Skin cancer audit show greater need for GP training

GPs treating skin cancer patients should be given increased training and support, according to research due to be released at the British Association of Dermatologists annual conference in Liverpool last week.

Nine studies carried out at different hospitals across the UK found that skin cancers treated in primary care* were not done so appropriately, prompting calls for better compliance with national guidance.

There are three main types of skin cancer - basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma.

Surgical excision is the treatment of choice for most skin cancers. If the cancer is not completely removed, this can lead to recurrence and further surgery, which can be technically more difficult and cause more scarring. Melanoma, the most deadly type, is more likely to spread if not completely removed.

The studies due to be presented indicate that some GPs do not have the technical competence to undertake this type of surgery safely. These studies have found that up to half of skin cancers are incompletely removed and the BAD is therefore anxious to ensure that quality of outcome for patients is identical no matter who undertakes the surgery.

NICE guidance** introduced in 2006, stresses that all doctors who knowingly treat skin cancer patients in the community should be members of the local hospital skin cancer multidisciplinary team (MDT). This is to allow for on-going medical education and review.

For low-risk BCCs, the least deadly type of skin cancer, treatment can be carried out either in primary care by a doctor who is a member of the MDT, usually a GP with Special Interest (GPwSI) in dermatology, or in secondary care, usually by a dermatologist.

However, any lesion that might be a high-risk BCC, an SCC or a melanoma, or where the diagnosis is uncertain, must be referred straight to a specialist - usually a dermatologist in secondary care. These cancers should not be treated by GPs.

Nine local studies examined the number of skin cancer excisions taking place in the community, who by, and whether the cancers were completely excised and appropriately treated. All studies examined skin cancers treated in 2006 or 2007, predominantly after the publication of the NICE guidance.

Skin cancer excisions - different types
Four of the studies looked at excisions for more than one type of skin cancer.

In an audit of BCC, SCC and melanoma specimens sent to Derbyshire Royal Infirmary over six months in 2007¹, 31 percent operated on in primary care were incompletely excised. Furthermore, none of the operations were performed by a GPwSI, or other member of the MDT.

In the second study, reviewing excisions of all skin lesions in Sussex over two months in 2007², 14 percent of skin cancers were treated inappropriately in primary care, compared to just three percent in secondary care.

In the third study, looking at biopsies for all three types of skin cancer sent to a teaching hospital in London over a three-month period in 2006³, 14 percent of tumours operated on by GPs should instead have been referred to hospital, owing to their high risk nature.

A study of BCC and SCC excisions taken in primary care in Surrey4 over two months in 2007, revealed that a third were SCCs so should have been referred to a specialist.
For 38 percent of skin cancers excised by GPs, cancer was suspected at the time of biopsy, yet only a third of these biopsies was done by a GPwSI.

The remaining five studies looked at treatment of specific types of skin cancer, rather than biopsies of all cancerous lesions.

Three studies focused on excisions of basal cell carcinomas. Collectively, these found that over a third of BCCs excised in primary care were done so incompletely.

A team of researchers from Essex5 found that 46 percent of BCCs were incompletely excised by GPs in primary care compared to just six percent in secondary care dermatology.

The findings were similar in a county-wide study of all BCC excisions carried out in 2006 in Cornwall6, where more than half (54 percent) of high-risk BCCs were incompletely removed in primary care, compared to just 11 percent in secondary care. According to NICE guidance, these skin cancers should have been referred from the outset.

The results were not much better for low-risk BCCs, of which a fifth were incompletely excised in primary care compared to seven percent in secondary care.

Overall, for both high and low risk BCCs, incomplete excision rates were four times higher in primary care - 37 percent in primary care compared to nine percent in secondary care.

In the third study of BCCs, a sample of records from Norfolk and Lincolnshire was examined7. 22 percent were incompletely removed in primary care, compared to eight percent in secondary care.

Dr Elisabeth Fraser-Andrews, one of the Essex study's authors said: "The proportion of BCCs completely excised in primary care is low, showing that patients receive suboptimal treatment in primary care compared with secondary care. These findings support recommendations in the NICE guidance and Department of Health on provision of skin cancer treatment and indicate that it is imperative for GPs who wish to carry out surgical treatment of skin cancer in primary care to be adequately trained, audited regularly and accountable to a clinical governance structure."

