Skin Cancer: Management Guidelines for the Peninsula … · Web viewAdvise patients of advantages and disadvantages (see NICE guideline NG14 July 2105) 4.11 Vitamin D Advice The peninsula

GUIDELINES FOR THE MANAGEMENT OF SKIN CANCER

11-1C-110j

Agreed network-wide clinical guidelines for the management of skin cancer

Agreed: April 2015

Review: April 2017

Agreement cover sheetThe Guidelines of the Peninsula Cancer Network Skin Cancer Group have been agreed by:

Chair Peninsula Cancer Network Skin Cancer Group Date agreed

Name Karen DaviesOrganisation Northern Devon Healthcare NHS Trust 24/04/2012

MDT Lead CliniciansName Organisation Date

agreedKaren DaviesAndrew Watts Northern Devon Healthcare NHS Trust

24/04/2012

Duncan MacKenzie

Plymouth Hospitals NHS Trust 27/09/2011

Preshita Divekar

Royal Cornwall Hospitals NHS Trust 27/04/2012

Chris Bower Royal Devon & Exeter NHS Foundation Trust 21/09/2011Sheau Ng South Devon Healthcare NHS Foundation Trust 22/09/2011

Cancer Lead Clinicians Date agreed

Katie Cross Northern Devon Healthcare NHS Trust 27/04/2012Sarah Pascoe Plymouth Hospitals NHS Trust 27/09/2011Giles Maskell Royal Cornwall Hospitals NHS Trust 27/04/2012John Rennison Royal Devon & Exeter NHS Foundation Trust 27/04/2012David Sinclair South Devon Healthcare NHS Foundation Trust 27/04/2012

CCG Managers for CancerName Organisation Date

agreedLynne Kilner NHS New Devon Western LocalityYash Patel NHS New Devon Eastern LocalitySara Wright NHS New Devon Northern LocalityEmma Herd NHS South Devon and Torbay

Andy Gordon NHS Kernow

Table of Contents1 Premalignant Lesions.........................................................................................................................................6

1.1 Primary care referral guidelines................................................................................................................7

2 Basal Cell Carcinoma..........................................................................................................................................7

2.1 Primary care referral guidelines.................................................................................................................7

2.2 Treatment...................................................................................................................................................9

2.3 Incomplete excisions:.................................................................................................................................9

2.4 BCC Follow up:..........................................................................................................................................10

3 Squamous Cell Carcinoma................................................................................................................................10

3.1 Primary care referral guidelines...............................................................................................................10

3.2 Primary treatment....................................................................................................................................10

3.3 Discussion at MDT....................................................................................................................................11

3.4 Follow up..................................................................................................................................................11

3.5 Clinical Imaging.........................................................................................................................................11

4 Malignant Melanoma.......................................................................................................................................11

4.1 Primary care referral guidelines...............................................................................................................11

4.2 Primary Excision........................................................................................................................................11

4.3 Dermoscopy....................................................................................................................................................12

4.4 Wide excision:...........................................................................................................................................12

4.5 Imaging:....................................................................................................................................................12

4.6 Sentinel Lymph Node Biopsy....................................................................................................................12

4.7 Completion Lymphadenectomy for Positive SLNB..........................................................................................12

4.8 Follow up..................................................................................................................................................12

4.9 Genetic Testing of Tumours......................................................................................................................13

4.10 Enhanced Follow-up with Imaging for patients at increased risk of metastasis:......................................13

4.11 Vitamin D Advice..........................................................................................................................................13

4.12 Melanocytic Lesions of Uncertain Malignant Potential............................................................................13

5 Skin Lymphoma`...............................................................................................................................................13

5.1 Referral.....................................................................................................................................................13

5.2 T Cell Lymphoma......................................................................................................................................13

5.3 Photopheresis and Total Skin Electron Beam Therapy.............................................................................14

5.4 B Cell......................................................................................................................................................14

6 Merkel Cell Carcinoma......................................................................................................................................14

6.1 Adequate Local Excision...........................................................................................................................14

6.2 Lymph Nodes............................................................................................................................................14

6.3 Radiotherapy............................................................................................................................................15

6.4 Distant Metastases...................................................................................................................................15

6.5 Follow-Up.................................................................................................................................................15

7 Skin Cancer for Specific Groups........................................................................................................................15

7.1 Skin Cancer of Specific Anatomical Sites..................................................................................................15

7.2 Skin Cancers in Children & Young People.................................................................................................16

8 Immunocompromised and Transplant Patients...............................................................................................16

8.1 Initial assessment.....................................................................................................................................16

8.2 Follow up..................................................................................................................................................17

8.3 Pre-malignant lesions...............................................................................................................................17

8.4 New or fast-growing skin tumour.............................................................................................................17

8.5 Secondary prevention......................................................................................................................17

8.6 Alteration in immunosuppression............................................................................................................17

9 Mohs Surgery...................................................................................................................................................17

10 Community Skin Cancer Services........................................................................................................................17

10.1 Levels of care that may be treated in the community.................................................................................18

10.1.1 Definition of Low Risk Basal Cell Carcinoma.........................................................................................18

10.1.2 Providers that may diagnose and treat low risk BCCs in the Community.............................................19

10.1.3 Practitioners that may perform surgery on pre-diagnosed lesions......................................................20

10.2 A ccreditation...............................................................................................................................................20

10.2.1 Clinical accreditation.............................................................................................................................21

10.2.2 GPs performing skin cancer treatment within the framework of the DES or LES under.......................22

GMS or PMS......................................................................................................................................................22

10.2.3 GPs with a Special Interest.......................................................................................................25

10.2.4 Model 2 Practitioners...........................................................................................................................26

10.3 Clinical Governance.....................................................................................................................................26

10.3.1 Overlap between practitioners............................................................................................................27

10.3.2 Process for GPs who provide care that is outside of these guidelines.................................................27

10.4 Quality assurance........................................................................................................................................27

10.4.1 Histopathology.....................................................................................................................................27

10.5 Data collection and audit.............................................................................................................................28

10.6 Educational Meeting....................................................................................................................................28

10.7 Communication............................................................................................................................................28

10.8 Facilities.......................................................................................................................................................29

10.9 Support Services..........................................................................................................................................29

11 The Multidisciplinary Team................................................................................................................................29

12 Clinical Trials......................................................................................................................................................29

Appendix 1- Primary care referral guidelines for skin cancer...................................................................................30

Appendix 2 - Referral guidelines between Local and Specialist MDTs......................................................................33

Appendix 3 - Extract from the South East London Cancer Network Constitution for Skin Cancer...........................34

Appendix 4 - Levels of Care......................................................................................................................................35

Appendix 5 – Peninsula Cancer Network Urology Site Specific Group Penile Cancer Guidelines 2009....................37

Appendix 6 - Excision of Skin Cancer in the Community Outside of the Guidelines.................................................38

Table of Peer Review Measures

11-1C-110j Agreed network-wide clinical guidelines for the management of skin cancer ................. 111-1A-215j Arrangements with haemato-oncology teams for lymphoma involving skin ................. 1311-1A-208j Agreed network referral guidelines to named supra-network T-cell lymphoma MDT for

TSEBT ....................................................................................................................... . 14

11-1A-209j Agreed network guidelines for referral for photopheresis............................................. 1411-1A-211j Arrangements for head and neck skin cancer ............................................................. 1511-1A-212j Arrangements for anal and perianal skin cancer.......................................................... 1511-1A-213j Arrangements for skin cancer of external female genitalia .......................................... 1511-1A-214j Arrangements for skin cancer of external male genitalia ............................................. 1511-1A-216j Arrangements with sarcoma MDTs for sarcoma involving skin .................................... 1511-1A-207j Network agreed referral guidelines between teams ..................................................... 1511-1A-210j Agreed network distribution of clinics for immunocompromised patients with skin cancer

..............................

