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The waiting game

NICE melanoma guidelines ‘need greater primary care focus’

New guidelines on the assessment and treatment of melanoma proposed by NICE should be rewritten with a greater emphasis on GPs’ role in identifying potential malignant skin cancer, according to primary care dermatology experts.

The draft guidelines, published today, set out a number of key recommendations aimed at tackling ‘wide variation across the country in diagnosis and treatment of melanoma’, and stress that any pigmented skin lesions referred by GPs for specialist investigation should be assessed using dermoscopy.

However, experts from the Primary Care Dermatology Society (PCDS) said the guidelines should be redrafted to encourage more use of dermoscopy by GPs themselves, to improve the initial assessment of potential melanomas.

The guidelines cover diagnosing and staging of melanoma, including the use of sentinel lymph node biopsy, and the latest in treatments of stage 0-4 as well as metastatic melanoma.

The foremost recommendation on diagnosis states: ‘Assess all pigmented skin lesions that are referred for further assessment, and during follow-up, using dermoscopy carried out by healthcare professionals trained in this technique.’

However, Dr Stephen Kownacki, chair of the PCDS, told Pulse the guidelines needed a greater focus on early diagnosis – including better training in and use of dermoscopy in primary care.

Dr Kownacki said: ‘The PCDS feels that dermoscopy is an essential addition to history taking, as supported by the draft guidelines, although we believe this needs to be done in general practice as well as in secondary care.’

He added: ‘I’m not decrying the rest of the guidelines – but I don’t think there’s enough emphasis at the front to say the history, the examination and using a dermatoscope in primary care and would significantly increase the chance of picking up a melanoma at an early stage.’

Dr Kownacki said GPs trained in dermoscopy are able to more confidently recognise benign lesions, helping to streamline referrals, and that every practice should have a dermatoscope with at least one GP trained to use it, with the cost of the machines and training GPs outweighed by the long-term savings on referrals.

He added: ‘Quite a lot of CCGs have realised this and are buying these machines for their practices and sending their GPs on our courses so that they develop the expertise.’

A NICE spokesperson said: ‘Registered stakeholders now have the opportunity to comment on the draft recommendations. Consultation is a crucial part of developing a NICE guideline. The comments received help the Guideline Development Group make sure the guideline is accurate and relevant to people who will be using it and to people using services.’

NICE – Assessment and management of melanoma

Readers' comments (5)

  • Thers that saying again" GPs have a vital role".What about more community specialist, or even just more dermatolgy opds to refer to.

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  • As a Dermatology GPwSI I was taught that only those who are regularly undertaking dermoscopy have the skills to fully interpret what you are seeing.

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  • Vinci Ho

    (1) Funding is a issue . The machines range from £600 to 1,000 and over (for instance , DermLite). A proper three months course(e.g.Cardiff) is just under a grand.
    (2) I use the machines(own two myself) everyday for in house referrals. Most seborrhoeic keratosis can be picked up even by beginners , hence saving some secondary care referrals. Tricky ones are still those dysplastic naevi or melanoma in situ needing some more experiences. Of course, one can argue those typical melanoma does not need dermoscopy.
    (3) Yes. Only practice makes perfect. With help , the more you see, the better skill. It is a practical skill . Had to learn from basics even after the completion of diploma and MSc in practical dermatology.

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  • Refer Refer Refer any mole which is coloured or if you are having any doubts. You won't get anything for decreasing referrals but a letter from a lawyer (or GMC, CQC...take your pick ) for not. So as nike would say "just do it".

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  • Took Early Retirement

    The last 2 patients I referred (urgently fortunately) with odd skin lesions, turned out to be MMs despite NONE of the warning features we are told about!

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