Improving outcomes for people with skin tumours including melanoma

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Improving Outcomes for People with Skin Tumours including Melanoma Follow-up The Cancer Services Collaborative Project in England 54 has shown that the perceived need for lifetime follow-up of cancer patients in hospital clinics can be challenged by a review of the evidence. With appropriate education and training, patients can be discharged to active self-follow-up, releasing significant capacity in outpatient clinics for the management of new patients. Patients with precancerous and cancerous lesions of the skin are extremely numerous and the vast majority will not die of their disease. Although the risk of metachronous disease for patients presenting with cancer is high, for most patients follow-up will make no difference to survival, although later presentation may result in more extensive treatment and related morbidity. It is therefore essential that only those patients who will benefit be recalled for doctor- or nurse-based follow-up. This will include patients with: • advanced-stage disease at presentation • disease for which the management is difficult 5 • a high risk of developing recurrent disease • a high risk of developing metachronous tumours • failure to respond to the initial treatment • lesions at sites that are difficult to examine. Reducing the number of patients attending for formal follow-up will improve the capacity to provide high-quality treatment to the everincreasing numbers of new patients and patients re-presenting with metachronous lesions. Moreover, as the skin is visible to patients and carers, most can be trained to identify new lesions. A. Recommendations Cancer networks should develop locally agreed protocols for followup of each skin cancer type, taking into account national guidelines, the risks of local recurrence, metastatic spread and new primary lesions. 54 www.aswcs.nhs.uk/aswcs/csc/default.htm 104 National Institute for Health and Clinical Excellence
Follow-up for patients after treatment for skin cancer should be tailored, as much as possible, to the individual, taking into account the patient’s needs and wishes. Options and decisions regarding follow-up should be made jointly with the patient. Improving Outcomes for People with Skin Tumours including Melanoma Follow-up All patients should be given both oral and written information about the different types of skin cancer and instruction about selfsurveillance. All patients should be given written instruction on how to obtain quick and easy access back to see a member of the LSMDT/SSMDT when necessary. GPs should be given advice about local arrangements for patients to re-access skin cancer services. Follow-up arrangements may include a combination of selfsurveillance, GP or other community doctor, and specialist nurse or hospital specialist clinic. Some patients, such as those who are immunocompromised or who have a genetic predisposition to the development of skin cancers (e.g. Gorlin’s syndrome, xeroderma pigmentosum), may need lifelong surveillance (see chapter on ‘Management of special groups’). Positron emission tomography (PET) scanning is not routinely recommended for follow-up; however, it may be useful for a small number of patients with suspected recurrent disease when clinical doubt remains after other forms of imaging. PET scanning should therefore be available on a supraregional basis for these patients. 5 Basal cell carcinoma and squamous cell carcinoma Patients with BCCs or SCCs, with a low risk of recurrence, do not need long-term surveillance and should be discharged from formal follow-up, but should be given information and instruction as recommended above. Patients who are at high risk of recurrent or metachronous cancer or who find self-examination difficult require formal follow-up. The period of time and frequency will depend on the degree of risk, which should be discussed with the patient. This may be particularly important for patients with high-risk SCCs, because of the more serious implications of locoregional recurrence. Guidance on cancer services: skin tumours including melanoma 105
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NHS National Institute for Health a
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Contents Improving Outcomes for Peo
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Patient information ...............
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Resource implications .............
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Foreword Improving Outcomes for Peo
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- referral - review of patient care
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early detection have been published
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The epidemiology of skin cancers an
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The incidence of MM increases with
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Figure 5. Mortality from MM, Englan
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Figure 8. Incidence of NMSC, Englan
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Risk factors for skin cancer As ski
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Figure 12. Rates of episodes of inp
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Two-week wait data Urgent skin canc
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• Improving the experience of car
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12. National Institute for Clinical
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Patient-centred care Improving Outc
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This document and the NICE Referral
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A checklist may be used by healthca
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Quality assurance Surveys of patien
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One cross-sectional study found tha
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One RCT conducted with patients wit
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• Every skin cancer MDT having ac
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to estimate a separate cost for ser
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department or they may be referred
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The 2-week waiting time standard an
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The local hospital skin cancer mult
Page 55 and 56: A function of the LSMDT is to audit
Page 57 and 58: • lymphoedema therapists • phar
Page 59 and 60: SSMDT meetings should be at least f
Page 61 and 62: As set out in the section on ‘Arr
Page 63 and 64: • Palliative care specialists. Si
Page 65 and 66: Videoconferencing and teleconferenc
Page 67 and 68: A basic knowledge of skin cancer hi
Page 69 and 70: B. Anticipated benefits At present,
Page 71 and 72: One systematic review (of the abili
Page 73 and 74: One retrospective study compared pa
Page 75 and 76: • Critical incidents where treatm
Page 77 and 78: Network-wide protocols It is not po
Page 79 and 80: Initial investigation, diagnosis, s
Page 81 and 82: Figure 14. Skin lesion - patient pa
Page 83 and 84: curettage (as recommended in BAD gu
Page 85 and 86: Diclofenac 3% gel (Solaraze) is lic
Page 87 and 88: Histopathology services for skin ca
Page 89 and 90: Patients with anogenital Bowen’s
Page 91 and 92: B. Anticipated benefits Better-qual
Page 93 and 94: One RCT compared teledermatology wi
Page 95 and 96: One systematic review based upon 12
Page 97 and 98: Expert review evidence suggests tha
Page 99 and 100: Immunotherapy An RCT comparing allo
Page 101 and 102: • Adherence to treatment protocol
Page 103 and 104: F. Research priorities • Given th
Page 105: For patients with low-risk BCC or S
Page 109 and 110: C. Evidence Evidence exists that ea
Page 111 and 112: One observational study found that
Page 113 and 114: The written and photographic inform
Page 115 and 116: Genetic predisposition to MM may al
Page 117 and 118: patients with cutaneous lymphoma sh
Page 119 and 120: A. Recommendations Generic recommen
Page 121 and 122: Cutaneous lymphoma All patients sho
Page 123 and 124: Children and young people with skin
Page 125 and 126: Gorlin’s syndrome Two expert revi
Page 127 and 128: Process • Audit of adherence to p
Page 129 and 130: • Cutaneous lymphoma is so rare t
Page 131 and 132: Dermal and subcutaneous tumours Aty
Page 133 and 134: c) The guidance will also refer to
Page 135 and 136: 4.2.2 Healthcare settings and servi
Page 137 and 138: Referral from the Department of Hea
Page 139 and 140: Table A1. Summary of service option
Page 141 and 142: For those cancer networks with part
Page 143 and 144: Appendix 4 How this guidance manual
Page 145 and 146: Appendix 5 People and organisations
Page 147 and 148: Professor Julia Newton-Bishop Mr Ba
Page 149 and 150: • Bristol South and West PCT •
Page 151 and 152: • Healthcare Commission • Help
Page 153 and 154: • Royal College of Surgeons of En
Page 155 and 156: Appendix 5.3 Researchers carrying o
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Appendix 5.4 Expert advisers to the
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Appendix 5.5 Report* commissioned t
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Appendix 6 Glossary of terms Improv
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Chemoprophylaxis The use of a drug
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Electrodesiccation A surgical metho
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Immunotherapy Treatment by stimulat
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Morbidity A diseased condition or s
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Prognosis A prediction of the likel
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Systemic therapy Treatment that rea
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KS LHB LSMDT MCC MDT MM MRI NCC-C N
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Improving outcomes for people with skin tumours including melanoma

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