................................................................................................. ..... 1611-1C-111j NSSG designated hospital practitioners for Mohs surgery and their caseload ............. 1711-1A-203j Policy for the provision of skin cancer services in the community ................................ 17

11-1C-112j NSSG agreed clinical governance arrangements for community practitioners............. 1711-1C-113j NSSG agreed training policy for model 2 community practitioners with named

trainers/assessors ............................................................................................... ........ 17

named consultant dermatologist .................................................................................. 1711-6A-104j GPwSI training specific to skin cancer given under the supervision of a

named consultant dermatologist ............................................................................................................. . 18

11-6A-105j GPwSI accreditation group should have a lead clinician of a skin MDT who should be involved in the accreditation and re-accreditation of community skin cancer clinicians 26

11-1C-113j NSSG agreed training policy for model 2 community practitioners with named trainers/assessors ............................................................................................... ........ 26

11-1C-110j Agreed network primary care referral guidelines and their distribution......................... 3211-6A-101j Network/PCT agreed primary care referral policy and distribution of the

primary care referral guidelines............................................................................................... ......... 32

11-1A-207j Network agreed referral guidelines between teams ..................................................... 33

1 Premalignant Lesions

1.1 Primary care referral guidelinesPremalignant lesions may be treated by any GP in the communityIncludes actinic keratoses, Bowens disease (SCC in situ)

2 Basal Cell Carcinoma

2.1 Primary care referral guidelines

High Risk BCCHigh risk of incomplete excision and recurrence, defined as:

recurrent BCCs BCCs on the head (face and scalp) large BCCs > 2cm diameter

unless they are superficial BCCs (see below)

lesions that have a clinical appearance of morphoeic, infiltrative or basosquamous

lesions with poorly defined margins BCCs in patients who are

immunosuppressed or have Gorlin‟ssyndrome

BCCs located over important underlying anatomical structures (for example, major vessels or nerves) or where primary surgical closure may be difficult (for example, digits or front of shin).

Refer to core member of Local MDTSuspected BCCs should usually be referred as routine.Consider 2 week referral if there is particular concern that delay may have an impact because of site or size of lesion.

Extended Low Risk BCCThere is no diagnostic uncertainty that the lesion is a primary nodular low-risk BCC and it meetsthe following criteria:

The patient with BCC is not: aged 24 years or younger (that is,

a child or young adult) immunosuppressed or has Gorlin‟s

syndrome

The lesion: Is not on the nose and lips

(including nasofacial sulci and nasolabial folds), or around the eyes (periorbital) or ears

Is less than 2 cm in diameter if below the clavicle (unless they are superficial BCCs see below).

Is less than 1 cm in diameter if above the clavicle (unless they are superficial BCCs see below).

Is not morphoeic, infiltrative or basosquamous in appearance

Does not have poorly defined margins Is not located:

o over important underlying anatomical structures (for

Refer to either Core member of

local MDT Or Group 3 GPwSI in

dermatology and skin surgeryOr

Group 3a GPwSI in skin lesions and skin surgery

Suspected BCCs should usually be referred as routine.Consider 2 week referral if there is particular concern that delay may have an impact because of site or size of lesion.

example, major vessels or nerves)

o in an area where primary surgical closure may be difficult (for example, digits or front of shin)

o in an area where excision may lead to a poor cosmetic result.

If any of the above exclusion criteria apply, or there is any diagnostic doubt, the patient should be referred to the LSMDT.

Incompletely excised BCCs should be discussed with a member of LSMDTLow Risk BCCThere is no diagnostic uncertainty that the lesion is a primary nodular low-risk BCC and it meets the following criteria:



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

is not morphoeic, infiltrative or basosquamous in appearance

is not locatedo over important underlying

anatomical structures (for example, major vessels or nerves)





Group 3a GPwSI in skin lesions and skin surgeryOr

GP accredited in Skin Cancer Suspected BCCs should usually be referred as routine.Consider 2 week referral if there is particular concern that delay may have an impact because of site or size of lesion.

o in an area where difficult excision may lead to a poor cosmetic result

o at another highly visible anatomical site (for example, anterior chest or shoulders) where a good cosmetic result is important to the patient.

Incompletely excised BCCs should be discussed with a member of the LSMDT.BCC where there is any doubt about high orlow risk status

Refer to core member of Local MDT

Superficial BCCs – on the face Refer to core member of Local MDT

Superficial BCCs – not on the faceIf the lesion is thought to be a superficial BCC theGP should ensure that the patient is offered the full range of medical treatments, including photodynamic therapy. This may require referral to the LSMDT.





GP accredited in Skin Cancer

2.2 Treatment

BCC Type TreatmentSmall well-defined BCCs on trunk and limbs

excision (with 3-4mm margin) or curettage &cautery

Superficial BCCs excision, cryotherapy, imiquimod, 5-fluorouracil, curettage or PDT: all treatment options guided by site, size, clinician and patient preference

High-risk BCCs Surgical excision with at least 4mm margins

Monitoring rather than immediate treatment may be appropriate in cases of asymptomatic BCC in a patient with a short life expectancy.

Consider Mohs surgery for more difficult and high risk cases such as: Recurrent BCC Poorly defined BCC Aggressive histology High risk sites Where tissue conservation is particularly important

Radiotherapy may be useful, particularly for patients unwilling or unable to tolerate surgery.

2.3 Incomplete excisions:

Lateral margins Offer re-excision or observationDeep margins Recommend immediate re-excision (and

possibly Mohs) unless patient very elderly in which case observation may be more appropriate, or consider radiotherapy.

2.4 BCC Follow up:Complete excision or other definitive treatment – no follow up required, re-referral by GP if any sign ofrecurrence.

Exceptions where follow-up may be appropriate: Skin graft/flap reconstruction: review once at 3 months in selected

cases to check cosmesis/complications.• High tumour load (ie 2 or more new BCCs per year or previous history of >10

BCCs). This decision to be at the discretion of the treating clinician.• Incomplete excision and opt for observation- consider follow-up 6 monthly for 1

year, then annually for 2 years- or discuss self-observation or GP follow-up.• Treatment with PDT/Imiquimod/Cryotherapy/C&C. Consider review once at 3 months to

check on effectiveness of treatment.

3 Squamous Cell Carcinoma


Squamous Cell Carcinoma 2 Week Referral to core member of Local MDT

Keratoacanthoma 2 Week Referral to core member of Local MDT

3.2 Primary treatment

SCC Type TreatmentHigh risk SCCHigh risk is defined as one or more risk factors for recurrence or metastasis. The risk factors aredefined as:

poorly differentiated, recurrent tumours, tumours >2cm across, perineural or lymphovascular

Excision with ≥6 mm clinical margins (see below).

extension histologically depth > 4mm transplant or immunosuppressed patients large >2cm lesions site: ear/lip/non-sun-exposed SCCs developing in

scars/sinuses/chronic inflammationLow risk SCCLow risk is defined as not high risk. This therefore includes:

Well differentiated tumours with no risk factors

Moderately differentiated tumour with no risk factors

Excision with ≥4 mm clinical margins

Small well-defined and obviously well-differentiated tumours in elderly patients may be suitable for treatment via curettage and cautery by practitioners experienced in this technique. Also in patients with high tumour load, where patient is already having long-term follow-up.

Re-excisionIf incomplete re-excise with 5mm margin.

Further treatmentDependent upon relative risk of tumour metastasising/recurring. Adjuvant radiotherapy should be considered for large poorly differentiated tumours and those close to excision margins.

3.3 Discussion at MDT

C omp l ete l y e x c i se d , w e l l d i f f e r e n t i ated SCC s need not be discussed at the MDT All other SCCs (ie any incompletely excised SCCs or any moderately or poorly differentiated

SCCs) should be discussed that the MDT

3.4 Follow up

SCC Type Follow upHigh risk SCC Consider 3 or 6 monthly follow-up for 2

years

depending on clinical situation (more need for follow-up if more than 1 poor prognostic factor present). Examine for local recurrence, and lymph node draining basins. Consider GP or patient self follow-up if appropriate/acceptable

Low risk SCC None required Risk factors should be identified at the time of treatment by the dermatologist.

