>> Clinical Guidelines

Providing Cutaneous Oncology Services (1998)

This document has been produced by the BAD to give guidance to dermatologists and purchasers. It can be adapted by the user to suit local requirements and is available on disk from the BAD offices.

28/8/97

Skin Cancer

Purchasing and Commissioning Cutaneous Oncology Services
Information for Dermatologists and Purchasers

Prepared According to NHS Management Executive Guidelines 

Authors: Rona M MacKie MD FRCP FRCPath., Clinician
Simon Skinner MA, Assistant Director of Commissioning Greater Glasgow Health Board. Purchaser
Sara Twaddle PhD, Head of Health Services Research. Stobhill NHS Trust. Health Economist
Yvonne Duncan MA, Chair, Tak Tent Cancer PatientsSupport Group and also a patient

Introduction

The recent Policy Framework for Common Commissioning Cancer Services (Calman 19951) established the essential principle of uniform high quality of care for all cancer patients nationally. It also stated that contracts should be negotiated for each cancer type. The purpose of this document is to suggest purchasing arrangements for skin cancer.

The Policy Framework Document suggests the establishment of cancer units, mainly within district general hospitals which have an ability to diagnose and treat uncomplicated cases of commoner cancers, and larger cancer centres which would serve a larger population and offer more specialised and sophisticated services including radiotherapy.

The purpose of this document is to outline the roles of skin cancer centres and skin cancer units.

Background

The range of skin cancers is wide. The conditions which require to be treated include:

• Basal cell carcinomas
• Squamous cell carcinomas
• Malignant melanoma
• Cutaneous lymphoma
• Kaposi's sarcoma
• Skin appendage tumours

An appendix describing these skin tumours is included at the end of this paper.

Incidence and changing incidence

Throughout the 1980s, the incidence of the three main types of cutaneous malignancies, basal cell carcinoma, squamous cell carcinoma and malignant melanoma rose rapidly, approximately doubling between 1980 and 19902. Pathological studies from groups of European centres indicate that in the case of malignant melanoma this is a real rise, not an artefact due to changes in pathological reporting. Charting the rate of increase throughout the UK is no longer possible in the case of basal cell carcinoma as some cancer registries, eg South Thames, have ceased recording these tumours 3. This is unfortunate as although they are rarely fatal, they are by far the commonest type of skin tumour and a frequent cause of morbidity in the elderly. All require treatment and are a large financial burden on the NHS as a result, particularly in parts of the country where there is a high proportion of the population aged 65 and over. Some knowledge of the incidence trends for basal cell carcinoma is therefore highly desirable for future planning of adequate skin cancer service provision. In those areas of the UK where skin cancer registration is thought to be accurate, an increase in the incidence of basal and squamous cell carcinomas of around 5% per annum is currently recorded, and from these figures it is estimated that in 1993 approximately 50,000 basal cell carcinomas and squamous cell carcinomas were first treated in England, Scotland and Wales4. The incidence rises with increasing age 5, and thus with an ageing population more patients are likely to require treatment over the next decade. The incidence of cutaneous malignant melanoma has also risen rapidly at 7% per annum in the UK 6 over the past decade. This is a cause for particular concern as cutaneous malignant melanoma is the main cause of skin cancer related death7.

Incidence figures for other rarer skin cancers such as lymphoma, Kaposi's sarcoma, and appendage tumours are not readily available. While the numbers of patients affected by these problems are relatively small compared with those affected by the major three malignancies, all are potentially fatal and require treatment which may involve expensive and specialist equipment such as photochemotherapy apparatus for cutaneous lymphoma, or expensive therapy including interferons and antiviral therapy for Kaposi's sarcoma.

Mortality

Skin cancer related mortality is also rising, 5. The main cause of skin cancer mortality is malignant melanoma. Over the past decade the rate of increase in melanoma mortality has been 2% per annum in England and Wales.

Health of The Nation Target

The Health of The Nation target for skin cancer is "to halt the year-on-year increase in the incidence of skin cancers by 2005"8. Thus a target for reducing incidence is given rather than a target for reducing mortality. At the present time the most important etiological factor for basal cell carcinoma, squamous cell carcinoma and melanoma is excessive exposure to ultra violet radiation, mainly natural sunlight9. It is likely that this excessive sun exposure will have occurred over a period of many years, frequently beginning in childhood or 20 to 30 years before development of the skin malignancy. Thus a target with a 10 year lead period is a challenge, but may well be achievable if UV exposure plays a major role as a promoter .

