most common subsequent cancers in this population.2,3 Not only is the risk elevated, but skin cancers are highly amenable to prevention, early detection, and screening because they're in a visible location, unlike for example, colon cancer, which cannot be readily detected by patients themselves.
The combination of increased risk and the opportunity for early screening and detection provides a strong rationale for developing innovative ways to intervene in this group. Skin cancers also tend to occur at younger ages among transplant survivors than in the general population.
When transplant survivors develop skin cancer, it may be more aggressive, requiring more invasive surgery or systemic therapy. That makes proactive screening and detection even more important.
Can you explain the key features of the study that were meant to improve screening for skin cancer?
We designed the intervention around several key principles. First, we wanted to reach survivors at a moment when they may be especially receptive to taking charge of their health. Many of our patients have relapsed/refractory disease or aggressive disease that requires a transplant. They go through the acute phase of the transplant and all the associated toxicities, once they emerge from that phase, they enter a new stage of life. I look at that as a hopeful chapter, a chapter of optimism marked by a renewed focus on the future. This study was about harnessing that moment to empower patients.
We anchored the intervention at a specific time point after the completion of the treatment, when patients naturally ask: “What can I do to protect my health and reduce the likelihood of going through another experience like this?” By pairing messages of optimism and empowerment with clear information about their individual risks and practical steps they can take, we hoped to reduce their long-term burden of illness.
We also wanted to leverage technology. It is incredibly important for us to think about a scalable strategy. We didn't want this clinical trial to be relevant only to patients coming to Duarte, California. We wanted the intervention to work across geographic locations and age groups, with technology expanding access to information and empowering patients to pursue screening.
How did you reach out to patients and physicians in the study?
We focused on patients who were in remission from their primary disease and were willing to participate. The randomized study had 3 arms; we reported on 2 arms. The intervention had 2 important components.
One was educating and empowering survivors about their unique risks and providing practical guidance on skin cancer screening: “What does skin cancer look like? What lesions may be suspicious? How do you perform a comprehensive skin self-exam? How often should you be doing it?”
The second component addressed the clinicians caring for transplant survivors in the community setting. After patients transitioned from the cancer center to primary care, we contacted their primary care physicians. We wanted to educate them about the unique risks in this population, what makes these patients special, and the tools they need for early detection and screening of skin cancer: How often should screenings occur? What should they do if they notice a suspicious lesion? How should they counsel and reassure patients when a lesion does not appear suspicious?
That component was equally important because intervening with patients alone might not be enough. Patients also need a partner in the community who understands the importance of prevention and screening.
What were the most interesting findings from the study?
Participants in both arms of the study received the same patient-directed intervention, included educational materials, text messages, instructions for performing comprehensive skin self-examinations, and encouraging messages focused on patient empowerment. In both arms, we saw a very similar increase in reported skin cancer screening rates.1 It went from below 35% to over 80% in certain subgroups, which was quite remarkable and potentially transformative. Within a relatively short period, several patients identified suspicious lesions that were subsequently identified as cancer.
KEY FINDINGS
In the patient-only intervention group, the rate of skin self-examination and physician skin examination increased from 15.8% at baseline to 47.5% at 12 months; in the group that also had outreach to physicians, the increase was from 18.0% to 52.1%. Self-examination rates rose from 34.7% to 81.5% and from 31.5% to 79.0% in the respective arms.1
In the patient-only intervention group, 174 of 351 received clinical skin examination, leading to a biopsy in 39 and 17 skin cancer diagnoses by self-reporting; in the physician outreach group, 228 of 369 received clinical examination, leading to biopsy in 45 and 13 reporting a skin cancer diagnosis.
The big surprise for us was the arm that included the physician intervention. There was an improvement in physician-performed skin cancer screening rates, but we saw similar improvements in both arms. We had anticipated a bigger incremental benefit from physician outreach.
Several factors may have contributed to this. The study was initiated in October 2020, when health systems were confronting major surges of the COVID-19 pandemic. Primary care doctors were focusing on acute management of COVID-19, COVID-related symptoms, vaccination messaging, high patient volumes, and staffing shortages. In that context, implementing a very specific intervention for skin cancer screening among transplant survivors was particularly challenging.
We were also working within established referral practices. We hoped that by educating and physicians and providing them with the tools for skin cancer screening, they would take a more active role. In current practice, time constraints mean that if there are any suspicious lesions, a primary care physician is likely to refer the patient to dermatology rather than performing the management and triage themselves.