All patients should be made aware of the sign or symptoms that should prompt them to seek medical advice. The Skin Cancer Service should ensure those patients who have problems can quickly and easily be seen by the skin cancer service.

3.5 Clinical ImagingHigh-risk SCC require CT for recurrent tumours

Not required for other primary SCC unless clinically indicated eg lymphadenopathy.

4 Malignant Melanoma


Melanoma 2 Week Referral to core member of Local MDT

4.2 Primary Excision2-5mm clinical margins

4.3 DermoscopyAll pigmented lesions referred for assessment should be assess using dermoscopy carried out by healthcare professional strained in this technique

4.4 Wide excision:Dependent on staging:

Lentigo maligna 5mm excision clinical margin to achieve completehistological excision

In-situ MM 2-5mm margin to achievecomplete histological excision

Stage 1 melanoma 1cm marginStage 2 and above melanoma

at least 2 cm margin

4.5 Imaging:Stage III and above: Staging CT required

4.6 Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy may be offered to patients with melanoma more than 1mm Breslow thickness. Patients should be offered SLNB as a staging tool and advised about advantages and disadvantages (see NICE guideline NG14 July 2015). Patients should be advised about possible clinical trials and allowed to make an informed choice.

4.7 Completion Lymphadenectomy for Positive SLNBConsider completion lymphadenectomy for people whose SLNB shows micro metastases. Give the patient verbal and written information about advantages and disadvantages as per the NICE guidelines NG14 July 2015.

4.8 Follow up

LM or in-situ MM One follow up and then dischargeStage IA 3 or 6 monthly for 1 yearStage IB or above 3 monthly for 3 years, then 6 monthly for a further

2 years

At follow up: Examination of scar, in-transit metastases, lymph node basins, liver. General skin check. Discuss self-examination.

4.9 Genetic Testing of TumoursIf targeted systemic therapy is a treatment option, offer genetic testing (BRAF etc) on:- the secondary deposit if this is possible, or- the primary if there is no adequate sample from the secondary

4.10 Enhanced Follow-up with Imaging for patients at increased risk of metastasis:

(stage 2C with no SLNB, or stage 3) who would be eligible for systemic therapy:Offer patients enhanced follow-up with CT scans chest/abdo/pelvis 6 monthly for 3 years. Consider CT brain for adults. Advise MRI scanning for those under 24 years.Advise patients of advantages and disadvantages (see NICE guideline NG14 July 2105)

4.11 Vitamin D Advice

The peninsula network has agreed there is no good evidence for routine measurement of Vitamin D levels in patients with primary melanoma. All melanoma patients should be advised about vitamin D supplementation if they are sun avoiding. There is a very small risk of renal stones with this treatment.

4.12 Melanocytic Lesions of Uncertain Malignant Potential

These should be managed as melanoma

5 Skin Lymphoma`

5.1 ReferralSystemic or nodal lymphomas should be referred to the haemato-oncology MDTs. Primary cutaneous lymphoma should be discussed at the Skin SSMDTs.11-1A-215j Arrangements with haemato-oncology teams for lymphoma involving skin

5.2 T Cell Lymphoma

Patients may be referred to the Lymphoma Service in Bristol, or to St Johns Institute.St John‟s Institute of Dermatology (Guy‟s & St Thomas‟ NHS Foundation Trust) is the Supra NetworkT-cell Lymphoma MDT to which the Peninsula relates. It is part of the South East London CancerNetwork. See Appendix 3 for the relevant extract from the South East London Cancer Network SkinNSSG Constitution.

Stage above 1b: consider/ offer referral to Lymphoma Unit, BUT may not be appropriate or feasible in certain clinical situations eg:

single isolated tumours very ill erythrodermic patients who are unable to travel

5.3 Photopheresis and Total Skin Electron Beam Therapy Patients with erythrodermic cutaneous T cell lymphoma (stage 3 and 4) should be referred to

the Lymphoma Unit for consideration of photopheresis. Patients with nodular mycosis fungoides (Stage 2b or over) should be referred to St John‟s for

consideration of Total Skin Electron Beam Therapy.

Some patients may be given Total Skin Electron Beam Therapy locally (in Plymouth) if this is more acceptable for the patient and where the management has been planned by St John‟s.

11-1A-208j Agreed network referral guidelines to named supra-network T-cell lymphoma MDT for

TSEBT11-1A-209j Agreed network guidelines for referral for photopheresis

5.4 B CellFor systemic disease: refer to haematology as above. For primary cutaneous disease:

Multiple or recurrent lesions: refer to St Johns Local isolated disease: local skin/ haematology SSMDT

6 Merkel Cell CarcinomaThe principles of the management or Merkel cell carcinoma include:

All patients should be discussed at SSMDT wide local excision possible frozen section to confirm clearance possible SLNB to assess lymph nodes possible radiotherapy

It was agreed that there is no strong evidence base for treatment options.It was agreed that these can be fast growing tumours and that wider excision should be timely, in line with melanoma management.

6.1 Adequate Local Excision

Clinical local excision margins of 1-2cm Aim for 1cm margin for tumour less than 2cm diameter. Aim for 1- 2cm margin for tumour greater than or equal to 2cm diameter. Consider using frozen section to confirm margins at time of operation. If performing wider excision where original margins incomplete or close: ensure

procedure is arranged urgently (as tumours are potentially fast growing).

6.2 Lymph Nodes

Consider SLNB for patients who are clinically node negative. For patients who are lymph node positive: Fine Needle Aspirate or Open Biopsy If nodes positive then consider lymph node dissection (to improve loco-regional control). If nodes positive then CT scan.

6.3 RadiotherapyConsider for:

Large tumour >2cm Lymph node involvement

6.4 Distant Metastases

Consider radiotherapy/ chemotherapy.

6.5 Follow-Up

As per melanoma patients ie 3 monthly for 3 years, then 6 monthly for further 2 years.

With thanks to Suyin Ong for drafting these guidelines

7 Skin Cancer for Specific Groups

7.1 Skin Cancer of Specific Anatomical SitesThe pathology for these cases should be referred to the following specified MDTs for an opinion on management.

Anatomical Site Cancer Type MDT to refer toHead & Neck Nasal Mucosal MM Head And Neck MDT

Ocular Mucosal MM

Ophthalmologists refer to oncologists

Periocular Oculoplastic/Plastic as Extended Member Of SkinMDT

Anal Cancer Any Colorectal MDTExternal femalegenitalia

SCC Gynae MDTMM Skin And Gynae MDTBCC Skin And Gynae MDT

External maleGenitalia/Penile

Any Avon Somerset& Wilshire Supranetwork MDT(see PCN Guidelines for Penile Cancer – Appendix5)

Any Sarcoma (see below)

Sarcoma MDT Exeter or Plymouth

Rare Tumours Other rare tumours(see list below)

Any SSMDT

11-1A-211j Arrangements for head and neck skin cancer11-1A-212j Arrangements for anal and perianal skin cancer11-1A-213j Arrangements for skin cancer of external female genitalia11-1A-214j Arrangements for skin cancer of external male genitalia11-1A-216j Arrangements with sarcoma MDTs for sarcoma involving skin11-1A-207j Network agreed referral guidelines between teams

Sarcoma includes all dermal and subcutaneous tumours, namely:

Dermatofibrosarcoma protuberans. Leiomyosarcoma. Angiosarcoma. Kaposi‟s sarcoma. Haemangioendothelioma. Epithelioid sarcoma. Primary cutaneous rhabdomyosarcoma. Cutaneous malignant nerve sheath tumours (including cutaneous

neurofibrosarcoma and malignant Schwannoma).Other Rare Tumours

Merkel Cell Tumours Apocrine carcinoma. Hidradenocarcinoma. Eccrine porocarcinoma. Sebaceous carcinoma.

