‘‘Improving Outcomes for people Improving Outcomes for people with skin tumours, including with skin tumours, including

Melanoma’Melanoma’

Dr Dafydd RobertsDr Dafydd Roberts

Consultant Dermatologist, Swansea Consultant Dermatologist, Swansea NHS TrustNHS Trust

Lead Clinician Skin Cancer NICE Lead Clinician Skin Cancer NICE Guidance Development GroupGuidance Development Group

How Common Is NMSC?How Common Is NMSC?

Much commoner than expected!Much commoner than expected! Crude incidence rate – 173/100,000, 1988Crude incidence rate – 173/100,000, 1988 Crude incidence rate – 265/100,000, 1998Crude incidence rate – 265/100,000, 1998 55% increase in 10 years55% increase in 10 years Over 125,000 new cases per annum in England Over 125,000 new cases per annum in England

and Wales.and Wales. Cancer registry rate – 60-80/100,000Cancer registry rate – 60-80/100,000 Australia - 2002 National non-melanoma skin Australia - 2002 National non-melanoma skin

Cancer survey - 1200/100,000. 374,000 people per Cancer survey - 1200/100,000. 374,000 people per annum with NMSC each year.annum with NMSC each year.

How Common Is MM?How Common Is MM?

SCOTLAND – rise of 300%(M), 187%(F) SCOTLAND – rise of 300%(M), 187%(F) in 30yrs, 10/1000,000in 30yrs, 10/1000,000

5yr survival rose by 30% to 80%5yr survival rose by 30% to 80% WALES - Crude incidence rate – WALES - Crude incidence rate – M 15.5/100,000 – F 18.1/100,000M 15.5/100,000 – F 18.1/100,000 Increase of 74% in 10 yearsIncrease of 74% in 10 years Australia and New Zealand - 23 – Australia and New Zealand - 23 –

59/100,00059/100,000

Current provision for skin cancer Current provision for skin cancer servicesservices

Fragmented and varies across country.Fragmented and varies across country. Most skin cancer managed by Dermatologists.Most skin cancer managed by Dermatologists. Less than 30% of hospitals have a skin cancer MDT.Less than 30% of hospitals have a skin cancer MDT. Some (? how many) NMSC and MM managed in primary Some (? how many) NMSC and MM managed in primary

care.care. Between 1% and 15% of skin biopsies occur in primary Between 1% and 15% of skin biopsies occur in primary

care.care. No organised audit of management.No organised audit of management. Poor data collection, especially for NMSC.Poor data collection, especially for NMSC. No agreement for need or funding by NHS for SNB, Mohs No agreement for need or funding by NHS for SNB, Mohs

etcetc

NICE Skin Cancer Guidance - Guidance NICE Skin Cancer Guidance - Guidance Development GroupDevelopment Group

Dermatologist - 2Dermatologist - 2 Plastic SurgeonPlastic Surgeon Surgical OncologistSurgical Oncologist Maxfax SurgeonMaxfax Surgeon Members of Public – 2Members of Public – 2 Palliative carePalliative care Radiotherapist/oncologistRadiotherapist/oncologist AHP – RadiographerAHP – Radiographer GPGP Public Health ConsultantPublic Health Consultant Specialist Dermatology nurseSpecialist Dermatology nurse CommissionerCommissioner

ScopeScope

All skin cancers (not benign skin tumours)All skin cancers (not benign skin tumours) All health care settingsAll health care settings Services for clinical management – Services for clinical management –

including diagnosis, staging, treatment and including diagnosis, staging, treatment and follow-up.follow-up.

Supportive care and palliative care.Supportive care and palliative care. Prevention and education – excluded.Prevention and education – excluded.

Key RecommendationsKey Recommendations

MDT workingMDT working

Cancer Networks should establish two Cancer Networks should establish two levels of skin cancer MDT - Local hospital levels of skin cancer MDT - Local hospital based and specialist MDTs based in Cancer based and specialist MDTs based in Cancer Centres. Centres.