Economic Implications

The great majority of patients with skin cancer have basal cell carcinoma. This if treated early is a dermatological problem easily dealt with by simple daycare dermatological surgery in the great majority of cases. A small proportion of patients with tumours which are very large or in anatomically difficult areas such as the eyelid may require more complex plastic or ophthalmological surgery. For some elderly frail individuals, radiotherapy or curettage are acceptable alternatives, but excision surgery is the gold standard for most cases as it allows full pathological examination of the entire specimen, both for diagnosis, and also to confirm complete excision. Thus the resource implications of the management of basal cell carcinoma is that of daycare surgery for large numbers of patients with a small unit cost per patient. Success rates for cure of basal cell carcinomas after surgery are high at over 90%, but follow up is needed to detect second primary basal cell carcinomas which are also common.

Cure or long disease free remissions are also possible for over 80% of squamous cell carcinomas and malignant melanomas , provided they are clinically recognised and treated at an early stage of growth .

A small proportion of all patients with skin cancer who have more advanced disease may require inpatient treatment involving extensive surgery. Mohs' micrographic surgery, and chemotherapy may be required in rare cases. Thus at this end of the spectrum the pattern is one of small numbers of cases requiring expensive treatment with high unit costs per patient, often with the prospect only of palliation or delay of tumour spread rather than cure.

Publicity campaigns encouraging the public to seek medical advice about new or changing pigmented lesions results in referral from GPs for consultant opinion of large numbers of patients who have benign pigmented lesions which require clinical differentiation from likely early melanoma10.The ratio of these referrals is around twenty benign pigmented skin lesions for each early melanoma. The frequency with which general practitioners see malignant melanomas in their own practices is around less than 1 new case per year in a list of 2,000. Thus it is unlikely that even with more extensive GP education on skin cancer recognition that the average GP will ever acquire enough experience to safely and confidently exclude early melanoma. Triage of these lesions has therefore to be the responsibility of the consultant dermatologist who has had adequate training and experience11. Without this, unnecessary surgery and accompanying patient anxiety are inevitable. Time must be allowed for this, preferably a specialist skin cancer clinic with a waiting list of not longer than 3 weeks.

Members of the primary care team require regular updates on guidelines for referral to this clinic

Research and clinical trials of new therapies

Research into new and better methods of treating skin cancer is essential, as is research into the epidemiology and genetics of skin cancer susceptibility. It is important in any contract to include time for investigation of newer treatments and for the organisation of appropriate audit and clinical trials and other aspects of research designed to improve the prospects for patients with skin cancer. Some of theses areas should attract NHS R and D funding.

Treatment

The great majority of patients with basal cell cancer, squamous cell cancer and malignant melanoma require daycare dermatological surgery which should be carried out in appropriate outpatient theatres with adjacent daycare facilities. Other methods of treatment such as cryotherapy should also be available. It is likely that lasers of various types will in the future be used as part of the management of some patients for certain types of skin cancer.

A small proportion of patients will require more sophisticated surgical treatment such as skin grafts, flaps or Mohs' micrographic surgery. The latter is only available in a small number of centres in the UK at present. A small number of patients with advanced squamous cell carcinoma, malignant melanoma and cutaneous lymphoma may require systemic chemotherapy.

Most patients with cutaneous lymphoma respond well to light therapy (photochemotherapy or PUVA). This technique is available in a great many district general hospital dermatology departments and virtually all teaching hospital dermatology departments. A small proportion of patients with cutaneous lymphoma may require chemotherapy or interferon therapy. This can usually be given on an outpatient basis, but a few will require skilled dermatological nursing because of loss of large areas of skin from the body surface .

Palliative care

The majority of patients with skin cancer have it treated or controlled successfully and die of other causes. A very small proportion, usually with malignant melanoma, cutaneous lymphoma or Kaposi's sarcoma require palliative care which should be available reasonably close to the patients home.