Tumours associated with Muir–Torre syndrome Eccrine epithelioma (syringoid carcinoma) Microcystic adnexal carcinoma Primary adenoid cystic carcinoma Primary mucoepidermoid carcinoma Primary mucinous carcinoma Digital papillary adenocarcinoma Malignant cylindroma Malignant spiradenoma (spiradenocarcinoma) Malignant pilar tumour Malignant pilomatrixoma Neuroendocrine carcinoma (Merkel cell tumour/trabecular carcinoma) Atypical fibroxanthoma

7.2 Skin Cancers in Children & Young People

All children (ages 0-16) and young people (ages 16-24) with skin cancer should be discussed with the local lead consultant for children & young people‟s cancer. This should happen as soon as is practical.

8 Immunocompromised and Transplant PatientsClinics/allocated slots for transplant patients to be held at all 5 centres

NDH Dr Karen DaviesPHT Dr Cairine WilkinsonRCH Dr Samantha HannRDE Dr Rebecca BatchelorSDH Dr Ng Sheau

Clinics to be held 1 – 3 monthly depending on need/ numbers11-1A-210j Agreed network distribution of clinics for immunocompromised patients with skin cancer

8.1 Initial assessment1 year post transplant: advice and information particularly sun protection and self monitoring. Assessment for high risk factors including:

older patients white skinned patients who have had excess sun exposure presence of pre-malignant warty lesions or actinic keratoses

8.2 Follow upFrequency of follow-up to be decided by clinician on basis of clinical need. This should be annual follow-up as an ideal minimum, but then 3-6 monthly for patients with skin cancers, depending on various factors including tumour type and presence of high risk factors (eg poorly differentiated SCC).

8.3 Pre-malignant lesionsThere should be active treatment of all pre-malignant lesions.

8.4 New or fast-growing skin tumourPatients should be given instructions on how to access service at short notice in the event of a new or fast-growing skin tumour.

8.5 Secondary preventionRetinoids and/or reduction of immunosuppression as below should be considered.

8.6 Alteration in immunosuppressionTransplant physicians should be contacted with regard to possible alteration in immunosuppression particularly with: >25 NMSCs per yr high risk SCC Merkel cell tumour melanoma especially stage 11a or above

Management will vary according to type of transplant.

9 Mohs Surgery11-1C-111j NSSG designated hospital practitioners for Mohs surgery and their caseloadThe only practitioners authorised to carry out Mohs surgery (including 'Slow Mohs surgery') are the following:Dr Samantha Hann, Dr Tom Lucke (RCHT) Dr Chris Bower, Dr Emily

McGrath (RD&E)

The Mohs surgery practice is well established in Cornwall, and has started in Exeter.

10 Community Skin Cancer ServicesThis section covers the protocols for the accreditation, training and Governance of skin cancers services carried out in the community.11-1A-203j Policy for the provision of skin cancer services in the community11-1C-112j NSSG agreed clinical governance arrangements for community practitioners11-1C-113j NSSG agreed training policy for model 2 community practitioners

with named trainers/assessors11-6A-104j GPwSI training specific to skin cancer given under the

supervision of a named consultant dermatologist

All healthcare professionals managing skin lesions in the community should have specialist training in the diagnosis and management of skin lesions appropriate to their role.

All GPs who diagnose, manage and excise low-risk BCCs in the community should be fully accredited to do so and undergo continuous professional development in the diagnosis and management of skin lesions to maintain their accreditation. All Services for low-risk BCCs should adhere to national cancer peer review measures.

10.1 Levels of care that may be treated in the communityThe Levels of Care can be found at Appendix 4.

Level of Care Practitioners who may diagnoses & treat in the community1 All GPs and MDT members2 (low risk BCCs)

See below

3 Community outreach from Local or Specialist MDT4 Community outreach from Local or Specialist MDT5 Community outreach from Specialist MDT6 None

10.1.1 Definition of Low Risk Basal Cell Carcinoma

Diagnosis CriteriaLow Risk BCC

There is no diagnostic uncertainty that the lesion is a primary nodular low-risk BCCand it meets the following criteria:

The patient with BCC 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 is not morphoeic, infiltrative or basosquamous in appearance is not located

o over important underlying anatomical structures (for example, major vessels or nerves)



o at another highly visible anatomical site (for example, anterior chest

or shoulders) where a good cosmetic result is important to thepatient.

See below for superficial BCCs

Incompletely excised BCCs should be discussed with a member of the LSMDT.

ExtendedLow Risk BCC

There is no diagnostic uncertainty that the lesion is a primary nodular low-risk BCCand it meets the following criteria:

The patient with BCC is not: aged 24 years or younger (that is, a child or young adult) immunosuppressed or has Gorlin‟s syndrome

The lesion: Is not on the nose and lips (including nasofacial sulci and

nasolabial folds), or around the eyes (periorbital) or ears Is less than 2 cm in diameter if below the clavicle (unless they are superficial

BCCs see below).


Is not morphoeic, infiltrative or basosquamous in appearance Does not have poorly defined margins Is not located:

o over important underlying anatomical structures (for example, major vessels, nerves or temple)

o in an area where primary surgical closure may be

difficult (for example, digits or front of shin)o in an area where excision may lead to a poor

cosmetic result.


Incompletely excised BCCs should be discussed with a member of LSMDT.

SuperficialBCCs

If the lesion is thought to be a superficial BCC the GP should ensure that the patientis offered the full range of medical treatments, including photodynamic therapy. This may require referral to the LSMDT.

All superficial BCCs on the face should be referred to the LSMDT

10.1.2 Providers that may diagnose and treat low risk BCCs in the Community

Provider Accreditation BCCs that can be treated

Community outreach from Local orSpecialist MDT (a consultant led service that may include staff grade and

Training is covered by conventional specialty training in dermatology, and practitioners are subject to the MDT

All

associate specialist doctors and specialist nurses.

measures for core members in theManual for Cancer Services.

Group 3 GPwSI in dermatology and skin surgery

On PCT GPwSI list 1,2 Annually accredited by Local

MDT according to Error! Reference source not found.

Extended Low Risk BCCs


On PCT GPwSI list 1

(Completion ofSS1 and SS2 modules of GPwSItraining (without having completed fullGPwSI training)

Annually accredited by Local MDT according to Error! Reference source not found.

Extended Low Risk BCCs

GPs performing skin surgery within theframework of the Directed Enhanced Services and Local

Annually accredited by Local MDT according to Error! Reference source not found.

Low RiskBCC

s

Enhanced Services under General Medical Services or Personal Medical Services

1 Department of Health (2007) Guidance and competencies for the provision of services using GPs with special interests (GPwSIs): dermatology and skin surgery. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074665Department of Health (2007) Implementing care closer to home: convenient quality care for patients. Part 3: the accreditation of GPs and pharmacists with special interests. London: Department of Health2 Revised guidance and competences for the provision of services using GPs with Special Interests (GPwSIs)

10.1.3 Practitioners that may perform surgery on pre-diagnosed lesions

Model 2 PractitionersA Model 2 practitioner should be one of the following:

a medical practitioner performing skin surgery in a community setting a suitably trained specialist nurse.

Model 2 practitioners can perform surgery on pre-diagnosed lesions including the full range of BCCs as well as other types of skin cancer provided that

they have demonstrated surgical competence surgery is performed after the lesions have been diagnosed by an MDT

member and a management plan identified.

10.2 A ccreditationAll community skin cancer clinicians should identify the Local Skin Cancer MDT to which they relate. Good communication should be established to ensure the consistency and continuity of services for patients.

The accreditation and governance arrangements are set out in the table below.

Service Clinicalaccreditation byMDT

Placed on PCTGPwSI list

Employerresponsible for clinical governance

Community outreach from Local orSpecialist MDT (a consultant led service that may include staff grade andassociate specialist doctors andspecialist nurses.

Assumed through consultant ledservice

No Acute Trust hosting MDT

Model 2 Practitioners Yes No Acute Trusthosting MDT

Group 3 GPwSI in dermatology and skinsurgery

Yes Yes GP Practice orGPwSI (depending on contractual arrangements)


Yes Yes GP Practice orGPwSI (depending on contractual arrangements)

GPs performing skin surgery within the framework of the DES and LESEnhanced Services under GMS or PMS

Yes No, but placed on PCT list forGPs performing skin surgery within theframework of theDES and LES EnhancedServices underGMS or PMS

GP Practice

*Some GPs may be accredited as both a GPwSI and a Model 2 practitioner.

