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Skin Cancer in Primary Care

Skin Cancer in Primary Care. Simon De Vos West Street Surgery Chipping Norton November 2010. Quiz. Green card – Benign Deal with in GP may refer as functional / non cancer derm Amber card – consider ref / 2 nd opinion ?email adv Red card – refer: 2ww (MM, SCC) routine BCC.

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Skin Cancer in Primary Care

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  1. Skin Cancer in Primary Care Simon De Vos West Street Surgery Chipping Norton November 2010

  2. Quiz • Green card – Benign • Deal with in GP • may refer as functional / non cancer derm • Amber card – consider ref / 2nd opinion • ?email adv • Red card – refer: • 2ww (MM, SCC) • routine BCC

  3. Skin Cancer in Primary Care - Agenda • Who am I? • Review of Cancers/Premalignant and benign lumps • Procedure Selection/Anatomical Risks • Current Situation at West Street / OCDS • NICE skin cancer guidelines • Minor Ops DES • Future Opportunities

  4. Skin Lesions • Keratotic Lesions (scaly) • Flat • raised • BCCs (pearlesence) • Flat • Raised • Melanocytic lesions (pigment network)

  5. Keratotic Lesions • Seborrhoeic • Viral warts • Squamoproliferative lesions • Solar (Actinic) • Malignant change potential 0.60% at 1 year and 2.57% at 4 years • Bowen’s Disease • Keratoacanthomas • Baso-squamous carcinomas • SCC

  6. Flat keratotic pink/red lesions • Actinic Keratosis • Sun exposed sites, on face can get Bowenoid Actininc keratosis. Flat, no meat • Bowen’s • Uniform scaly, not itchy, lower legs on women (note also in this area are dermatofibromas) • Superficial BCC • Key sign is sheen / pearlesence, may have telangectasia, milky pink

  7. Raised Keratotic lesions • Traumatised Seborrhoeic Keratosis • steroid / antibiotic oint as diagnostic tool • Hyperkeratotic Actinic Keratoses • Get picking! No dermal thickness • Hypertrophic AK • Consider referral • Keratoacanthoma • History all important – refer • SCC • Dermal thickness, meat to base, indurated base • May be tender

  8. BCC • Nodular • Pearlescence • Rolled edge • Telangectasia • Superficial • Sheen • Scaly • milky-pink • Telangectasia

  9. Melanocytic lesions • Melanocytic? • Dermoscopy: pigment network/globules/dots • Nodule (raised), or Macule (flat) • History of change (ABCDE rule)

  10. Dermoscopy • Super-bright LEDs • Polarised / Non-polarised • 2 day course • Quarterly updates

  11. Melanocytic Lesions • ABCDE rule: Change in… • A - Asymmetry • B - Border (irregular) • C - Colour (variation) • D - Diameter (>6mm) • E – Evolution (getting bigger)

  12. Melanocytic Lesions • Lentigo simplex • Solar Lentigo (assn with seb K) • Dysplastic naevus • Mild, moderate, severe • Melanoma in situ • Invasive MM. • Special sites: Lentigo maligna, soles, nail bed

  13. Other Lesions that might be mistaken for cancers • Sebaceous gland hyperplaisia (BCC) • Dermatofibromas (SCC) • Eczema (Bowen’s, sup BCC)

  14. Primary Care Minor Ops • Procedure Selection • (high risk sites for closure or damage) • Limbs / digits • Genitalia / Perineum • Head and neck

  15. Primary Care Minor Ops • Margins • BCC : 4mm margin • SCC :< 2cm – 4mm margin, > 2cm - 6mm margin • Dysplastic naevus: 2mm – no dog ears • MIS / Severely dysplastic : 5mm • Invasive MM < 1mm deep: 1cm re-excision • Invasive MM > 1mm deep: 2cm re-excision, via plastics

  16. Primary Care Minor Ops • Head and Neck • Nerves • Arteries • Big veins • Muscle / Other deeper structures • Eyes / Mouth

  17. Head and Neck

  18. Primary Care Minor Ops Current Situation at West Street • Case Mix / NICE Guidance / Minor Surgery DES • Minor Ops room • HCA • Clinical Governance • Cap • Clinical assistant / GPwSI Community Work

  19. Primary Care Minor Ops Oxford Community Dermatology Service (OCDS): • 2 GPwSIs in skin cancer (Model 1 practitioners): • Simon De Vos and Martyn Chambers • Chipping Norton, Deddington (Banbury, Brackley) • Direct referral from GP to GPwSI • Seamless onward ref to and from dermatology dept • Tight reporting and clinical governance

  20. Primary Care Minor Ops • Case Selection - GP • Minor Surgery DES: Benign – for diagnosis or treatment • (i) injections (muscles, tendons and joints) • (ii) aspirations on bursae and effusions of major joints • (ii) invasive procedures, including incisions and excisions • Benign, but functional problem • Borderline lesions (?Dermoscopy) / Rashes Patient risks: • DM, Warfarin, Infection risk

  21. Primary Care Minor Ops • West street Minor Ops 06-07 • Melanocytic Naevus incl Dysplastic 18 • Seborrhoeic Keratosis 18 • Pilar Cyst / Epidermoid cyst 13 • BCC 7 • Squamoproliferative Lesion 5 • Dermatofibroma 3 • Large cell Acanthoma 3 • Keratoacanthoma 3 • Bowen’s disease 3 • Solar Keratosis 3 • Spongiotic dermatitis 2 • Lipoma / angiolipoma 2 • Neurofibroma 1 • Lichen planus 1 • Actinic Granuloma 1 • Naevus sebaceous 1 • SCC 1 • ‘Other’ 4 • TOTAL 89 • Not sent for pathology / aspirations / injections / I&D: 32

