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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