‘Improving Outcomes for people with skin tumours, including Melanoma’ Dr Dafydd Roberts Consultant Dermatologist, Swansea NHS Trust Lead Clinician Skin Cancer NICE Guidance Development Group

How Common Is NMSC? Much commoner than expected! Crude incidence rate – 173/100,000, 1988 Crude incidence rate – 265/100,000, 1998 55% increase in 10 years Over 125,000 new cases per annum in England and Wales. Cancer registry rate – 60-80/100,000 Australia - 2002 National non-melanoma skin Cancer survey - 1200/100,000. 374,000 people per annum with NMSC each year.

How Common Is MM? SCOTLAND – rise of 300%(M), 187%(F) in 30yrs, 10/1000,000 5yr survival rose by 30% to 80% WALES - Crude incidence rate – M 15.5/100,000 – F 18.1/100,000 Increase of 74% in 10 years Australia and New Zealand - 23 – 59/100,000

Current provision for skin cancer services Fragmented and varies across country. Most skin cancer managed by Dermatologists. Less than 30% of hospitals have a skin cancer MDT. Some (? how many) NMSC and MM managed in primary care. Between 1% and 15% of skin biopsies occur in primary care. No organised audit of management. Poor data collection, especially for NMSC. No agreement for need or funding by NHS for SNB, Mohs etc

NICE Skin Cancer Guidance - Guidance Development Group Dermatologist - 2 Plastic Surgeon Surgical Oncologist Maxfax Surgeon Members of Public – 2 Palliative care Radiotherapist/oncologist AHP – Radiographer GP Public Health Consultant Specialist Dermatology nurse Commissioner

Scope All skin cancers (not benign skin tumours) All health care settings Services for clinical management – including diagnosis, staging, treatment and follow-up. Supportive care and palliative care. Prevention and education – excluded.

Key Recommendations

MDT working Cancer Networks should establish two levels of skin cancer MDT - Local hospital based and specialist MDTs based in Cancer Centres. All clinicians who treat patients with any type of skin cancer should be a member of a skin cancer MDT, whether they work in the community or in a hospital setting.

Precancerous Lesions (AKs, Bowen’s) May be treated by any GP. Or GP may refer to GPwSI or other doctor working in the community (member of a MDT) or to a hospital specialist. If there is doubt about the diagnosis the patient should be referred to the local hospital skin cancer specialist. Follow up may be with the GP

Low risk BCC Patients with low risk BCC may be diagnosed, treated and followed up by a doctor working in the community who is a member of the local MDT, or a hospital specialist (‘normally a Dermatologist’).

High risk BCC, SCC and MM All patients with skin lesions which are suspicious of these skin cancers, including all suspicious pigmented lesions and skin lesions where the diagnosis is uncertain , should be referred to a hospital specialist (Dermatologist). GPs will no longer be allowed to treat these cancers.

Cancer Networks should ensure that local and specialist MDTs work to network-wide protocols for referral, management and audit.

Follow up Agreed jointly between patient and doctor Low risk – self examination and/or community based High risk – secondary care plus self examination backed by written and photographic information

Information All patients and carers should have access to high quality information about their condition and support services.

High Risk groups Network wide protocols for high risk group and rare skin cancers. To include patients with Genetic disorders, Transplant patients, rare skin tumours, cutaneous lymphoma, children and young adults.

Data collection Cancer registration, particularly for NMSC very poor or non-existent. Improve data collection – establish two centres to collect accurate data on NMSC.

Research Commissioners should create an infrastructure to encourage research into all aspects of skin cancer.

Suggested pathway for patients with suspicious skin lesions

Patient presents to GP with skin lesion Benign or pre-cancerous - treat Benign pigmented lesion – oral and written advice to return if changes occur Patient presents to GP with skin lesion Pre-cancerous or low risk BCC High risk BCC Diagnosis uncertain ? MM or SCC Rapid referral Community skin cancer clinic LSMDT Hospital pigmented lesion clinic/rapid access clinic /Dermatology clinic SSMDT

Specific issues Multidisciplinary Teams Histopathology SNB Adjuvant Alfa-interferon Mohs surgery Specialist nurses Organ Transplant patients Data collection

Multidisciplinary Teams Meet at least every two weeks Core membership to include Dermatologist, Surgeon, Oncologist, palliative care, Nurse, pathologist. Must attend 50% of meetings except for GPs who must attend four meetings per annum. Extended membership could include psychologist, radiologist etc

Cases for discussion All high risk BCCs and SCCs – incomplete excisions and recurrent lesions, All MMs Rare skin tumours Cutaneous lymphoma High risk patients eg transplant patients and those with genetic disorders

Specialist MDTs MMs stage 2a or higher Metastatic tumours Patients for SNB Patients suitable for clinical trials

Histopathology Cases referred to the Specialist skin cancer MDT should have a formal histopathology review. All MMs and severely atypical naevi should be double reported if resources allow the report to be generated within 2 weeks. ‘…it is desirable that eventually all MDT skin cancers are double reported’ An appropriately resourced national system of histopathology review should be established.

Sentinel Node Biopsy Not routine in UK currently. Evidence – excellent as a staging investigation but no evidence of overall survival benefit. SNB should only be carried out in centres where there is clinical experience of the procedure and only in the context of clinical trials.

Adjuvant alpha interferon Evidence – no firm evidence of overall survival but may be of benefit to some subsets of patients Should only be given as part of clinical trial

Mohs’ surgery Currently about six trained Mohs’ surgeons in UK. Excellent evidence of margin control and reduced recurrent rate in selected cases. Availability should be extended At least one Mohs’ surgeon for each cancer network - 34 networks

Skin Cancer Specialist Nurse Currently very few in UK Role may include – health education, counselling, treatments (PDT, cryotherapy (skin surgery), and follow up. Increase numbers so that all patients with skin cancer will have access.

Transplant patients Those who have developed a skin cancer should be seen in a dedicated ‘transplant patient skin clinic’ Dermatologists should liase closely with the transplant team to discuss management and consider reduction in immunosuppression, use of retinoids and other treatments.

Data collection Cancer registration, particularly for NMSC very poor or non-existent. Improve data collection – establish two centres to collect accurate data on NMSC.

Conclusion Some of the recommendations are controversial and will affect the way skin cancer care is delivered in the UK. Evidence base sometimes lacking. Changes will not happen overnight and some may take years to be fully implemented. Hopefully skin cancer care in the UK will improve and all patients will have access to high standards of care regardless of where they live and who carries out the treatment.