This view was echoed by Dr Helena Malhomme de la Roche of the Cornwall study, who said: "The incomplete excision rates for patients with high risk BCC managed by GPs is unacceptably high at 54 percent. This audit validates some of the key recommendations of the NICE guidelines and poses the question of how to manage the large number of patients with BCC who are currently being treated by their GPs."

However, it is not just BCCs that are not being treated appropriately, which is why dermatologists are keen to highlight the NICE guidance to GPs, to help them with referrals of skin cancers.

A study in Norfolk8 focused on 100 SCC cases and the length of time taken for the patient to be referred. Only 20 percent were referred via the two-week wait urgent route for suspected cancerous lesions, as per Department of Health guidance, and a quarter of these had already undergone a diagnostic surgical procedure in primary care. However, according to NICE guidance, these cancers should be referred straight to secondary care specialists.

Patients had to wait more than twice as long if their lesion was initially biopsied by their GP than if they had been sent straight to a dermatologist. The average time to complete surgical excision from the initial surgery in primary care was 79.5 days, compared to just 35.8 days for patients referred straight to secondary care.

A further study in Norfolk9 found that over a six-month period in 2007, 80 melanomas - the deadliest types of skin cancer - were operated on in primary and secondary care. 13 percent of these were incompletely excised or biopsied in primary care. Furthermore, of those that were incompletely excised or biopsied, 60 percent were suspicious of melanoma at the time of operation, based on their symptoms.

Dr David Shuttleworth, Clinical Vice-President of the British Association of Dermatologists, said: "These audits show that skin cancers can be extremely difficult to diagnose and treat, so it makes sense that GPs who wish to treat skin cancers should receive increased training and support.

"The NICE guidance simplifies the process by allowing all high risk BCCs and other skin cancers to be referred straight to specialists. However, the guidance has not been widely publicised so many doctors may not be aware of its existence."

The guidance was published in February 2006 and measures to ascertain compliance are expected to be introduced later this summer.

Trusts and PCTs will be expected to fully conform to the guidance within six months of publication of these measures.

However, from the date of the guidance's initial publication in 2006, healthcare providers should have been working towards adhering to the guidance.

* ‘Primary care' refers to health services in the community, such as GPs, which are usually the first port of call for patients, who can then be referred on to ‘secondary care', which defines medical professionals who are usually based in a hospital. In these audits, secondary care refers to hospital specialists, e.g. Consultant Dermatologists.

**National Institute for Health and Clinical Excellence "Improving Outcomes for People with Skin Tumours including Melanoma", February 2006.

1. All BCC, SCC and melanoma samples taken in primary care, July - Dec 2007, and sent to Derbyshire Royal Infirmary.
2. 1000 consecutive BCC, SCC and melanoma as well as benign samples taken in primary care and secondary care, April - May 2006, Brighton and Sussex University Hospitals NHS Trust (BSUH) and Worthing and Southlands NHS Trust (500 each).
3. All BCC, SCC and melanoma samples taken in primary care and secondary care, Oct-Dec 2006, and sent to Royal Free Hospital, London.
4. All BCC and SCC samples taken in primary care, two 4-week periods (13th March-10th April 2007 and then from 4th May to June 1st 2007), and sent to Epsom and St Helier NHS Trust, Surrey.
5. All BCC samples taken in primary care, Jan - Dec 2006, NE Essex PCT, and secondary care, Oct 2006 - March 2007, Essex Rivers NHS Trust (now Colchester Hospital University NHS Foundation Trust).
6. All BCC samples taken in primary care and secondary care, Jan - Dec 2006, Cornwall (county-wide audit).
7. All BCC samples taken in primary and secondary care, Oct 2006, Norfolk and Norwich University Hospital, Cromer Hospital and James Paget Hospital Great Yarmouth, as well as data from the private sector and primary care within Norfolk, and Nov 2006 - March 2007, May 2007 - July 2007, Lincolnshire (including Lincoln County Hospital, Pilgrim Hospital Boston, Grantham and District Hospital, County Hospital Louth, John Coupland Hospital Gainsborough and primary care within Lincolnshire.)
8. 100 SCC cases taken in primary care, Jan - June 2007, sent to Norfolk and Norwich University Hospital.
9. All melanoma samples taken in primary care, Jan - July 2007, sent to Norfolk and Norwich University Hospital.

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