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Is initial excision of cutaneous melanoma by General Practitioners (GPs) dangerous? Comparing patient outcomes following excision of melanoma by GPs or in hospital using national datasets and meta-analysis

Published:October 27, 2017DOI:https://doi.org/10.1016/j.ejca.2017.09.034

      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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