All clinicians who treat patients with any All clinicians who treat patients with any type of skin cancer should be a member of a type of skin cancer should be a member of a skin cancer MDT, whether they work in the skin cancer MDT, whether they work in the community or in a hospital setting.community or in a hospital setting.

Precancerous LesionsPrecancerous Lesions(AKs, Bowen’s)(AKs, Bowen’s)

May be treated by any GP.May be treated by any GP. Or GP may refer to GPwSI or other doctor Or GP may refer to GPwSI or other doctor

working in the community (member of a working in the community (member of a MDT) or to a hospital specialist.MDT) or to a hospital specialist.

If there is doubt about the diagnosis the If there is doubt about the diagnosis the patient should be referred to the local patient should be referred to the local hospital skin cancer specialist.hospital skin cancer specialist.

Follow up may be with the GPFollow up may be with the GP

Low risk BCCLow risk BCC

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

High risk BCC, SCC and MMHigh risk BCC, SCC and MM

All patients with skin lesions which are All patients with skin lesions which are suspicious of these skin cancers, including suspicious of these skin cancers, including all suspicious pigmented lesions and skin all suspicious pigmented lesions and skin lesions where the diagnosis is uncertain , lesions where the diagnosis is uncertain , should be referred to a hospital specialist should be referred to a hospital specialist (Dermatologist).(Dermatologist).

GPs will no longer be allowed to treat GPs will no longer be allowed to treat these cancers.these cancers.

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

Follow upFollow up

Agreed jointly between patient and doctorAgreed jointly between patient and doctor Low risk – self examination and/or Low risk – self examination and/or

community basedcommunity based High risk – secondary care plus self High risk – secondary care plus self

examination backed by written and examination backed by written and photographic informationphotographic information

InformationInformation

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

High Risk groupsHigh Risk groups

Network wide protocols for high risk group Network wide protocols for high risk group and rare skin cancers.and rare skin cancers.

To include patients with Genetic disorders, To include patients with Genetic disorders, Transplant patients, rare skin tumours, Transplant patients, rare skin tumours, cutaneous lymphoma, children and young cutaneous lymphoma, children and young adults.adults.

Data collectionData collection

Cancer registration, particularly for NMSC Cancer registration, particularly for NMSC very poor or non-existent.very poor or non-existent.

Improve data collection – establish two Improve data collection – establish two centres to collect accurate data on NMSC.centres to collect accurate data on NMSC.

ResearchResearch

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

Suggested pathway for patients Suggested pathway for patients with suspicious skin lesionswith 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

Pre-cancerous or low risk BCC High risk BCC Diagnosis uncertain ? MM or SCC

Rapid referralCommunity skin cancer clinic

LSMDTHospital pigmented lesion clinic/rapid access clinic/Dermatology clinic

SSMDT

Specific issuesSpecific issues

Multidisciplinary TeamsMultidisciplinary Teams HistopathologyHistopathology SNBSNB Adjuvant Alfa-interferonAdjuvant Alfa-interferon Mohs surgeryMohs surgery Specialist nursesSpecialist nurses Organ Transplant patientsOrgan Transplant patients Data collectionData collection

Multidisciplinary TeamsMultidisciplinary Teams

Meet at least every two weeksMeet at least every two weeks Core membership to include Dermatologist, Core membership to include Dermatologist,

Surgeon, Oncologist, palliative care, Nurse, Surgeon, Oncologist, palliative care, Nurse, pathologist.pathologist.

Must attend 50% of meetings except for Must attend 50% of meetings except for GPs who must attend four meetings per GPs who must attend four meetings per annum.annum.