Thus for the great majority of skin cancer patients, diagnosis can be carried out by dermatologists trained in recognition of early skin cancer and dermatological surgery techniques. Dermatologists are therefore the appropriate initial referral speciality from primary care, and should act as co-ordinators of other specialities who may be required as part of the management team for patients who have more advanced skin cancer. These may include plastic surgeons for excision and reconstruction of large tumours, and in the treatment of skin cancers on difficult anatomical sites. Radiation oncologists will be required to manage a small proportion of cases of basal cell carcinoma, squamous cell carcinoma and Kaposi's sarcoma and medical oncologists for the management of patients with more advanced cutaneous malignant melanoma and lymphoma. The dermatologist is well placed to co-ordinate patient care from referral via primary care to the necessary members of this team for the individual patient through combined clinics, by treatment planning meetings or by individual case conferences.

General Principles of commissioning skin cancer services

Commissioning skin cancer services should be a subsection of the dermatology contract rather than part of the general oncology contract. This is because of the very high incidence of cutaneous malignancies, because dermatologists with their specific training in the clinical features of early malignancy are appropriate points of first referral from primary care, and because the vast majority of patients will not need the expensive facilities of already overburdened general oncology centres but will need minor day-care dermatological surgery. Clinical oncologists will have a valuable role to play in the treatment of a small proportion of skin cancer patients with advanced disease, but are not trained in the clinical differential diagnosis and cannot perform initial biopsies of the very large number of patients referred with non malignant skin disease because of concern about possible malignancy.

The pattern for skin cancer services best suited to current patient needs is that the dermatologist should be the first point of referral from primary care, and that all district general hospitals should have adequate numbers of fully trained and accredited consultant staff on the appropriate specialist register. The current recommendation is one consultant dermatologist per 100, 000 population. Waiting lists of less than 3 months even for non urgent cases are desirable.

Appropriate supporting medical and nursing staff are required to contribute to the team. One trainee or associate specialist per consultant is the minimum necessary, and more may be required in geographically widespread areas. One or more members of the team should have a special interest and additional training in dermatological surgery.

Skin cancer units

The facilities available should include high quality outpatient clinics, a minor surgery suite, equipment for cryotherapy and diathermy, and a rapid good quality diagnostic dermatopathology service. The above would be the minimum requirement for a skin cancer unit. Patients with basal cell carcinomas and squamous cell carcinomas could all be referred to these centres for clinical assessment and an excision biopsy which may be all the treatment required. It is however essential that even in small centres there is a fast track system so that those with possible skin cancer do not wait more than four weeks to be seen and appropriate treatment planned. In the case of suspected malignant melanoma, this is essential.

Skin cancer centres

Larger centres with 3 or more consultant dermatology staff and more extensive facilities including a day surgery area and inpatient facilities may be designated skin cancer centres. In these centres one designated consultant should act as the co-ordinator of skin cancer services for the department. These skin cancer centres should have staff and facilities appropriate for more extensive skin cancer surgery for larger basal and squamous cell carcinomas, and should have experience in techniques for early diagnosis of malignant melanoma and current appropriate surgery. They should also have experience in diagnostic techniques and management of cutaneous lymphomas and have phototherapy (PUVA) services available. They should also be able to manage Kaposi's sarcoma in collaboration with colleagues.

Not all larger dermatology units will wish or feel equipped to become skin cancer centres. It is suggested that appropriate units should be in areas serving a substantial population (e.g. 0.5 million) and accustomed to dealing with a reasonable number of rarer skin cancers i.e. 20 - 30 melanomas annually and 6 - 10 cutaneous lymphomas in addition to the commoner skin cancers.

Many of these skin cancer centres will be in hospitals with general oncology departments with radiotherapy facilities, and dermatologists involved in skin cancer centres should liaise with medical and radiation oncologists in the management of patients with more advanced skin cancers as appropriate. Similarly some patients with large skin cancers will require more extensive surgery which will be best performed by either a dermatological or a plastic surgeon depending on local circumstances. The over-riding principle must be that the individual treatment plan for the individual patient should take account of all best local facilities.

Very few skin cancer patients will require extra contractual referrals. A small number of patients with recurrent or large basal cell carcinomas may require Mohs' micrographic surgery, some patients with locally recurrent malignant melanoma may require arterial limb perfusion, and a small number of patients with rarer variants of cutaneous lymphoma may require to be considered for photopheresis. None of these treatment modalities is required often enough to make it necessary for them to be widely available at the present time.

