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GPs go forth

Study backs safety of GP melanoma biopsies

GPs perform melanoma biopsies just as safely as their specialist secondary care colleagues, concludes new research that adds to questions over current guidance that stipulates all suspicious lesions should be referred for investigation.

Researchers from Scotland found patients diagnosed with melanoma had just as good survival if they had their initial diagnostic biopsy excised in primary rather than secondary care.

Those whose initial biopsy was done by a GP were no more likely to die of any cause or from melanoma, and had fewer hospital stays and spent less time in hospital than those who underwent the biopsy in secondary care.

The study, published in this month’s British Journal of General Practice, included a total of 1,263 patients with cutaneous melanoma, of whom 262 had the biopsy done in primary care and 1,001 in secondary care.

The findings back previous research from the same group that showed GPs were able to perform melanoma biopsies at least as well as, if not better than surgeons.

But because some earlier reports had suggested GPs were more likely to perform an incomplete initial excision biopsy, latest NICE guidelines on skin cancer recommend GPs refer patients with suspected melanoma for diagnosis by a specialist, which has led to an ongoing row between GP specialists in minor surgery and secondary care colleagues.

Up to about a fifth of melanomas diagnosed in the UK are still first biopsied in primary care, but such patients are often perceived as having been mismanaged, explained study authors Dr Peter Murchie and colleagues at the University of Aberdeen.  The team said their findings mean ‘patients who have had a melanoma inadvertently excised in primary care can be reassured by the current evidence that this does not mean impaired survival or increased morbidity’.

Moreover, the researchers said current guidelines ‘may not necessarily offer patients the best opportunity of timely diagnosis and superior long-term outcomes’.

They concluded: ‘The current study clearly signifies the need for a randomised controlled trial to definitively establish the role of initial excision biopsy in primary care in the diagnosis and treatment of cutaneous melanoma in the UK.

‘The findings provide reassurance that such a trial can be safely conducted and, if appropriately designed, could determine the most cost-effective and clinically effective diagnostic management pathway for melanoma in the future.’

Dr Murchie told Pulse: ‘I think this shows, for the first time, that certainly within our cohort there is no worsening in survival or subsequent morbidity when a GP excises a melanoma.

‘Taken together, and with the emphasis on secondary care workload and achieving the earliest possible cancer diagnosis, these results would certainly seem to argue for revisiting the guidelines.

‘I’m not at all confident, however, that guidelines will be revisited. There seems to be an almost unshakeable “GP excision bad” orthodoxy within secondary care with respect to melanoma, despite evidence to the contrary and the possibility that the patient experience could be improved by revisiting the issue.’

Dr Jonathan Botting, RCGP lead for minor surgery, said: ‘I support research that shows that GPs are as capable of undertaking minor surgical procedures as their hospital colleagues. In many ways the initial treatment of melanoma is the most straightforward surgery for any skin cancers.’ 

He added: ‘Peter Murchie’s paper demonstrates GPs can do this just as well as hospital doctors, and the long term outcomes appear to be cost effective.

‘The most difficult part in the initial management of melanoma is not the surgery it is the diagnosis. Improved diagnostic accuracy comes with training and experience. With the incidence of melanoma doubling every 10 years the NHS needs to support suitably skilled GPs being involved in melanoma management as part of an extended, community based, cancer network.’

A NICE spokesperson said: ‘NICE is currently developing a new clinical guideline on the assessment and management of melanoma, so it is likely that this new research will be considered as part of the guideline development process.’

The new guideline is due for publication in 2015.

Br J Gen Pr 2013; 613: e563-e572



Readers' comments (12)

  • Fine - so turn up to weekly local skin cancer MDT meetings with your secondary care colleagues to make it a proper team event. You can't just pick and choose which bits of the service you want to do. Of course, I'm afraid there is no fee for being an active part of the MDT, but I'm sure this won't be a problem for you.

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  • Oh to be salaried so I could make comments like that

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  • Anon 10:23

    No, the challenge is evidence-based and fair. Hospitals run MDTs for no income, why shouldn't GPs have to join in, if they truly want to provide a quality service? It, has been shown to have lots of advantages, reducing professional isolation and raising standards. But it does have a cost, in staff time and lost productivity.

    The problem is that your current contract does act as a barrier to this kind of professionalism. Maybe you should consider being salaried...

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  • Anon 11.26

    Pathologists definitely have MDT's as part of their job plan and is planned for as part of their contract.

    How evidence based the advantages are may be an interesting debate! Not sure every cancer area is the same.

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  • It is fairly routine for the Australian GPs to do the suspected Melanoma Excision biopsy before referring to Secondary care and they deal with 6 -10 times more Melanomas. Its time to look at good practice elsewhere and actually do something about improving things here rather than protect a cake, based on old entrenched beliefs.

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  • I'm sorry - I must have misunderstood. The rest of this publication is full of claims that you can't possibly do any more and are already completely exhausted as a result of dealing with the CQC, QOF, GMC and myriad other quangos. There is a bit more to melanoma management than simply cutting it out!

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  • Secondary care dermatology departments are bursting at the seams with too many patients. Primary care GPs are struggling with an ever increasing burden of shifted care. However, GPs who carry out minor surgery do so to stimulate and refresh the parts of their brain which QOF etc cannot reach. This is not for every GP, but for some, it is enough of a breath of fresh air to restore balance. I have seen too many of my colleagues fall by the wayside through stress and ill health in the last year. For those of us who cannot afford to retire yet......minor surgery is just different enough to avoid meltdown.

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  • Speaking as a pathologist the main problem is incomplete initial excision which is commoner in primary care. As far as I know this does not worsen prognosis but subsequent inflammation and scarring destroys prognostic microscopic features needed to plan treatment. Ideally a suspicious lesion should be excised in-toto intact first time.

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  • Melanoma and non melanoma skin cancer are easily and safely diagnosed and treated in primary care in Australia, where published figures show 65% of NMSC and 35% of melanoma are diagnosed and TREATED in primary care with a better overall survival rate than the UK. If, as asserted by UK consultants that GP management is inappropriate, then that is an indication for the necessity of appropriate education, not deskilling further! Full skin exam, dermatoscopic exam, excisional biopsy plus or minus margins of 5 mm or 10 mm for in situ or thin (<1mm) invasive respectively. It's not brain surgery!

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  • There are many GPs who have diploma in dermatology, have done dermatoscopy course, perform minor surgery regularly and assessed 3yrs under the new criteria. Some of these GPs have/do work as hospital practitioners. its worth training them further if needed but with above evidence in survival rates for GPs vs secondary care practitioners should support and encourage passing this responsibility to primary care.
    Its probably not for all GPs who do minor surgery, as previously said the skill lies in suspecting MM rather than the surgery. once appropriately suspected a complete excision with adequate margin can be performed.
    hope the dermatology consultants agree with me (GP)

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