First, we would like to say that the National Institute of Health and Clinical Excellence skin cancer improving outcomes guidance (IOG), far from being arbitrary, was based on appraisal of a wide range of evidence. Regrettably, prior to the IOG, some high-risk skin cancer patients received treatment below an acceptable standard from less experienced practitioners, including curetted and otherwise incompletely excised melanomas, as well as melanomas that had been repeatedly frozen or simply misdiagnosed as benign. The IOG was intended to level up to best practice, and this has largely been achieved.
Results of the study by Murchie et al indicate that the GPs concerned carried out adequate excisions,1 but we are not told how many benign lesions were needlessly excised, nor is there information about quality of scars, follow-up, or other important factors. The IOG has delivered integrated services in which multidisciplinary teams provide evidence-based holistic care including follow-up, specialist nursing support, and patient education. Cutting out the lesion is only one part of the process.
The authors have included punch biopsies and incisional biopsies in their analysis of completeness of excision. The number of incisional biopsies and punch biopsies in the secondary care group was significantly higher. It is in the nature of the biopsy that it is incomplete, therefore, they should have excluded this group of biopsies from the analysis. It would be interesting to re-analyse the data excluding this group of biopsy.
The rapid access pigmented lesion service in Aberdeen has undergone a significant reconfiguration since this study was undertaken. Therefore, conclusions drawn from this study cannot be compared with the service that is now being provided by the dermatology department at Aberdeen Royal Infirmary.
The issue of GP excision avoiding delay does not arise, as any lesion referred as a suspected melanoma will be seen by a specialist within 14 days. Many lesions referred urgently as suspicious are found to be benign on expert examination and do not require excision.
This problem is compounded by the issue that in many NHS Trusts, GP-derived histopathology samples are immediately graded as routine, as GPs do not have a mandate to excise malignancy. This may incur waits as long as 6 weeks for the sample to be reported, whereas in secondary care the samples are graded as urgent and reported within 3 weeks in most trusts.
Of course trained GPs can capably excise small lesions on non-critical sites, as can specialist nurses, but many lesions do not require excision. Diagnosis and treatment planning are critical. Regrettably, the medical undergraduate curriculum and GP training underemphasise dermatology. Consequently, excellent skin lesion recognition skills are not universal. The British Association of Dermatologists lobbies for better training, and with the Primary Care Dermatology Society recently sent a joint letter to the Royal Colleges, Department of Health, and other parties advocating better skin lesion diagnostic training for all GPs.
Within the Measures Document for Skin Cancer there is a provision for GPs to integrate into the local multidisciplinary team structure as Model 2 practitioners, removing lesions that have been diagnosed by accredited members of the multidisciplinary team.
Recent revision of the 2006 skin cancer IOG allows suitably-qualified GPs to treat smaller well-defined basal cell carcinomas on trunk and limbs under LES/DES schemes subject to audit. However, we should reflect that melanoma is a potentially fatal cancer. Should it be treated on a casual basis by well-meaning generalists who are inevitably behind the curve on current best evidence? Most GPs will only see one melanoma every 3 or 4 years.
Best clinical outcomes are achieved in specific areas (whether fitting IUCDs, administering cognitive behavioural therapy, or through paediatric heart surgery) by healthcare workers who practice to current best evidence in teams and are accredited and audited. This also applies to skin cancer. We believe that one study showing that GPs were capable of doing simple excisions (setting aside the above point about punch and incisional biopsies that may invalidate even this finding) gives no grounds to overturn the current status quo. We believe the emphasis instead should be to improve both patient education, as well as GP and other healthcare workers' lesion recognition skills to achieve earlier diagnosis and better outcomes in melanoma.
The direction of travel in skin cancer management is to develop integrated community-based services within an multidisciplinary team structure, that ensures clinical governance and enhances patient safety. Many excellent examples of this model already exist in the UK.
- © British Journal of General Practice, April 2011