Quality contracting and commissioning

It is important that the patients with suspected skin cancer are seen rapidly so that the diagnosis can be confirmed and treatment planned. In parts of the country where general dermatology waiting lists are long, departments who wish to be designated as skin cancer units or skin cancer centres will require to have in place rapid referral arrangements and a fast track skin cancer clinic so that patients with suspected cutaneous malignancy are seen within a maximum of four weeks after GP referral.

Agreed referral protocols should be discussed as part of the skin cancer purchasing contract, and documented policies for primary diagnosis and onward referral should be developed. There should be agreed measures of provider performance established between purchaser and provider, and there also should be an agreed policy of developing early detection and prevention services and educational programmes, with integral audit and evaluation of these activities.

Children and adolescents

Skin cancer is extremely rare in children and adolescents and is best managed by a paediatric dermatologist in collaboration with a paediatric oncologist.

Communications between patients, general practitioners and hospital doctors

All patients with skin cancer and their relatives require clear treatment plans which should be explained and discussed individually. Communication between dermatologists, other members of the hospital skin cancer team and primary care must be rapid and clear.

Professional and public education

All members of the primary care team require continuing medical education and update on the prevention of skin cancer, early recognition of skin cancer and current best therapy. This is particularly appreciated by practice nurses and community nurses who often take a large share of responsibility for the care of elderly individuals in their practice and are therefore well positioned to recognise early changes on the skin.

Dermatologists should take responsibility for regular update sessions for members of the primary care team in the area they serve and should liaise with local health education departments in carrying out appropriate public education activities aimed at both early self-referral and prevention of skin cancers. Current UK experience suggests that messages on recognition of early curable malignant melanoma can be very effectively delivered either through brief television messages or be illustrated in newspapers and magazines.

Follow-up and outcome assessment

This is important to establish standards of care. Follow-up can be carried out either at a hospital level or as a combined shared care arrangement between primary care and the relevant hospital department. Follow-up visits and subsequent outcome is an obvious situation for careful audit with the aim of developing evidence based treatment guidelines. At present the proposals for cancer centres and cancer units are novel as far as skin cancers are concerned, and therefore careful record of outcomes requires to be kept in both types of working group so that effective audit can be performed.

Appendix

Types of skin cancer with a brief description

Basal Cell Carcinoma

This is much the commonest type of skin cancer and is a slowly growing tumour which mainly affects older people on the face. Around 40,000 are diagnosed annually currently in the UK.

Treatment
Normal treatment is local surgical excision which is usually curative. If not dealt with reasonably early however these lesions can be extremely invasive and destructive, destroying both bone and cartilage. Radiotherapy, curettage and cryotherapy may all be appropriate management for some patients. Extensive reconstructive surgery is rarely needed. For a small number of patients with difficult or recurrent basal cell carcinomas Mohs' micrographic surgery is an excellent treatment option. This is a labour intensive form of surgery involving removing small quantities of tumour with regular pathological checks. The principle is to remove all tumour cells but as little as possible in the way of normal tissue round about. This is obviously extremely valuable in areas such as around the eye where it is important to try to preserve structures.

With early surgical treatment, cure rates of over 90% can be achieved, but there is a risk of a second or subsequent basal cell carcinoma developing.

Squamous Cell Carcinoma

A form of skin cancer arising from the keratinocytes in the epidermis. Usually affects older people and frequently on sun exposed skin such as the head, neck and backs of the hands. Commoner and more aggressive in patients who have had renal or other organ transplants. Around 10,000 squamous cell carcinomas are diagnosed annually in the UK at present.

Treatment
Squamous cell carcinoma is usually managed by surgical excision, but these tumours also respond to radiotherapy. Cure rates of 70-80 % are achievable, and these could be higher with earlier diagnosis . As with basal cell carcinoma, there is a risk of a second or subsequent primary squamous cell carcinoma developing.

Malignant Melanoma

An aggressive form of skin cancer arising from the pigment producing cells in the skin, the melanocyte. At present around 5,000 are diagnosed annually in the UK.

Treatment
Successful treatment of malignant melanoma depends on early diagnosis. Early malignant melanomas are treated by simple surgical excision and longterm survival rates are good. Later melanoma may require more extensive surgery with skin grafting. Melanoma which has spread beyond the primary site is frequently treated in experimental settings with interferon, chemotherapy and/or radiotherapy for palliation.