10.2.1 Clinical accreditation

Clinical accreditation will only assure competency and knowledge at the time and setting of accreditation. It does not confer any responsibility on the MDT for the actual service. Nor does it make any judgment on the suitability of the service model or environment in which the service is carried out. These issues are a matter for the clinical governance of the provider and their commissioner.

10.2.2 GPs performing skin cancer treatment within the framework of the DES or LES under

GMS or PMS

There are contractual requirements for GPs and other primary care health care professionals performing skin surgery within the framework of the DES under General or Personal Medical Services. National guidance sets out how these contractual requirements should be assessed. These are setout below with an indication of the method of assessment.

Contractual requirements for GPs and other primary care health care

professionals performing skin surgery within the framework of the DES under General or Personal Medical Services

Contractualrequirement

Measures of competency and activity against theserequirements

Assessmentmethod

The contractor ensuresthat any health care professional who is involved in performing any surgical procedures has:

i. any necessary experience, skills and training with regard to that procedure

ii. resuscitation skills

A. Has a new skin surgery practitioner demonstrated

competency to a suitably qualified external body using objective evidence and competency based assessment tool (ie Direct Observation of Procedural Skills, known as DOPS)?

Skin CancerCourse

B. Has an existing practitioner demonstrated competency to perform the designated procedure(s) to a suitably qualified external body using objectiveevidence and competency based assessment tools within the preceding three years? DOPSassessment is appropriate

Skin CancerCourse

C. Does the practitioner continue to perform skin

surgery with a regular, sustained level of activity and follow a program of revalidation? 100 skin surgery procedures per year that leave a scar (excluding cryosurgery) is recommended. If less than 100 procedures per year are performed, it is suggested that the practitioner demonstrate ongoing competency to perform the designated procedure(s) by completion of further DOPS assessments at three yearly intervals, unless the activity increases to the recommended amount

Revalidation toassess that at least 20 cases of skin cancer have been treated per year

Commissioner to asses thatat 100 skin surgeryprocedures peryear that leave a scar(excludingcryosurgery) are undertaken (accounting for suspected skin cancer andnon skin

cancer procedures)

D. Has the practitioner demonstrated training and ongoing medical education in the recognition andmanagement of skin lesions appropriate to their role(for example, a practice nurse performing skin surgery on pre-diagnosed skin lesions will have different skin lesion diagnostic skill requirements to a GP diagnosing and excising lesions)?

Skin CancerCourse

Revalidation

E. Does the practitioner have evidence of annual training in resuscitation?

Commissioner to assess

The contractor:i. obtains

written consent for thesurgical procedure before it is carriedout (where a person consents on apatient‟s behalf, thatperson‟s relationshipto the patient mustbe recorded on the consent form), and

ii. takes all reasonable steps to ensure that the consent form is included in the lifelong medical records held by thepatient‟s generalpractitioner

F. Is the practitioner familiar with Department of Health and General Medical Council guidance on informed consent, particularly in relation to the MentalCapacity Act and obtaining consent from minors, and has best practice as detailed in these guidancedocuments been adopted?

Skin CancerCourse

The contractor ensures

G. Does the practitioner send all skin specimensremoved to histology for analysis and

Skin CancerCourse

that all tissue removedby surgical procedures is sent for histologicalexamination, unlessthere are acceptable reasons for not doing so

provide information about the site of excision and provisional diagnosis on the histology request form?

Revalidation

H. Does the practitioner maintain a ‟fail-safe„ log of all

procedures performed with histological outcome toensure that patients are informed of the final diagnosis, and whether any further treatment orfollow-up is required? Is this undertaken in a timely fashion?

Revalidation

The contractor ensures that it has appropriatearrangements for infection control and decontamination inpremises where surgical procedures areundertaken

I. Is the practitioner aware of, and following, all relevant national guidance in relation to policies andprocedures (for example premises, facilities, infection control, needlestick injuries etc)?

Commissioner to assess

The contractor ensures that all records relatingto all surgicalprocedures are maintained in such a

J. Does the practitioner provide evidence of an annual review of clinical compared with histologicalaccuracy in diagnosis to demonstrate diagnosticcompetency?

Revalidation

K. Has a wound infection and patient experience study

Revalidation

way:

i. that aggregated data and details of individual patients are readily accessible for lawful purposes, and

ii. as to facilitate regular audit and peer review by the contractor of the performance of

been completed?L. When low risk BCCs are excised, does

the practitioner demonstrate that the requirements inImproving Outcomes for people with skin tumoursincluding melanoma (update) - The management of low-risk basal cell carcinomas (May 2010) are met(see Annex E).

Revalidation

M. Is the above considered as part of the annual appraisal process?

Revalidation

surgical procedures under the plan

Skin Cancer CourseSkin Cancer Courses will be run in the Peninsula to train and accredit GPs against measures A, B, D, F & G and the following

appropriate treatment selection. performance of local anaesthesia, punch biopsy, shave excision, curettage

and elliptical excision. knowledge of NICE and Peninsula Skin Cancer Guidance for treatment of skin cancer.

Accreditation will involve completion of 4 satisfactory formal assessments: 2 clinical assessments (modified mini-CEX) relating to diagnosis of benign

and malignant skin lesions 2 DOPS (Directly Observed Practices) assessments relating to surgical procedures

Fulfilment of the above criteria is likely to require attendance at secondary care clinics for training, unless the practitioner can demonstrate adequate previous experience and quality of care.

Initial AccreditationGPs operating on Skin Cancer will need to

attend a Skin Cancer Course that fulfils the requirements set out above and be accredited as having met the clinical requirements of the course.

Be accredited by their commissioner against measures C, E & I. be linked to a named skin cancer MDT and be accredited by the Skin MDT Lead.

RevalidationGPs should attend an annual Skin Cancer Review. This will be organised by the Peninsula CancerNetwork. GPs should collect and present information at this annual review sufficient to demonstrate:

Measure C specifically the treatment, using any modality, of at least 20 cases of suspected skin cancer in the previous year.

Measure D – specifically one CPD session (a total of 4 hours) on skin lesion recognition and

the diagnosis and management of low-risk BCCs Measure G (histology) Measure H (fail safe log) Measure J – specifically that at least 90% of excisions of skin cancers have a clear margin Measure L (compliance with Guidance)

Measure M (annual appraisal) Measure J - specifically a diagnostic accuracy of 70% (ie clinical vs. histological

diagnosis) for the low-risk BCCs they have managed.

GPs that are unable to meet these revalidation requirements will need to undergo further training and accreditation as per initial accreditation.

Practitioners operating on Skin cancer in the Community should follow these guidelines (Section 9.5 –9.9) regarding facilities and support services (Community skin services may only be carried out in facilities approved by the PCT), data collection and audit, and communication.

10.2.3 GPs with a Special InterestThis accreditation applies to:

Group 3 GPwSI in dermatology and skin surgery Group 3a GPwSI in skin lesions and skin surgery

A new „Group 3a GPwSI in skin lesions and skin surgery‟ is being developed by the Department ofHealth whose role is as follows:

training and accreditation to the same standard as the „Group 3 GPwSI in dermatology and skin surgery‟ but for skin lesions only (excluding the inflammatory skin disorders) all othercriteria, including referral pathways, link to the MDT, clinical governance arrangements and

CPD requirements, to match the Group 3 GPwSI in dermatology and skin surgery

Initial accreditationGPwSIs performing skin surgery should follow the framework for the training and accreditation ofGPwSIs, which is defined by the Department of Health as follows:

they are accredited by the PCTs according to national guidance appropriate to their role asGPwSIs. This will include demonstrating competency in performing local anaesthesia,punch biopsy, shave excision, curettage and elliptical excision using the direct observationof procedural skills (DOPS) assessment tool in the Department Health Guidance for

th

GPwSIs in dermatology and skin surgery.e GPwSI is linked to a named skin cancer MDT.

