Guidelines on skin cancer should be re-evaluated after a study showed GPs were just as good at excising squamous cell carcinomas as specialists, say UK researchers.
Current NICE guidance – published in 2006 - bars GPs from performing minor surgery on SCCs, but this has been questioned after one of the largest studies to compare SCC surgery in primary and secondary care.
The guideline was revised in 2009 to allow GPs to remove low-risk basal cell carcinomas, if they could satisfy their PCT of their competence, and the authors of this new analysis concluded GPs should now be allowed to excise SCCs as they were becoming ‘increasingly burdensome' to secondary care.
The Scottish researchers conducted a retrospective analysis of all SCCs excised in one area of Scotland between 1 January and 31 December 2005. Of the 1,184 SCC-positive biopsies, GPs excised 281 (24%), 216 of which were excisional biopsies.
After adjusting for patients' sex, age and biopsy site, there was no significant difference in excision adequacy when the excision was performed by a GP rather than a hospital skin specialist such as a dermatologist or plastic surgeon – with an odds ratio of 0.84. GPs completely excised the lesion in 86% of cases, compared with 86% for dermatologists and 87% for plastic surgeons.
GPs were significantly more likely to excise adequately than hospital non-specialists, who completely excised the lesion only 71% of cases.
There was no significant difference in performance between GPs who excise frequently (more than ten times over the study duration) or infrequently, with an odds ratio of 0.93.
The authors concluded SCCs excision should be considered as part of the drive to shift the balance of care from secondary to primary care to reduce costs.
Study lead Dr Elizabeth Delaney, clinical lecturer at the University of Aberdeen and GP in the city, said: ‘Current guidelines perhaps need rethought against the backdrop of increasing skin cancer incidence.'
Dr Soon Lim, director of minor surgery at the RCGP Bedfordshire and Hertfordshire Faculty and a GP in Watford, Hertfordshire, agreed with the findings if GPs could demonstrate their competence.
He said: ‘Accreditation of GPs to remove skin malignancies should be encouraged as long as they can demonstrate competence in skills and knowledge through proper audit and assessment. Patient groups have called for this to maintain confidence in any GP skin minor surgery service.'
Family Practice 2012, published online 9 February
http://fampra.oxfordjournals.org/content/early/2012/02/09/fampra.cms007.abstract
BOX: Clinical performance on SCC excision
|
Surgeon |
Adequate (%) |
Inadequate (%) |
|
GPs |
81.9 |
13.9 |
|
Dermatologist |
83.8 |
13.5 |
|
Plastic surgeon |
85.8 |
12.7 |
|
Other |
70 |
28.8 |
Source: Family Practice 2012, published online 9 February
