I read Murchie et al's article1 concerning primary excision of cutaneous melanoma by GPs and secondary care with great interest. Evidence, as they point out, has been very varied in this area but there has been a heavy preponderance for studies that have recommended against GP excision to fail to be blinded and to all be conducted by secondary care doctors. This blinded study showed that it is far from clear whether patients would be more likely to benefit from rapid primary care excision or a referral to secondary care for further assessment.
Purdy and de Berker's editorial2 did not share my opinion. They felt that National Institute of Health and Clinical Excellence (NICE) guidelines recommending a 2-week wait referral should stand. Their argument that it is unclear if GP excision is quicker than that of secondary care is hard to support. GPs who offer minor surgery in their clinics will almost always be able to excise a lesion within the week. Secondary care may take 2 weeks just to have the lesion assessed, let alone excised.
GPs should not be excising lesions of which they are not reasonably confident of the diagnosis, and certainly not if they are not confident of clearing the margins. More thorough training may be needed for those who wish to perform this minor surgery. However, NICE guidelines should take account of Murchie et al's article; patients should be offered the choice of a quick excision in the surgery or referral for a second opinion when this is appropriate. If we can promote patient choice and reduce the burden on secondary care then everyone could benefit.
- © British Journal of General Practice, April 2011