This finding emphasizes the importance of patient engagement. Even in the study arm that did not involve outreach to physicians, the rates of physician examinations nearly doubled, likely in part because the patients themselves were asking their physicians to perform the screening. Never underestimate the power of patients. When they understand what is at stake and feel empowered to participate in screening, they can take a more active role in their care.
Were you able to determine the reasons why outreach to primary care physicians was less effective than expected?
Unfortunately, we weren't able to obtain direct feedback. The indirect feedback suggested that the barriers varied according to the size of the practice, the knowledge of the physician, and the competing demands facing each practice, including pandemic-related pressures early in the study. These challenges reflect the rapidly evolving health care environment and the growing pressures on primary care.
The reassuring silver lining for me was that the one constant was the patient. Our findings reinforce the value of patient-directed strategies, rather than strategies focused solely on physician or individual providers, because the context in which medicine is practiced is so varied and continues to change so rapidly that a single physician-directed approach is unlikely to work equally well everywhere.
We are using a pivotal moment after a life-changing experience to provide patients and survivors with hopeful, empowering guidance. None of our patients asked to get cancer, but once they've gone through that journey there's a point at which they ask the very natural question “What can I do to make sure that something bad doesn't happen to me moving forward?” We can show them practical steps that are within their control. This also speaks to the broader ethos of helping survivors take an active role in their health and preventive care.
How are you incorporating these findings into City of Hope’s survivorship program, and how are you looking to improve in the future?
We are developing the next phase of this strategy, including how we use technology to bridge gaps in survivorship care. This includes using technology and the electronic medical record to communicate with patients through their portal about individualized, evidence-based recommendations for screening, prevention, and early detection, while continuing to communicate remotely through supportive and empowering messages.
Although we hoped reported skin cancer screening rates would rise from 35% or less to 100%, they did not. One in five patients who still did not perform skin self-examinations despite receiving education, materials, and regularly scheduled text messages and understanding that their risk was elevated. Clearly, elements of the intervention must be refined or intensified to better meet the needs and perspectives of those who did not follow through.
No intervention will achieve 100% success rate, but that should not prevent us from trying to get as close as we can. We will continue working with survivors to identify approaches that are motivating, meaningful, and capable of improving their long-term health.
What advice would you have for oncologists and primary care physicians following patients for these long-term issues?
We recognize that primary care physicians manage many patient populations and cannot reasonably be expected to know every issue affecting every subgroup. Whenever possible, they should partner with the transplant center to obtain clear information about the patient’s diagnosis, treatment, transplant history, and the long-term risks and recommended screening schedule. The transplant center should take responsibility for communicating those recommendations clearly; primary care physicians should not have to develop them independently.
Transplant survivors are also at risk for multiple conditions that are either a direct result of their treatment, or in some cases, an underlying genetic predisposition. These patients don't make up a large part of any given practice, and taking a minute before seeing a transplant survivor to understand that the patient’s unique risks and recommended screening can yield substantial benefits over time.
That investment is worthwhile. If we can identify patients at risk for developing long-term issues and provide targeted screening, early detection, and prevention, we can transform many lives with a relatively modest investment of resources.
For hematopoietic cell transplant survivors, skin cancer screening is a low-cost, scalable, and efficient strategy that clinicians can implement in routine practice. At least once a year, every transplant survivor should have a comprehensive skin exam by a clinician. It takes only a few minutes and could have a meaningful impact on long-term outcomes. Given the effective treatments now available for many skin cancers, timely screening and early detection should be considered essential components of survivorship care.
REFERENCES
1. Armenian SH, Du X, Bosworth A, et al. Technology-enabled patient and physician activation to enhance skin cancer screening After HCT: a randomized controlled trial. J Natl Compr Canc Netw. Published online August 6, 2026. doi:10.6004/jnccn.2026.7030
2. Mansilla-Polo M, Montoro J, López-Davia J, et al. Incidence and risk factors of skin cancer and preneoplastic lesions after autologous and allogeneic hematopoietic cell transplantation. Transplant Cell Ther. Published online July 5, 2025. doi:10.1016/j.jtct.2025.06.031
3. Sun CL, Kersey JH, Francisco L, et al. Burden of morbidity in 10+ year survivors of hematopoietic cell transplantation: report from the bone marrow transplantation survivor study. Biol Blood Marrow Transplant. 2013;19(7):1073-1080. doi:10.1016/j.bbmt.2013.04.002
