Authors' response

Johnny Wake's point is that once a GP has decided to remove something they will do it quicker than in secondary care. This was not the objective of Murchie et al's study and is not a conclusion that is possible to draw from it.1

There are two groups of patients whose outcomes need to be considered if GPs without appropriate training are to remove suspicious lesions in primary care. First is the group of patients with lesions that the GPs may have chosen not to excise because their clinical threshold has not been triggered by making a diagnosis. The second is the group of patients whose numbers would increase if GPs were expected to excise all pigmented lesions of concern. As GPs would rely heavily on histology for clinical diagnosis, they would need to cut out a great many benign lesions. These two groups highlight the problem where entry into a clinical pathway requires diagnostic expertise. If you lack diagnostic expertise in pigmented lesions you need to cut out a great many to have enough sensitivity to not miss the melanomas. If you fall short of this then you will defer or decline to do surgery on patients and miss evolving melanomas. Cutting out the pigmented lesion should be the end not the beginning of the diagnostic pathway, and where NICE guidance is followed, the patient has the benefit of seeing a clinician experienced in the assessment of pigmented lesions enabling many to avoid surgery.

As Murchie et al state in their conclusions ‘… the relative outcomes of patients receiving their primary biopsy in primary or secondary care are unknown, although existing evidence suggests that survival is not compromised by having a melanoma excised in primary care.’

As we highlight in our accompanying editorial, this is reassuring, but the importance of diagnostic accuracy is not diminished by these findings.2

• © British Journal of General Practice, April 2011