Melanoma is the most serious form of skin cancer in that it is responsible for the great majority of skin cancer deaths. If diagnosed early when the tumour has invaded less than 1.5mm into the underlying dermis, five year disease free survival rates are over 85%, but if the tumour has invaded deeper to 3.5mm, five year survival falls to under 50%. Survival once the tumour has spread beyond the primary site falls to under 25%. Paradoxically, melanoma is commoner in the more affluent but this group of the population have significantly better survival prospects than the less affluent.

In some geographic areas of the UK there are agreed treatment guidelines. These require continual review and update as new approaches to therapy become available.

Cutaneous Lymphoma

A rare form of lymphoma arising in the skin. This condition usually affects older patients and presents as itchy nodules and lumps on any part of the skin surface. The incidence of newly diagnosed cases in the UK is 1-2/100,000 /year

Treatment
Treatment of cutaneous lymphoma may involve in the early stages control of symptoms with potent corticosteroid creams, in later stages the use of ultraviolet therapy or PUVA, and in more advanced situations interferons, radiotherapy and chemotherapy.

Kaposi's Sarcoma

A form of malignancy arising from the lining of the blood vessels in the skin. This condition is commoner in patients with HIV infection and it therefore has fairly high profile. There are however other variants of Kaposi's sarcoma which affect individuals who have had no contact with the HIV virus. The exact numbers of patients with Kaposi's sarcoma are unknown.

Treatment
Treatment of patients with Kaposi's sarcoma usually involves combinations of radiotherapy and chemotherapy.

Skin Appendage Tumours

Rare lesions arising from the cells in the skin responsible for production of hair, sweat glands etc. The exact number of these patients is unknown but they are probably extremely rare.

Treatment
Simple dermatological surgical excision is usually curative.

Suggested measures of assessing provider performance

For both skin cancer units and centres

1. Is there a clear publicised referral clinic for patients with suspected skin cancer?
2. Is this clinic consultant led?
3. Are all patients referred to this clinic seen within four weeks of referral?
4. Are all patients who require surgical treatment after attending such a clinic treated within 4 weeks of referral?
5. Is necessary surgery carried out by individuals with an appropriate level of training?
6. Are pathology reports issued by individuals with an appropriate level of training ?
7. Is communication to the general practitioner from the designated skin cancer timely and appropriate?
8. Are patients given a satisfactory explanation of their condition and likely progress?.
9. Is written information in the form of handouts made available to patients?
10 Are patients who request it offered access to a patient support group?
11. Is there an opportunity for members of the primary care team to attend skin cancer clinics and update their diagnostic skills?

For skin cancer centres only

1. Is there access to a radiotherapy department?
2. Is there access to medical oncologists?
3. Are communications between dermatologists and radiation and medical oncologists satisfactory ?

References

1. A policy framework for commissioning cancer services. A report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. Dept. of Health Welsh Office. April 1995; pp2 para 1.4.

2. Devesa SS, Blot WJ, Stone BJ, Miller BA, Tarone RE, Joseph F I et al. Recent Cancer Trends in the United States. J. Natl. Cancer Inst., 1995; 87: 175-182.

3. Cancer in South East England 1990. Cancer incidence, prevalence and survival in residents of the District Health Authorities in the four Thames Regions. Thames Cancer Registry, Oct. 1993.

4. Bowers P W. Skin Cancer in Cornwall 1980-1990. Brit. J. Dermatol., 1993; 129 Suppl. 42: 50-51.

5. Office of population, censuses and surveys. Cancer Statistics Registration. England and Wales 1993. London HMSO; 1995 (Series DH2 No. 20).

6. MacKie R, Hunter JAA, Aitchison TC, Hole D, McLaren K, Rankin R et al. Cutaneous malignant melanoma, Scotland, 1979-89. Lancet 1992; 339: 971-75.

7. MMWR. Deaths from melanoma- United States, 1973-1992. Arch. Dermatol, 1995; 131: 770-72.

8. The Health of the Nation - A strategy for health in England. 1992, pp69-70.

9. IARC monographs on the evaluation of carcinogenic risks to humans. IARC 1992; 55.

10. Docherty VR & MacKie RM. Experience of a public education campaign on early detection of malignant melanoma. Br Med J 1988 297 388-391.

11. MacKie RM and Hole D Audit of a public education campaign to encourage earlier detection of malignant melanoma. Br Med J 1992 304 1012-1015.

October 1997