  22. Primary Care Minor Ops • Dermoscopy • £700 • 2 day course to learn + quarterly updates • Clarifies Seb Warts / Atypical melanocytic lesions / dermatofibromas etc… • Business case under PBC – J37 costs

  23. Who should remove skin cancers? • Dermatology: • MM • Suspicious moles • SCCs • KA’s • High risk BCCs + others • Accredited GPs • Low risk BCCs • Group 1 skin cancer clincians • BCC’s out of T-zone / ears (and other exclusions)

  24. Who should remove BCCs? (NICE 2010) Criteria for accreditation of GPs within the framework of the DES and LES under General or Personal Medical Services: GPs performing skin surgery on low-risk BCCs within the framework of the DES and LES under General or Personal Medical Services should: • demonstrate competency in performing local anaesthesia, punch biopsy, shave excision, curettage and elliptical excision using the direct observation of procedural skills (DOPS) assessment tool in the Department Health Guidance for GPwSIs in dermatology and skin surgery72 and then follow a program of revalidation • have specialist training in the recognition and diagnosis of skin lesions appropriate to their role. • send all skin specimens removed to histology for analysis • provide information about the site of excision and provisional diagnosis on the histology request form • maintain a ’fail-safe‘ log of all their procedures with histological outcome to ensure that patients are informed of the final diagnosis, and whether any further treatment or follow-up is required

  25. Who should remove BCCs? • provide quarterly feedback to their PCT or LHB on the histology reported as required by the national skin cancer minimum dataset73, including details of all proven BCCs • provide details to their PCT or LHB of all types of skin cancer removed in their practice as described in the 2006 NICE guidance on skin cancer services74 and should not knowingly remove skin cancers other than low-risk BCCs • provide evidence of an annual review of clinical compared with histological accuracy in diagnosis for the low-risk BCCs they have managed • attend, at least annually, an educational meeting (organised by the Skin Cancer Network Site Specific Group), which should: o present the 6-monthly BCC network audit results, including a breakdown of individual practitioner performance o include one CPD session (a total of 4 hours) on skin lesion recognition and the diagnosis and management

  26. What is Low risk BCC? Services should be commissioned from these GPs where there is no diagnostic uncertainty that the lesion is a primary nodular low-risk BCC and it meets the following criteria: The patient is not: • aged 24 years or younger (that is, a child or young adult) • immunosuppressed or has Gorlin’s syndrome. The lesion: • is located below the clavicle (that is, not on the head or neck) • is less than 1 cm in diameter with clearly defined margins • is not a recurrent BCC following incomplete excision • is not a persistent BCC that has been incompletely excised according to histology

  27. What is low risk BCC? • is not morphoeic, infiltrative or basosquamous in appearance • is not located: • over important underlying anatomical structures (for example, major • vessels or nerves) • in an area where primary surgical closure may be difficult (for example, • digits or front of shin) • in an area where difficult excision may lead to a poor cosmetic result • at another highly visible anatomical site (for example, anterior chest or • shoulders) where a good cosmetic result is important to the patient. • If the BCC does not meet the above criteria, or there is any diagnostic doubt, • following discussion with the patient they should be referred to a member of the • LSMDT. • If the lesion is thought to be a superficial BCC the GP should ensure that the • patient is offered the full range of medical treatments (including, for example, • photodynamic therapy) and this may require referral to a member of the LSMDT. • Incompletely excised BCCs should be discussed with a member of the LSMDT

  28. Model 1 Practitioners in skin cancer • GPwSI dermatology and skin surgery • GPwSI skin lesions and and skin surgery • Can remove all low risk BCC’s except T-zone and ears

  29. Criteria for accreditation of Model 1 practitioners by PCTs or LHBsGPwSIs performing skin surgery as ‘Group 3 GPwSI in dermatology and skin surgery’ should follow the framework* for the training and accreditation of Model1 practitioners, which is defined by the Department of Health as follows: • they are accredited by PCTs or LHBs according to national guidance appropriate to their role as GPwSIs77,78 • the GPwSI is linked to a named skin cancer LSMDT and attends four LSMDT meetings per year, skin cancer clinical practice is audited annually as defined in the dermatology and skin surgery GPwSI guidance79 • clinical governance arrangements are with the PCT or LHB and the GPwSI meets the continuing professional development requirements for community skin cancer clinicians specified in the dermatology and skin surgery GPwSI Guidance80 In addition they should: • provide evidence of an annual review of clinical compared with histological accuracy in diagnosis of the low-risk BCCs they have managed • attend, at least annually, an educational meeting (organised by the Skin Cancer Network Site Specific Group), which should: o present the 6-monthly BCC network audit results, including a breakdown of individual practitioner performance o include one CPD session (a total of 4 hours) on skin lesion recognition and the diagnosis and management of low-risk BCCs o be run at least twice a year.

  30. Primary Care Minor Ops • Minor Ops DES • ? Excludes ‘low priority work’ • refer “highly suspicious lesions” • 2 Injections aspirations = 1 excision • Cap • ? Future changes

  31. Primary Care Minor Ops • The Future • Approx 5 Accredited Primary care Skin Surgeons (GPwSI, Model 1 skin cancer clincian) • Accredited as Clinical Assistants in Dermatology • PBC business cases / PCT sponsored system • Surgery closer to home • Stable Dermatology Dept • ?What to do with ‘low priority’ benign work

  32. Any Questions? With thanks to Dr Richard Turner, Consultant Dermatologist and Dermatological Surgeon, dept Dermatology, Churchill Hospital, Oxford

  33. Skin Cancer in Primary Care Simon De Vos West Street Surgery Chipping Norton

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