Extended membership could include Extended membership could include psychologist, radiologist etc psychologist, radiologist etc

Cases for discussionCases for discussion

All high risk BCCs and SCCs – incomplete All high risk BCCs and SCCs – incomplete excisions and recurrent lesions,excisions and recurrent lesions,

All MMsAll MMs Rare skin tumoursRare skin tumours Cutaneous lymphomaCutaneous lymphoma High risk patients eg transplant patients High risk patients eg transplant patients

and those with genetic disordersand those with genetic disorders

Specialist MDTsSpecialist MDTs

MMs stage 2a or higherMMs stage 2a or higher Metastatic tumoursMetastatic tumours Patients for SNBPatients for SNB Patients suitable for clinical trialsPatients suitable for clinical trials

HistopathologyHistopathology

Cases referred to the Specialist skin cancer MDT Cases referred to the Specialist skin cancer MDT should have a formal histopathology review.should have a formal histopathology review.

All MMs and severely atypical naevi should be All MMs and severely atypical naevi should be double reported if resources allow the report to be double reported if resources allow the report to be generated within 2 weeks.generated within 2 weeks.

‘…‘…it is desirable that eventually all MDT skin it is desirable that eventually all MDT skin cancers are double reported’cancers are double reported’

An appropriately resourced national system of An appropriately resourced national system of histopathology review should be established.histopathology review should be established.

Sentinel Node BiopsySentinel Node Biopsy

Not routine in UK currently.Not routine in UK currently. Evidence – excellent as a staging Evidence – excellent as a staging

investigation but no evidence of overall investigation but no evidence of overall survival benefit.survival benefit.

SNB should only be carried out in centres SNB should only be carried out in centres where there is clinical experience of the where there is clinical experience of the procedure and only in the context of clinical procedure and only in the context of clinical trials.trials.

Adjuvant alpha interferon Adjuvant alpha interferon

Evidence – no firm evidence of overall Evidence – no firm evidence of overall survival but may be of benefit to some survival but may be of benefit to some subsets of patientssubsets of patients

Should only be given as part of clinical trialShould only be given as part of clinical trial

Mohs’ surgeryMohs’ surgery

Currently about six trained Mohs’ surgeons Currently about six trained Mohs’ surgeons in UK.in UK.

Excellent evidence of margin control and Excellent evidence of margin control and reduced recurrent rate in selected cases.reduced recurrent rate in selected cases.

Availability should be extendedAvailability should be extended At least one Mohs’ surgeon for each cancer At least one Mohs’ surgeon for each cancer

network - 34 networksnetwork - 34 networks

Skin Cancer Specialist NurseSkin Cancer Specialist Nurse

Currently very few in UKCurrently very few in UK Role may include – health education, Role may include – health education,

counselling, treatments (PDT, cryotherapy counselling, treatments (PDT, cryotherapy (skin surgery), and follow up.(skin surgery), and follow up.

Increase numbers so that all patients with Increase numbers so that all patients with skin cancer will have access.skin cancer will have access.

Transplant patientsTransplant patients

Those who have developed a skin cancer Those who have developed a skin cancer should be seen in a dedicated ‘transplant should be seen in a dedicated ‘transplant patient skin clinic’ patient skin clinic’

Dermatologists should liase closely with the Dermatologists should liase closely with the transplant team to discuss management and transplant team to discuss management and consider reduction in immunosuppression, consider reduction in immunosuppression, use of retinoids and other treatments.use of retinoids and other treatments.

Data collectionData collection

Cancer registration, particularly for NMSC Cancer registration, particularly for NMSC very poor or non-existent.very poor or non-existent.

Improve data collection – establish two Improve data collection – establish two centres to collect accurate data on NMSC.centres to collect accurate data on NMSC.

ConclusionConclusion

Some of the recommendations are controversial Some of the recommendations are controversial and will affect the way skin cancer care is and will affect the way skin cancer care is delivered in the UK.delivered in the UK.

Evidence base sometimes lacking.Evidence base sometimes lacking. Changes will not happen overnight and some may Changes will not happen overnight and some may

take years to be fully implemented.take years to be fully implemented. Hopefully skin cancer care in the UK will improve Hopefully skin cancer care in the UK will improve

and all patients will have access to high standards and all patients will have access to high standards of care regardless of where they live and who of care regardless of where they live and who carries out the treatment.carries out the treatment.