RevalidationGPwSIs will need to maintain accreditation annually and should:

demonstrate adherence to the requirements for community skin cancer clinicians specified in the dermatology and skin surgery GPwSI guidance.

Fulfil the revalidation requirements set out for GPs performing skin surgery within the framework of the DES or LES under GMS or PMS (see above).

attend four MDT meetings per year skin cancer clinical practice is audited annually as defined in the GPwSI guidance

GPwSIs who are unable to meet these revalidation requirements will need to undergo further training and accreditation as per initial accreditation.

11-6A-104j GPwSI training specific to skin cancer given under the supervision of

a named consultant dermatologist11-6A-105j GPwSI accreditation group should have a lead clinician of a skin MDT who should be involved in the accreditation and re-accreditation of community skin cancer clinicians

10.2.4 Model 2 Practitioners

Initial accreditationModel 2 practitioners should:

be trained in and have demonstrated competency in skin surgery techniques (as per SS1 and

SS2 frameworks in the GPwSI guidance) be associated with a named MDT perform surgery on pre-diagnosed skin cancers, receiving referrals from core

MDT members with an agreed treatment plan.

RevalidationPractitioners will need to maintain accreditation annually and should demonstrate:

Measure C specifically the treatment, using any modality, of at least 20 cases of suspected skin cancer in the previous year.

Measure D – specifically one CPD session (a total of 4 hours) on skin the management of low-

risk BCCs Measure G (histology) Measure H (fail safe log) Measure J – specifically that at least 90% of excisions of skin cancers have a clear margin Measure L (compliance with Guidance) Measure M (annual appraisal)

Model 2 Practitioners who are unable to meet these revalidation requirements will need to undergo further training and accreditation as per initial accreditation.

11-1C-113j NSSG agreed training policy for model 2 community practitioners with named trainers/assessors

10.3 Clinical GovernanceAll providers of community dermatology services that include skin cancer should ensure that:

Clinical governance arrangements are in place for all healthcare professionals providing these services (including private providers contracted to treat NHS patients) and they are accredited to perform skin lesion excisions.

All healthcare professionals providing these services work in accordance with the Network Skin

Cancer Guidelines (covering referral, treatment and follow-up. Healthcare professionals managing skin lesions in the community should

obtain informed consent before any treatment is undertaken.The clinical governance therefore sits with the employer of individual practitioners. PCTs will want to be assured that this is in place for all providers that they commission services from.

As the Guidance states that the clinical governance for Model 2 practitioners sits with the MDT, the MDT will want either to directly employ the Model 2 practitioner (for the relevant sessions) or formally subcontract with the practitioner. Other, informal, relationships will compromise the ability of the MDT to discharges its clinical governance responsibilities for which it is accountable.

10.3.1 Overlap between practitioners

An individual practitioner may be accredited in more than one group ie: GPwSIs Model 2 practitioner GPs working under the DES or LES

It is the responsibility of the practitioner and their employer to ensure that there is clarity about which role the practitioner is operating under and to ensure that the relevant guidance is followed in all cases.

10.3.2 Process for GPs who provide care that is outside of these guidelines

All GPs who perform treatment outside of these guidelines will be sent the statement -

“Excision of Skin Cancer in the Community Outside of the Guidelines” (Appendix 6). Each MDTand its lead PCT will agree which party sends the statement.

All occasions of GPs operating outside of these Guidelines will be shared with the PCT. GPs who continue to operate outside of these guidelines will be subject to the

PCTs Poor Performance Process1 Where a patient needs further treatment, a letter will be sent from the MDT specifying the actions that should be taken by the GP.

10.4 Quality assurance

10.4.1 Histopathology

All skin lesion samples (excision, incision, punch biopsy and curettage) should be sent for histologicalexamination as recommended in the NICE „Referral guidelines for suspected cancer‟. This shouldprovide information about the site of excision and provisional diagnosis on the histology request form.If a person has more than one lesion, samples should be sent in separate specimen pots with referral forms. Histology request and reporting forms, and the electronic recording of these data items, should be improved to capture the national skin cancer minimum dataset requirements2 and the Royal College of Pathology dataset).

All healthcare professionals should have a failsafe mechanism in place to ensure that they receive results for the skin lesion samples they send for histological assessment and act upon the results. This means that:

all samples sent to the laboratory should be accompanied with a numerical checklist any sample not received by the laboratory should be immediately notified to the operating GP

all results should be cross checked to ensure they have been seen and actioned.

Healthcare professionals should take appropriate action if the histology result reclassifies the lesion as a high-risk BCC or a SCC, malignant melanoma or other rare skin tumour and refer to approvedspecialists as recommended in „Improving outcomes for people with skin tumours including melanoma‟(NICE guidance on cancer services). The following histological criteria denote high-risk BCC:

incomplete excision margins morphoeic, infiltrative, micronodular or basosquamous perineural invasion below the dermis.

Each PCT should commission histopathology skin cancer services that clearly identify each individual healthcare professional. Audit data should be presented in an anonoymised fashion using individual identifier numbers, but individual healthcare professionals and PCTs should be given data that is identifiable.

GPs operating under DES/LES should send their low-risk BCC samples to the main histopathology laboratory that are linked to their local MDT.1 NHS Devon - Policy And Procedures For Managing General Practitioners, Dentists And Pharmacists In DevonWhose Performance Gives Cause For ConcernNHS Cornwall & IOS – Cause for Concern Process2 National Cancer Intelligence Network dataset project [in development Available from the National Cancer IntelligenceNetwork (NCIN): http://www.ncin.org.uk/index.shtml

10.5 Data collection and auditHealthcare professionals managing low-risk BCCs in the community should maintain a written or electronic record of the suspected and actual skin cancers they have managed in their individual caseload. This will need to specify the treatments offered and carried and the rationale for choosing a particular treatment modality.As required by the „Manual for cancer services 2008: skin measures‟ all BCCs excised by healthcare professionals in the community should be audited. The PCT should make these audit results available to the multidisciplinary team (MDT), cancer network and the individual practitioner on a quarterly basis and they should be included in the cancer network annual audit (cancer standards 08-6A-103J36).The quarterly dataset should be a standard PCT contract monitoring item for the DES.

Individual healthcare professionals should be responsible for collating their individual audit data for revalidation.

The MDT should source suitable patient reported outcome measures for the treatment of BCCs.

All BCCs should be registered with cancer registries to allow national, regional and local epidemiology and health service epidemiological studies to take place.

10.6 Educational MeetingThe Skin Cancer Network Site Specific Group should run two educational meetings per year, which should:

present the 6-monthly BCC network audit results, including a breakdown of individual practitioner performance

include one CPD session (a total of 4 hours) on skin lesion recognition and the diagnosis and management of low-risk BCCs

10.7 CommunicationAll healthcare professionals managing BCCs in the community should provide information, advice and support for patients and their families or carers.

10.8 FacilitiesCommunity skin services may only be carried out in facilities approved by the PCT (with guidance as appropriate by the MDT).

Facilities should be assessed for: Operating equipment Lighting Storage and use of liquid nitrogen (if being used, should be in line with Health

and Safety guidance) Infection control and decontamination issues

10.9 Support ServicesCommunity skin cancer services are responsible for:

The provision of information, advice and support for patients managed in primary care and their carers

Assessment and management of risk within the service

Community skin cancer services should have their own guidelines to include: Type of patients seen Frequency of consultations Range of interventions Referral criteria Communication pathways Confidentiality

Community skin cancer services must be supported by: Adequate record keeping and appropriate documentation Close links to the Skin MDT Clinical audit programme, including patient satisfaction survey Complaints process and review Incident reporting process and review, including significant event monitoring

11 The Multidisciplinary TeamThe Following principles apply to the members of MDTs to ensure the correct decisions are made to ensure best treatment.

