Diagnostic biopsy of melanoma: primary or secondary care?

Murchie et al1 compared morbidity and mortality in patients who had initial diagnostic excision biopsy in primary versus secondary care. The Breslow thickness of a melanoma is the main prognostic indicator in the melanoma patients included in this study. The mean thickness in both the primary and secondary care groups was ≤1mm: such patients have a 95% 10-year survival rate,2 so that mortality and morbidity are not particularly relevant endpoints.

Suspected melanoma is best managed in secondary care because meeting a patient at their initial clinic visit and diagnostic biopsy allows a more informed discussion at the MDT, leading to better management, and if the melanoma is diagnosed in secondary care, we can ensure that ‘breaking of bad news’ is made by a clinician or skin cancer support nurse, who have the knowledge and experience to explain the prognostic significance of the melanoma, the MDT decisions and the further treatments required.

We have looked at patients who had GP melanoma excisions in our region. In 70% of cases no clinical diagnosis was given on the pathology form, which may affect the interpretation of the pathology and the speed with which the material is processed. To improve lesion recognition and management by GPs in our region, GPs are invited to sit in on our weekly rapid access tumour clinics. We also plan to distribute a bi-monthly presentation of ‘lesion pictures’ to all GPs. A ‘minor surgery interest group’ has been formed who will meet annually to improve lesion recognition and management and to promote regional skin cancer pathways and communication between GPs and the local skin cancer team. We advise that suspicious pigmented lesions are referred urgently to secondary care. We hope our education programme will improve the experience of the patient, the GP and the secondary care physician involved in management of skin cancer patients.

• © British Journal of General Practice 2014