Following the recent publication of two reviews on melanoma,1,2 I wrote some notes on them for the Primary Care Dermatology Society Bulletin and a letter to the BMJ calling for better lesion recognition training and wider access to dermoscopy.3
The reviews say that melanoma incidence is rising and early excision (which depends on early diagnosis) is still the only cure. This article discusses the NICE guidance on skin cancer, melanoma and the role of GP dermoscopy as an aid to lesion recognition. The place of dermoscopy is under debate and as yet, there have been no UK primary care trials. However, there is evidence that dermoscopy works in trained hands.
Melanoma incidence and mortality
The incidence of malignant melanoma continues to rise, with 9,583 cases and 1,852 fatalities reported in 2005.4 The role of the GP is to diagnose and promptly refer. To this I would add opportunistic education, especially of mothers with red-haired children in view of their much higher risk from sun damage.
The NICE skin cancer guidance is clear that all suspected melanomas (and squamous cell cancers) should be referred to secondary care by 14-day faxed referral. As an aside on the guidance, some GPs are unhappy to be barred from all skin cancer work, but the guidance is being implemented and those who continue to excise or curette basal cell carcinomas (BCCs) may be hearing from clinical governance before long.
Where there is a good local case for a suitably skilled GP to do this work, the Primary Care Dermatology Society is contending that the accreditation rules should be applied with flexibility, but the days of any GP treating skin cancer at will are over.
Although GPs may not treat skin cancer unless approved, the hospital service cannot manage if we over-refer. The GP is the first point of contact for most patients and there is a lot for GPs to do. The NICE guidance runs to 173 pages, much of which concerns secondary and tertiary care, but our role can be summed up as follows.
Lesions on trunk and limbs 1cm or less in diameter are low-risk BCCs. Large, recurrent, poorly defined and head and neck lesions are high risk, as are those in immune-suppressed patients (for example, transplantees on ciclosporin or azathioprine). There is a debate about whether experienced and audited GPSIs may treat small, well-defined head and neck BCCs which are well clear of critical anatomy. It should be noted that there is a potential conflict between choice (Choose and Book) and the guidance. The guidance presumably takes precedence, at least until the next reorganisation.
Owing to limited dermatology training, GPs' lesion recognition skills are variable. This may cause over-referral, or delayed referral of a dangerous lesion, which is much worse. The Primary Care Dermatology Society hears of cash-strapped PCTs asking GPs to refer less, but the decision not to refer a pigmented lesion calls for good lesion recognition skills. Some PCTs are expressing interest in community-based dermoscopic screening of pigmented lesions to reduce referrals. This could help, but investment in training and equipment is required and no GP should be pressured to cut corners on safety; falsely reassuring a melanoma patient could prove fatal.
The role of dermoscopy
Dermoscopy allows a deeper view of skin lesions and can improve the trained user's ability to reassure patients about the many benign pigmented lesions that present. These patients need not then be referred. This saves money and eases pressure on busy clinics, but there is also a saving in patients' anxiety.
So is dermoscopy a quick fix for a rising melanoma rate and busy hospital clinics? Certainly not quick, because training is required and there will always be patients who, for whatever reason, present late. But I never hold a hospital clinic without seeing patients with obviously benign lesions.
These are usually haemangiomas, seborrhoeic warts, dermatofibromas and benign moles. It is disappointing to see dermatofibromas, because they have such a typical hardness, like a dried pea under the skin, which dimples when pinched between the examining finger and thumb, but then again, they often show irregular pigmentation, which can cause concern. The other lesions are readily identified with a modest level of dermoscopy skills.
There is still no recognised standard for dermoscopy training (see box 1), too few courses and scepticism in some quarters. I taught myself by attending a seminar, reading, applying the dermoscope to lesions and attending courses when I could. I honed my skills working with senior doctors in a hospital clinic and am still on a learning curve, but it took little time to learn to use the dermoscope well enough to recognise the typical signs of warts and haemangiomas. These cases could readily and safely be kept out of hospital clinics, with benefits to all, not least the urgently referred patient who fears a melanoma.
|BOX 1: TRAINING AND RESOURCES|
- Dr Stephen Hayes is a trustee and committee member of the Primary Care Dermatology Society and a dermatology GPSI and hospital practitioner in Southampton.
1. Bataille V, de Vries E. Melanoma - part 1: epidemiology, risk factors, and prevention. BMJ 2008; 337: a2249.
2. Thirlwell C, Nathan P. Melanoma - part 2: management. BMJ 2008; 337: a2488.
3. Hayes SF. Early detection of melanoma is key, so let's teach it. BMJ 2009; 338: a3138.
4. Cancer Research UK. CancerStats Key Facts on Skin Cancer.