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GPs urged to refer more suspected skin cancers urgently

NICE is urging GPs to refer more people with suspected skin cancer urgently, warning that nearly three out of 10 malignant melanomas are still being diagnosed after routine referrals to secondary care.

The call comes in a new ‘quality standard’ developed by the NHS watchdog to improve cancer services, following a review of data from the National Cancer Intelligence Network.

That analysis showed 56% of malignant melanoma diagnoses were made after a two-week referral in 2013, with 29% made after a standard GP referral, NICE said.

The standard also calls for GPs who remove low-risk basal cell carcinomas to maintain and audit records of their caseloads.

NICE said rates of malignant melanoma have increased by almost 50% in the UK over the past two decades. There were 12,246 new cases in England in 2013, and 2,080 people died from malignant melanoma in 2014.

Professor Gillian Leng, deputy chief executive of NICE, said: 'We want to improve the outcome for everyone diagnosed with skin cancer.

’The latest data from the National Cancer Intelligence Network shows that just 56% of malignant melanomas were diagnosed in secondary care following a two week referral for suspected cancer in 2013.

'The data shows that 29% of cases are still being referred to secondary care via the standard GP referral in 2013, which in some trusts is between 4 and 6 weeks. The remainder are diagnosed in outpatient clinics, at emergency presentation, and in inpatients, and in a number it is not known where they are diagnosed.'

Dr Rachael Robinson, GPSI and trust fellow in dermatology, Harrogate District Foundation Trust, and member of the quality standard advisory committee, said: ’There are competent GPs who are trained to perform basal cell carcinoma skin surgery and may do this in GP surgeries or part of a community clinic.

’However there is currently no agreed process in place to support good practice in this area and so this quality statement seeks to address this by recommending those GPs maintain training standards, record activity and perform audits.’

Skin cancer quality standards

1. Local authority health promotion activities on preventing skin cancer and recognising early signs are consistent with the messages in any national campaigns.

2. GPs who manage low‑risk basal cell carcinoma, including GPs with a special interest (GPwSI), maintain and audit records of their caseload.

3. People with suspected malignant melanoma are referred using a suspected cancer pathway for an appointment within 2 weeks.

4. People with pigmented skin lesions undergoing a specialist assessment have the lesions examined using dermoscopy.

5. People with malignant melanoma or squamous cell carcinoma have access to a skin cancer clinical nurse specialist.

6. People with stage IB–IIC melanoma with a Breslow thickness of more than 1 mm have a discussion about the advantages and disadvantages of sentinel lymph node biopsy as a staging procedure.

7. People with unresectable or metastatic melanoma are offered genetic testing of the tumour.

Source: NICE

Readers' comments (5)

  • Vinci Ho

    NICE again!
    While what was said about the rise in incidence of melanoma and the use of dermis copy is absolutely but also politically correct , one has to look at the real world , rather dystopic , of GP land .
    I use dermoscopy everyday as I fortunately had self invested in taking the courses and buying the machine(s)(which are expensive). Alongside with my diploma and MSc , I could just be able to be the in house dermatologist to help my partners . Even then , our referrals to secondary care is still on the rise . Reality bites when CCG is moving golf post curbing and rationing the number of referrals to hospitals . You just hope these academics in NICE can see the reality in the frontline .
    Whether it is for leisional or conventional dermatology , the expertise amongst most of our frontline colleagues(not GP with extended interest) is relatively short . This traces back to your medical school training of dermatology . How many days or weeks did you have in attachment to dermatology as a medical student ? The problem is deeply rooted.
    Blindly throwing down the gauntlet to GPs without addressing the root is simply pushing us to a corner.
    Sort out the politics(if you claim you are on the side of patients , then you cannot be friends to these bureaucrats and politicians ). Sort out the training and support of GPs as well as medical school learnings.

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  • Vinci Ho

    ....the use of dermoscopy......

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  • Vinci Ho

    We have a Chinese saying ,' Do not eat the smoke and fire in the human world ; Do not know what the human world is like .'(不吃人間煙火,不知人間為何是)
    Simply put , detached from reality , nice .

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  • Vinci Ho

    One of the saddest situations this year in supporting and providing ongoing education for those who previously completed the Diploma of Practical Dermatology (DPD) , is the alumni society had closed down after just over 10 years of age . I suspect something to do with politics and financial issues (my own opinion only).
    Primary Care Dermatology Society(PCDS) is the only accredited organisation otherwise ......

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  • Given that 29% are 'missed' surely the correct response would be that some melanomas are difficult to diagnose? GPs get shown dozens of skin lesions. Occasionally cancers look like seborrheic warts, dysplastic moles or in the case of amelanotic melanoma less aggressive cancers. Nodular melanomas are rarely seen in primary care.

    Melanoma is on the rise but castigating GPs doesn't help much. Why don't dermatologists just see all skin lesions in under a month if there is an unmet need? The 2ww system just raises the stakes of the game.

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