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NICE has today (26 May) published updated recommendations on the diagnosis and removal of ‘low risk’ basal cell carcinomas (BCCs) in primary care in its guidance “Improving outcomes in cancer for people with skin tumours including melanoma”.

Early in 2009 NICE was made aware of difficulties arising from the implementation of one aspect of its cancer service guidance on skin cancer, published in 2006. These were particularly in relation to the arrangements under which GPs could remove ‘low risk’ BCCs and how services for skin cancer patients were being commissioned. After fully considering these concerns, in July 2009 NICE announced that a formal review of the recommendations would take place.

The other recommendations made in the original guidance have not changed. The expert group reviewing the guideline specifically considered the diagnosis and removal of low risk BCCs in primary care.

The updated recommendation makes clear that Primary Care Trusts (PCTs) or Local Health Boards (LHBs) should ensure that all GPs and GPwSIs (GPs with a Special Interest) who diagnose, manage and excise low-risk BCCs in the community are fully accredited to do so, and undergo continuous professional development in the diagnosis and management of skin lesions to maintain their accreditation. For both groups (GPs and GPwSIs) this accreditation should be performed locally by PCTs or LHBs.

The standards and tools to support this process are contained within national guidance documents1 and within the guideline itself.

Dr Fergus Macbeth, Director Centre for Clinical Practice at NICE said: “We listened to the concerns about implementing the original guidance recommendations focussing on the diagnosis and removal of low risk BCCs in primary care, and have responded to them in this update. BCC is the most common type of cancer in the UK, with an average of 48,000 new cases registered each year. However, because it is not fatal, its importance can be underappreciated. It is vital that patients are accurately diagnosed, receive appropriate treatment and avoid unnecessary or incomplete surgery. We hope this updated guidance will ensure that patients get the care they need in the most appropriate setting.“

Dr Laurence Buckman, chairman of the BMA's GPs Committee said:"We are glad this guidance has been updated because it will be of great benefit both to patients who have suspected skin cancer and to the GPs responsible for their care. There is now a clear framework which will enable family doctors to make appropriate, informed decisions for their patients - whether this means a referral to hospital or minor surgery at their GP practice. We are pleased NICE has listened to our concerns and that this guidance acknowledges the important role family doctors have to play in treating patients with low risk skin lesions or tumours."

Professor Steve Field, Chair of the Royal College of General Practitioners (RCGP), said: ““The updated guidance is a major step forward for patients with skin lesions or tumours - and for the GPs who are usually their first port of call for help.

“All patients have the right to be accurately diagnosed and then safely and appropriately treated. Many patients will prefer to have minor surgery at their GP practice rather than going to hospital and the guidance acknowledges the important role of GPs in carrying out this treatment. But GPs are not expected to have expertise in this area so it is vital that we have a defined and consistent framework for referral when necessary.

“The new guidance sets clear boundaries that will enable GPs to work within the NICE priorities whilst making informed decisions resulting in the best outcomes for all patients with suspected skin cancers, whether they go on to be treated in primary or secondary care.

“We are pleased that NICE has listened to the concerns of GPs and made the necessary adjustments that should now enable all healthcare professionals involved in the diagnosis and treatment of skin cancers to deliver a better deal for patients - but we must do more to ensure that the GPs are properly represented on the groups that develop these guidelines.

“GPs are at the frontline of patient care, we see more patients per day and per year than any other healthcare professionals and we must make sure that we play a central role in influencing such important and potentially life-changing decisions affecting our patients.”

Dr Julia Verne, Deputy Regional Director of Public Health and SWPHO Director and Chair of the Guidance Development Group (GDG) said: “This new guidance puts patients at the centre of improving services for the management of low risk BCCs. They have clearly said that they want doctors who remove these lesions to be accredited and to participate in audit. BCCs are very common and their incidence is increasing. Whilst they are rarely fatal, because a very high proportion arise on the face and head, their treatment is potentially difficult and requires expertise to ensure they are both fully removed and the patient has a good cosmetic result.

“I am delighted with the support we received from professionals on the Committee to produce Guidance which I think will really improve services for patients.”

Dr Julia Schofield, Consultant Dermatologist, United Lincolnshire Hospital NHS Trust and guideline developer said: “This guideline clarifies the skills required to manage people with low risk basal cell carcinomas. It will be enormously helpful for commissioners and for those providing care for this group of patients. It will also provide reassurance to patients that the same standard of care applies for everyone, wherever it is given and whoever provides it.”

Dr Timothy Cunliffe, GP with a Special Interest in Dermatology and Skin Surgery, Middlesbrough Specialist Skin Service and guideline developer said:“BCC is a common skin cancer and for the foreseeable future the number of people affected in the UK is going to rise significantly. One of the main aims of the guidelines is to increase the number of health professionals across both primary and secondary care able to manage the condition. The guidelines also focus on quality of care so that no matter where a patient chooses to have their treatment they should receive a high level of surgical care, or a choice of non-surgical treatments for those BCCs that do not need to be cut out.”

Mrs Sylvia Toresen, patient member of the GDG said: “This updated recommendation on low risk BCCs should enable patients to be confident of an accurate diagnosis and mean that their healthcare professional will explain and evaluate the range of available treatments, allowing them to participate fully in decisions about their care. The range of treatments available means that BCCs can be removed effectively the first time with minimum loss of good tissue, maximum chance of removing cancer cells and produce a good cosmetic outcome. Patients should be aware that surgery is only one of the options and be assured that those healthcare professionals involved in their care will be properly trained and accredited to carry out the various types of treatments and that all samples removed will be tested and followed up."

The guideline, produced for NICE by the National Collaborating Centre for Cancer, aims to help clinicians to provide coherent and consistent care for patients with skin cancer, providing comprehensive information to ensure equal access to services across England and Wales. Key recommendations still in force published in 2006, but not included in this update include:

• Cancer networks should establish two levels of multidisciplinary teams - local hospital skin cancer multidisciplinary teams (LSMDTs) and specialist skin cancer multidisciplinary teams (SSMDTs). All health professionals who knowingly treat patients with any type of skin cancer should be members of one of these teams, whether they work in the community or in the hospital setting.
• People with precancerous skin lesions may be treated entirely by their GP or referred for diagnosis, treatment and follow-up to doctors working in the community who are members of the LSMDT/SSMDT. If there is any doubt about the diagnosis, people with precancerous lesions should be referred directly to their local hospital skin cancer specialist - normally a dermatologist, who is a member of the LSMDT/SSMDT.
• All patients with a suspicious pigmented skin lesion, with a skin lesion that may be a high-risk BCC, a SCC (squamous cell carcinoma) or a MM (malignant melanoma), a rare tumour, or where the diagnosis is uncertain, should be referred to a doctor trained in the specialist diagnosis of skin malignancy, normally a dermatologist, who is a member of either an LSMDT or an SSMDT.

1 Department of Health (2007) Guidance and competencies for the provision of services using GPs with special interests (GPwSIs). Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074665

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