Dermatologists who regularly treat skin cancer (and where this is a significant part of their workload) should be a core member of their local MDT

Those who do skin cancer work as a low percentage of their overall work (eg 10% of their workload) – and this will often apply to Plastic Surgeons - may be extended members of the

MDT ie attend 4 MDT meetings per year, but need not be core members of the MDT.

12 Clinical TrialsParticipation in clinical trials is encouraged, especially those which are part of the national Cancer Research network portfolio. In some instances the trial protocol will require diagnosis; treatment or follow-up which is at odds with these clinical guidelines. This should not be a concern where the trial has been through the appropriate ethical approval.

Appendix 1- Primary care referral guidelines for skin cancer

Premalignant lesionsIncludes actinic keratoses, Bowens disease (SCCin situ)

May be treated by any GP in the community

High Risk BCCHigh risk of incomplete excision and recurrence, defined as:

recurrent BCCs BCCs on the head (face and scalp) large BCCs > 2cm diameter

(unless they are superficial BCCs see below)

lesions that have a clinical appearance of morphoeic, infiltrative or basosquamous

lesions with poorly defined margins BCCs in patients who are

immunosuppressed or have Gorlin‟ssyndrome

BCCs located over important underlying anatomical structures (for example, major vessels or nerves) or where primary surgical closure may be difficult (for example, digits or front of shin).

Refer to core member of Local MDTSuspected BCCs should usually be referred as routine.Consider 2 week referral if there is particular concern that delay may have an impact because of site or size of lesion.

Extended Low Risk BCCThere is no diagnostic uncertainty that the lesion is a primary nodular low-risk BCC and it meets the following criteria:



syndrom

e

The lesion:





Suspected BCCs should usually be referred as routine.Consider 2 week referral if there is particular concern that delay may have

Is not on the nose and lips (including nasofacial sulci and nasolabial folds), or around the eyes (periorbital) or ears

Is less than 2 cm in diameter if below the clavicle (unless they are superficial BCCs see below).


Is not morphoeic, infiltrative or basosquamous in appearance

Does not have poorly defined margins Is not located:

o over important underlying anatomical structures (for example, major vessels or nerves)

o in an area where primary surgical

an impact because of site or size of lesion.

closure may be difficult (for example, digits or front of shin)

o in an area where excision may lead to a poor cosmetic result.


Incompletely excised BCCs should be discussed with a member of LSMDTLow Risk BCCThere is no diagnostic uncertainty that the lesion is a primary nodular low-risk BCC and it meets the following criteria:



syndrom

e

The lesion: is located below the clavicle (that

is, not on the head or neck)





GP accredited in Skin Cancer

Suspected BCCs should usually be referred as routine.Consider 2 week referral if there is particular concern that delay may have

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

is not morphoeic, infiltrative or basosquamous in appearance

is not locatedo over important underlying

anatomical structures (for example, major vessels or nerves)



o at another highly visible anatomical site (for example, anterior chest or shoulders) where a good cosmetic result is important to the patient.


an impact because of site or size of lesion.

BCC where there is any doubt about high or low risk status

Refer to core member of Local MDT

Superficial BCCs – on the face Refer to core member of Local MDT

Superficial BCCs – not on the faceIf the lesion is thought to be a superficial BCC theGP should ensure that the patient is offered the full range of medical treatments, including photodynamic therapy. This may require referral to the LSMDT.





GP accredited in Skin Cancer Suspected BCCs should usually be referred as routine.Consider 2 week referral if there is particular concern that delay may have an impact because of site or size of lesion.

Squamous Cell Carcinoma 2 Week Referral to core member of Local MDT

Keratoacanthoma 2 Week Referral to core member of Local MDT

Melanoma 2 Week Referral to core member of Local MDT

It is recognised that some skin cancers will be excised accidentally by GPs where the diagnosis was not apparent. These guidelines assume that GPs will not knowingly treat patients beyond their remit. See Section 9 for the Governance of skin cancer services in the community.11-1C-110j Agreed network primary care referral guidelines and their distribution11-6A-101j Network/PCT agreed primary care referral policy and distribution of the

primary care referral guidelines

Appendix 2 - Referral guidelines between Local and Specialist MDTs

Local MDT Specialist MDTPlymouth Hospital Plymouth HospitalNorth Devon Hospital

Royal Devon and Exeter HospitalRoyal Devon and Exeter HospitalSouth Devon HospitalRoyal Cornwall Hospital Royal Cornwall Hospital

Patients requiring care level 5 and above should be referred from the Local to the Specialist MDT, including:

Metastatic SCC Radiotherapy Other adjuvant therapy

Mohs‟ surgery Selected SCCs and BCCs Skin lymphoma Sarcoma Other rare tumours Patients with genetic syndromes including Gorlin‟s (these patients may be reviewed regularly

by the LSMDT team, with input as necessary from the SSMDT). Malignant melanomas stage 11b or above All malignant melanomas for patients under 19yrs (whose management plan need to be

agreed with the principal Treatment Centre for Children‟s Cancer in Bristol) Metastatic Malignant melanomas

See Section 5 for referral guidance for Skin LymphomasSee Section 6 fore referral for Kaposi‟s sarcoma and other rare skin cancers

11-1A-207j Network agreed referral guidelines between teams

Appendix 3 - Extract from the South East London Cancer Network Constitution for Skin Cancer

9. T-Cell Lymphoma MDT Supra Network for Total Surface Electron Beam Therapy (TSBET).See also supporting document TSEB Guidelines May 2009The St John‟s Institute of Dermatology, Guys‟ and St Thomas‟ NHS Foundation Trust will providesupra Network specialist services and the supra Network MDTs for SE London and wider populations to be determined in conjunction with the Specialist Commissioning Group. St John‟s operates as asupraregional centre for skin cancers and in the three years to 2006 received more than 600 referrals for primary cutaneous T-cell and B-cell lymphoma, of which three quarters came from outside SE London. It will continue to offer supra regional services for skin cancers referred from across the country

Patient PathwayJoint Skin Tumour Unit Out Patients St JohnsInstitute, St Thomas‟ HospitalConsultant Clinical Oncologist makes decision tooffer TSEBTPatient Consent and Information givenPatient Planning Appointment 2 weeks prior to start date

Boost treatmentPositions plannedShielding plannedPatch treatment plannedRadiotherapy Prescribed

Patient Treatment Weekly medical reviewDaily radiographer review

Patient Follow up See in Clinical Oncology Outpatients at weeks 1-3 if toxicity and ongoing care neededST Johns joint Clinic 1 month post

Audit and Outcome Monitoring10. Referral for Photopheresis See also supporting document TSEB Guidelines May 2009.There is a photopheresis facility available at St John‟s Institute of Dermatology, Guy‟s & St ThomasHospital.

C utane o us t umo u r S t a g e T 3 N 0 - 1 M 0 ( I I B ) Complete responses with TSEBT are lower with stage T3 tumours in the region 36 – 54% 4,6,12. This ishowever much superior to skin directed superficial radiotherapy and topical Nitrogen Mustard whichhas complete response rates of 8%. Therefore patients with stage IIB disease are offered TSEBT as first line treatment for its superior response rate and rapid palliative effect. It is combined with adjuvant treatment such as PUVA which improves the 5 year relapse free survival from 30% with TSEBT alone to 55% with TSEBT and adjuvant PUVA.

E r y t hrode r m a s t a g e T 4 N 0- 1 M 0 (I I I ) TSEBT can produce rapid and sustained responses in erthrodermic MF ameleriorating the severe cutaneous symptoms experienced by such patients. The reported complete response to TSEBT forstage III MF ranges from 60-100% with 5 year progression free survival of 69%. The complete responserate and progression free survival is less in patients with blood or visceral involvement. These patients may benefit from adjuvant photophoresis. TSEBT is an appropriate first line therapy for these patients.We currently use it as second line therapy following treatment with PUVA, A-interferon, photopheresisor methotrexate.

