Highlights
- •Evidence before this study Initial excision of melanoma by GPs could lead to earlier diagnosis, but UK specialist opinion is strongly against GP melanoma excision. When a melanoma is excised in primary care both patients and practitioners can be made to feel that outcomes will be compromised. We reviewed existing UK guidelines and searched the worldwide literature and found little good evidence to support this view.
- •Added value of this study We compared mortality and morbidity outcomes for Scottish patients receiving initial melanoma excision in primary versus secondary care. We also present a pooled analysis with a comparable Irish data in the largest and most rigorous observational study yet conducted on this topic. We found no evidence that initial primary care excision of melanoma compromises patient outcomes.
- •Implications of all the available evidence Where melanomas are excised in primary care patients and practitioners can be reassured that there is no increased risk of death.
Abstract
Background
Melanomas are initially excised in primary care, and rates vary internationally. Until
now, there has been no strong evidence one way or the other that excising melanomas
in primary care is safe or unsafe. European guidelines make no recommendations, and
the United Kingdom (UK) melanoma guidelines require all suspicious skin lesions to
be initially treated in secondary care based on an expert consensus, which lacks supporting
evidence, that primary care excision represents substandard care. Despite this, studies
have found that up to 20% of melanomas in the UK are excised by general practitioners
(GPs). Patients receiving primary care melanoma excision may fear that their care
is substandard and their long-term survival threatened, neither of which may be justified.
Methods
Scottish cancer registry data from 9367 people diagnosed with melanoma in Scotland
between 2005 and 2013 were linked to pathology records, hospital data and death records.
A Cox proportional hazards regression analysis, adjusting for key confounders, explored
the association between morbidity and mortality and setting of primary melanoma excision
(primary versus secondary care). A pooled estimate of the relative hazard of death
of having a melanoma excised in primary versus secondary care including 7116 patients
from a similar Irish study was also performed.
Results
The adjusted hazard ratio (95% CI) of death from melanoma for those having primary
care excision was 0.82 (0.61–1.10). Those receiving primary care excision had a median
(IQR) of 8 (3–14) out-patient attendances compared to 10 (4–17) for the secondary
care group with an adjusted relative risk (RR) (95% CI) of 0.98 (0.96–1.01). Both
groups had a median of 1 (0–2) hospital admissions with an adjusted rate ratio of
1.05 (0.98–1.13). In the meta-analysis, with primary care as the reference, the pooled
adjusted hazard ratio (HR, 95% CI) was 1.26 (1.07–1.50) indicating a significantly
higher all-cause mortality among those with excision in secondary care.
Conclusions
The results of the Scottish and pooled analyses suggest that those receiving an initial
excision for melanoma in primary care do not have poorer survival or increased morbidity
compared to those being initially treated in secondary care. A randomised controlled
trial to inform a greater role for GPs in the initial excision of melanoma is justified
in the light of these results.
Keywords
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References
- Ultraviolet radiation and the INTERSUN Programme.2015http://www.who.int/uv/faq/skincancer/en/index1.htmlDate accessed: May 5, 2015
- Mortality and morbidity after initial diagnostic excision biopsy of cutaneous melanoma in primary versus secondary care.Br J Gen Pract. 2013; 63: e563-e572https://doi.org/10.3399/bjgp13X670697
- Ann Oncol. 2015; 26: v126-v132https://doi.org/10.1093/annonc/mdv297
- Diagnosis and treatment of melanoma. European consensus-based interdisciplinary guideline –update 2016.Eur J Cancer. 2016; 63: 201-217https://doi.org/10.1016/j.ejca.2016.05.005
- The profile of dermatological problems in primary care.Clin Exp Dermatol. 2010; 35: 380-383
- Update on the current state of melanoma incidence.Dermatol Clin. 2012; 30: 355-361
- Revised UK guidelines for the management of cutaneous melanoma.Br J Dermatol. 2010; 163: 238-256
- Skin cancer. Quality standard QS130.NICE, London2016https://www.nice.org.uk/guidance/qs130Date accessed: May 30, 2017
- Cutaneous melanoma — a national clinical guideline.Scottish Intercollegiate Guidelines Network, Edinburgh2017 (SIGN guideline number 146)http://www.sign.ac.uk/guidelines/fulltext/146/index.htmlDate accessed: May 30, 2017
- Dermatological surgery: a comparison of activity and outcomes in primary and secondary care.Br J Dermatol. 2009; 161: 110-114https://doi.org/10.1111/j.1365-2133.2009.09228.x
- Safety of community-based minor surgery performed by GPs: an audit in different settings.Br J Gen Pract. 2016; https://doi.org/10.3399/bjgp16X684397
- A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial.Health Technol Assess. 2008; 12 (iii–iv, ix–38)
- Comparing initial diagnostic excision biopsy of cutaneous malignant melanoma in primary versus secondary care: a study of Irish National data.Eur J Gen Pract. 2016; 22: 267-273https://doi.org/10.1080/13814788.2016.1232386
Scottish Government. The Community Health Index (CHI). http://www.gov.scot/Publications/2015/04/6687/4 [Accessed 30 May 2017].
Scottish Government. Scottish Index of Multiple Deprivation (SIMD). http://www.gov.scot/Topics/Statistics/SIMD [Accessed 30 May 2017].
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chron Dis. 1987; 40: 373-383
- Graphical methods for assessing violations of the proportional hazards assumption in cox regression.Stat Med. 1995; 14: 1707-1723
- Clinical practice guidelines for the management of cutaneous melanoma in Australia and New Zealand.Australian Cancer Network and New Zealand Guidelines Group, Sydney and Wellington2008
- The Australian experience in sun protection and screening for melanoma.J Surg Oncol. 2004; 86: 236-245
- Skin lesions suspected of malignancy: an increasing burden on general practice.BMC Fam Pract. 2014; 15: 29
- Reliability of cancer registration data in Scotland, 1997.Eur J Cancer. 2002 Feb; 38: 414-417
- Excision versus incision biopsy in the management of malignant melanoma.J Dermatol Treat. 2016; 27: 88-90https://doi.org/10.3109/09546634.2015.1034083
- Skin conditions in the UK: a health care needs assessment.Centre of Evidence Based Dermatology, University of Nottingham, 2010www.nottingham.ac.uk/research/groups/cebd/documents/hcnaskinconditionsuk2009.pdfDate accessed: May 30, 2017
- Performance of skin biopsies by general practitioners.Br Med J. 1991; 303: 1177-1179
- Excision biopsy of malignant melanoma by general practitioners in south east Scotland 1982–91.Br Med J. 1992; 305: 1476-1478
- Melanoma excision by general practitioners in North-East Thames region.Engl Br J Dermatol. 1998; 138: 412-417
- Diagnosing and managing cutaneous pigmented lesions: primary care physicians versus dermatologists.J Gen Intern Med. 2006; 21: 678-682
- Management of melanomas in primary care.Br J Dermatol. 2011; 164: 680-682
- Skin cancer excision performance in Scottish primary and secondary care: a retrospective analysis.Br J Gen Pract. 2014; 64: e465-e470
- Primary excision of cutaneous melanoma: does location of excision matter?.Br J Gen Pract. 2011; https://doi.org/10.3399/bjgp11X556272
- Excision of malignant melanoma in North Wales: effect of location and surgeon on time to diagnosis and quality of excision.Fam Pract. 2008; 25: 221-227
Article info
Publication history
Published online: October 27, 2017
Accepted:
September 26,
2017
Received in revised form:
September 15,
2017
Received:
July 27,
2017
Identification
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