C&H Skin Cancer Referral Pathway

2013Dr 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 in-house 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 well-controlled 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)