Appendix 4 - Levels of Care

CareLevel

Case mix or Procedures

1 Benign lesions Actinic Keratoses Precancerous – SCC, in situ/Bowen‟s

2 Low risk BCC – defined as not high risk (see Level 3)3 High risk BCC other than categories

belowHigh Risk BCC - defined as recurrent BCCs BCCs on the head (face and scalp) large BCCs > 2cm diameter unless they are superficial BCCs

that can be managed non-surgically lesions that have a clinical appearance of morphoeic,

infiltrative or basosquamous lesions with poorly defined margins BCCs in patients who are immunosuppressed or have Gorlin‟s syndrome BCCs located over important underlying anatomical structures (for

example, major vessels or nerves) or where primary surgical closure may be difficult (for example, digits or front of shin).

SCC other than categories below4 High risk BCC Recurrent or with +ve excision

SCC Recurrent or with +ve excision Malignant Melanoma (MM) – new, single primary, adult, non-metastatic, not for

approved trial entry, up to and including stage II a (must fulfil all these criteria)

Radiotherapy if attendance by clinical oncologist at LSMDT Lesion where diagnosis is uncertain but may be malignant Incompatible clinical and histological findings

5 Selected BCCs and SCCs needing plastic/reconstructive surgery by SSMDT core member (as per Network clinical guidelines) • Radiotherapy (as per Network clinicalguidelines). If not discussed and treated by LSMDT clinical oncology core team member

Metastatic SCC on presentation or newly metastatic MM – stage IIb or more, or < 19 years or metastatic on presentation or newly

metastatic or recurrent or for approved trial entry Any cases for approved trial entry

Any cases for adjuvant therapy (as per Network clinical guidelines) Histology opinion from SSMDT core pathology team member Mohs surgery Skin Cancer in immunocompromised patients including organ transplant recipients Skin Cancer in genetically predisposed patients including Gorlin‟s

Syndrome.

Cases to be dealt with by only one agreed SSMDT per Network, if more than one in the Network: Cutaneous lymphoma Kaposi‟s sarcoma Cutaneous sarcoma above superficial fascia. (Below fascia, refer to sarcoma

MDT) in cancers

Other rare skin cancers (see appendix 1 in the Skin Cancer IOG pg 128/129.

Notes: Where a network chooses to have a MMDT all cases of MM for level 5 care from

the MMDT’s catchment area should be referred to the MMDT. There should be agreed working arrangements with certain site specialised MDT’s

(see topic 08-1A).6 T-cell Cutaneous Lymphoma: Total Body Surface Electron Beam Therapy

Appendix 5 – Peninsula Cancer Network Urology Site Specific Group Penile Cancer Guidelines 2009

The NSSG has adopted the Guidelines of the Avon, Somerset and Wiltshire Network as the Supra Network for penile cancer. These local guidelines are designed to explain the presentation and assessment which will be carried out within the PCN before referral to the penile cancer team, as well as the treatments which may be conducted locally after discussion at the Supra Network MDT meeting. They are not intended to be exhaustive list of different presentations, findings and assessments that apply to every single patient.

PRIMARY CARE SETTINGPresentation will usually be with an ulceration or mass on the penis. The presence of phimosis may make assessment difficult. Patients should be referred under the 2 week wait system if there is suspicion of cancer.

SECONDARY CARE SETTINGPatients will be assessed clinically at the out-patient department, specifically penile examination and assessment of inguinal lymph nodes. Biopsy of suspicious penile lesions may be carried out by the local team, and also aspiration cytology of any suspicious inguinal lymph nodes.

Following histological confirmation, CT or MR scanning of the thorax, abdomen and pelvis is performed for further staging and referral made directly to Mr D Dickerson, Southmead Hospital for discussion at the Supranetwork MDT meeting, with a view to seeing the patient to discuss further management. In some unfit patients referral may be made back to the local hospital for simple partial penectomy. More complex surgery will either be performed by the core penile team at Southmead Hospital, or by Mr J Palmer, Plastic Surgeon, Royal Devon and Exeter Hospital, or Mr R Pearcy, Derriford Hospital, who are members of the extended penile cancer team. Discussion of further staging, surgery or adjuvant treatment is detailed in the ASW supranetwork guidelines, and under their direction.

Follow-up may be delegated back to the local team after an appropriate period, as decided by the core team

Appendix 6 - Excision of Skin Cancer in the Community Outside of the Guidelines

In response to NICE Guidance, the Peninsula Cancer Network has agreed guidelines on the management of skin cancer in the community. [PCT Name] is committed to ensuring all services are carried out in accordance with this guidance, in collaboration with the Skin Cancer Multidisciplinary Team at [hospital name].

NHS [xxx] will be using information from the local Skin Cancer Multidisciplinary Team (MDT) Departments to review adherence to this guidance.

A Skin Cancers that SHOULD NOT be managed in primary careGPs, including GPwSIs, should not knowingly treat the following skin cancers Malignant melanoma Squamous cell carcinoma High risk basal cell carcinoma (BCC)

The following definition of high-risk BCC should be used for clinical triage in primary care: recurrent BCCs BCCs on the nose and lips (including nasofacial sulci and nasolabial folds), or

around the eyes (periorbital) or ears BCCs greater that 2 cm in diameter if below the clavicle (unless they are

superficial BCCs that can be managed non-surgically). BCCs greater that 1 cm in diameter if above the clavicle (unless they are

superficial BCCs that can be managed non-surgically). lesions that have a clinical appearance of morphoeic, infiltrative or basosquamous lesions with poorly defined margins BCCs in patients who are immunosuppressed or have Gorlin‟s syndrome BCCs 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 excision may lead to a poor cosmetic result.

Patients where there is diagnostic uncertainty Patients aged 24 years or younger

BCCs that have been incompletely excised according to histology Superficial BCCs on the face

B Skin Cancers that MAY be managed by an accredited GPwSIExtended Low Risk BCCThere is no diagnostic uncertainty that the lesion is a primary nodular low-risk BCC or superficialBCC and it meets the following criteria:

The patient with BCC is not: aged 24 years or younger (that is, a child or young adult) immunosuppressed or has Gorlin‟s syndromeThe lesion: Is not on the nose and lips (including nasofacial sulci and nasolabial folds), or

around the eyes (periorbital) or ears Is less than 2 cm in diameter if below the clavicle (unless they are superficial

BCCs that can be managed non-surgically). Is less than 1 cm in diameter if above the clavicle (unless they are superficial

BCCs that can be managed non-surgically). Is not morphoeic, infiltrative or basosquamous in appearance Does not have poorly defined margins Is not located:

o over important underlying anatomical structures (for example, major vessels or nerves)o in an area where primary surgical closure may be difficult (for example, digits or front of

shin)o in an area where excision may lead to a poor cosmetic result.

Incompletely excised BCCs should be discussed with a member of Skin Cancer MDT

C Skin Cancers that MAY be managed by an accredited GP primary careLow Risk BCCThe patient with BCC 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 is not morphoeic, infiltrative or basosquamous in appearance is not located

o over important underlying anatomical structures (for example, major vessels or nerves)o in an area where primary surgical closure may be difficult (for example, digits or front of

shin)o in an area where difficult excision may lead to a poor cosmetic resulto at another highly visible anatomical site (for example, anterior chest or shoulders)

where a good cosmetic result is important to the patient.


D Superficial Basal Cell CarcinomasPatients with superficial BCCs (not usually classified as high risk) should be appropriately referred in order that they can be offered a full range of medical treatments, including photodynamic therapy. This may require referral to the Skin Cancer Multidisciplinary Team. Healthcare professionals managing superficial BCC in the community should have experience and knowledge of this condition. All superficial BCCs on the face should be referred to the Skin Cancer MDT.

Histological Specimens1. ALL skin specimens removed should be sent to histology for analysis. GPs should

provide information about the site of excision and provisional diagnosis on the histology request form.4

2. Topical and ablative therapies (ie cryotherapy) should only be used if the diagnosis is certain.

Documents

Skin Cancer: Management Guidelines for the Peninsula … · Web viewAdvise patients of advantages and disadvantages (see NICE guideline NG14 July 2105) 4.11 Vitamin D Advice The peninsula