Download C&H Skin Cancer Referral Pathway 2013

C&H Skin Cancer
Referral Pathway
2013
Dr Sara Ritchie
CCG GP Dermatology Lead
• Designed to complement the 2WW form
• To include full pathway for MM, SCC
and also BCC
a melanoma..
Melanoma + SCC
• As per 2WW, refer suspected
melanoma or suspected SCC on 2WW
• Keratoacanthoma should all be referred
as suspected SCC
• Remember rapidly growing skin lesions
of unknown origin should also be
referred on 2WW
BCC
• BCCs can be referred either to
secondary care routinely, or to the
Primary Care Minor Surgery Providers
depending on the type of BCC
• BCCs are divided into Low-risk and
High-risk
a nodular BCC..
Low-Risk BCCs are:
• < 1cm diameter
• below the clavicle
• Nodular BCCs
• Superficial BCCs
High-Risk BCCs are:
• > 1cm
• on face (or above clavicle)
• aggressive histologic forms (eg
morphoeic, micronodular, multifocal,
infiltrative)
• recurrent at same site
• High-Risk BCCs must all be referred to
secondary care for full excision (initial
biopsy only may be done by GPSI or inhouse if beneficial for diagnosis)
• Low-Risk BCCs can be referred for
excision to Primary Care Minor Surgery
Provider or GPSI (provider must be
trained in BCC excision + attend 4
secondary care MDTs / year)
Skin cancer not
requiring excision:
• Bowens disease (SCC in-situ) can be
treated by Efudix or cryotherapy
• Superficial BCC can be treated by
Aldara or cryotherapy
• These require biopsy for diagnosis
Changing Moles
• If a changing mole cannot be
confidently diagnosed as benign it
should be referred on 2ww (do not
biopsy in primary care!)
• NB Presence of 3 colours in a mole is
suspicious
• Pyogenic granuloma - any rapidly
growing bleeding pink nodule now use
2ww
• Spitz naevi - consider 2ww at any age
Special Cases of
Pigmented Naevi
• Giant congenital naevi (>20cm) - if
history of change refer on 2WW. If
stable lesions just refer routinely to
secondary care for monitoring.
• Multiple naevi - if > 50 banal naevi, or >
5 atypical looking naevi but none
currently suspicious of melanoma consider routine secondary care referral
for monitoring
a keratoacanthoma..
Suspected SCC
• Assume all keratoacanthoma is SCC 2ww
• Cutaneous horn - 15% have SCC in
base - if atypical, or induration at base,
or vessels at base - consider 2WW
• Transplant patients /
Immunosuppressant Medication - these
patients are at v high risk of SCC, which
may be atypical and aggressive - if new
or growing skin lesion refer on 2ww
Non-Healing Skin Lesions
• Beware any non-healing lesion on a
sun-exposed site - always think of BCC!
• Remember some non-healing lesions
may be SCC eg if crusted / indurated /
ulcerated / or >1cm - then consider
urgent referral on 2ww
• NB In HIV +ve patients (even if wellcontrolled on ARVs) BCCs can occur at
a younger age, and have a higher risk
of recurrence
Actinic Keratoses
• Beware single actinic keratosis consider assessing with dermoscopy
(or actinic keratoses not responding to
cryotherapy - consider referral)
• If multiple can treat with cryotherapy or
Efudix, or refer to GPSI or secondary
care
• Multiple AKs in a transplant patient always treat or refer field change in
these patients (high risk of SCC)