As a kidney transplant recipient, Paris Malachias was accustomed to dealing with skin cancer. It’s a common side effect of post-transplant immunosuppressants, which leave transplant recipients extra sensitive to sun, and Malachias had developed multiple basal cell carcinomas over the years. But in the fall of 2022, he noticed a pimple on his face that didn’t look like the lesions he’d had removed.
When it didn’t go away, a dermatologist biopsied it. The results came back in late December: Malachias, then 73 and retired from the maritime industry in New Orleans, had Merkel cell carcinoma (MCC), one of the rarest and most aggressive skin cancers. Kidney transplant recipients are at a 25-fold increased risk of developing MCC than people who aren’t immune-suppressed.
“It was the worst Christmas we ever had,” said Anna Malachias, his daughter. “We were freaking out.”
It was the first MCC case that Paris Malachias’ dermatologist had ever seen, so his daughter and the rest of the family jumped into research mode.
“My daughter told me, ‘Don’t worry, we will find the best doctor,’” he said.
Determined to find a specialist, Anna Malachias spent Christmas Eve online. Her search led her across the country to Paul Nghiem, MD, PhD, head of the Merkel Cell Carcinoma Program at Fred Hutch Cancer Center and a world expert on this uncommonly diagnosed cancer, and Chris Blosser, MD, who runs a first-of-its-kind center at Fred Hutch focused exclusively on cancer and transplant patients.
She emailed Nghiem, who replied immediately and copied the entire MCC team: “Can you be here on January 2?”
Days later, Paris Malachias flew to Seattle with his daughter, son and wife. When they returned to New Orleans later that week, they had a plan: Paris Malachias would have surgery and radiation in New Orleans but would likely need follow-up in Seattle because MCC is a stubborn cancer that tends to return.
“He and his family were desperate for help,” said Nghiem, who holds the George F. Odland Endowed Chair in Dermatology at UW School of Medicine. “They were between an almost impossible rock and a hard place, needing immune suppression to keep the kidney and needing to stay alive and maintain a good quality of life. I am an optimist, but prior to Paris’ case, we had been unable to manage immune therapy so precisely that we could both keep the kidney and beat the cancer.”
Blosser established the Cancer and Organ Transplant Clinic (COTC) in 2021 to address the increased cancer risk that organ transplant recipients face as well as the unique considerations that cancer patients confront when they need a solid-organ transplant.
Such patients need extra support to navigate the additional challenges that transplant can pose. The COTC operates as an integrated multidisciplinary consult clinic with a real-time tumor and transplantation board, a group of cancer and transplant experts that meets during a patient’s visit to develop an optimal treatment plan. The clinic is part of the Center for Innovations in Cancer & Transplant.
In Paris Malachias’ case, Blosser noted that the small number of people who develop MCC and the even tinier subset who develop MCC as organ recipients requires expertise that few institutions can provide.
“I don’t know of any places other than our clinic that offer this level of support and coordination,” he said.
On one of the family’s trips to Fred Hutch, they discussed immunotherapy treatment, using Paris Malachias’ already compromised immune cells to seek out and destroy the MCC cells. It was a last resort because of the delicate tug-of-war between suppressing his immune system to prevent organ rejection and boosting it to fight cancer.
Nghiem, Blosser and Evan Hall, MD, MPhil, a medical oncologist who specializes in skin and kidney cancers, met with the family to discuss how to reduce the immunosuppressant drugs in order to maximize the effects of immunotherapy.
“It was really reassuring that we had three doctors who are the best of the best sitting in the room with us going over everything, all the risks and the benefits,” said Anna Malachias.
Several months before beginning immunotherapy, Paris Malachias weaned off the immunosuppressants. In June 2023, he started immunotherapy while the team used two new blood tests that provide early warning if the cancer is returning, or if the kidney is being attacked by the immune system. Soon after starting immune therapy for the cancer, there were signs that his kidney was in distress, so Blosser advised decreasing the frequency of immunotherapy and reintroducing a low dose of immunosuppressants.
Reassured by the level of care, the Malachias family decided to relocate to Seattle for six months. “We felt very comfortable and safe being there and meeting with the doctors every three weeks,” said Anna Malachias.
Three years later, Paris Malachias is back home in New Orleans and spent the past summer in his native Greece. He summed up his experience being treated at Fred Hutch: “All three doctors saved my life.”
Skin is the body’s largest organ; skin cells turn over quickly, creating more opportunity for cancer every time a cell divides. Transplant patients are more likely to develop skin cancers because of the immunosuppression drugs that they take every day post-transplant to prevent transplant rejection. It’s a medical conundrum: the same drugs that safeguard a transplanted organ also wreak havoc on a patient’s immune system. Part of the immune system’s job is to scan the body like a lighthouse operator, looking for cancer cells. But when it’s immune-suppressed due to transplant rejection drugs, the immune system can’t do its job.
Blosser and Nghiem maintain registries that track patient treatment and outcomes. In July 2025, they published a paper in the British Journal of Dermatology that analyzed the outcomes of MCC patients post-transplant, specifically focused on patients such as Malachias who were treated with immunotherapy. “We highlighted Paris’ case because of how well he did,” said Blosser.
Blosser continues to play an active consulting role in Malachias’ care, guiding adjustments to medications and helping interpret lab results.
“I consider this a huge success in terms of Paris’ ability to significantly control his cancer and retain his kidney function, to live and live well,” he said.
Blosser sees Malachias’ collaborative care as a model that can be expanded and translated to all types of cancer, ensuring that oncologists are coordinating with transplant physicians to combine their expertise and achieve better patient outcomes, at Fred Hutch and around the world.
“The culture at Fred Hutch is incredibly collaborative and oncologists are willing to give their time in ways that require them to shift their schedules,” said Blosser.
Although the COTC is the first clinic of its kind that Blosser is aware of, he has helped colleagues establish similar care models at Cleveland Clinic, Mayo Clinic, Brigham and Women’s Hospital, University of Wisconsin, University of Miami and University of Alberta. In the meantime, Blosser sees patients from around the world and offers quarterly patient-focused webinars called Life Lessons that involve a patient and clinician/scientist discussing a topic of interest.
Paris Malachias’ case represented the first time that Nghiem partnered with Blosser to balance organ survival with optimizing immune therapy to treat disease. Since then, they have partnered on nearly a dozen complex patient cases.
“Chris was super thoughtful about how to manage treatment by using these new tests in combination, helping our team pull off an immune balancing act that really hadn’t been possible until very recently,” said Nghiem.
Philanthropic contributions help make advances like these possible. Learn more about how you can support the Center for Innovations in Cancer & Transplant and the Merkel Cell Carcinoma Collaborative (MC3) Institute.
Bonnie Rochman is a senior editor and writer at Fred Hutch Cancer Center. A former health and parenting writer for Time, she has written a popular science book about genetics, "The Gene Machine: How Genetic Technologies Are Changing the Way We Have Kids—and the Kids We Have." Reach her at brochman@fredhutch.org.
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