The management of low-risk basal cell carcinomas in the community Implementing NICE guidance in general practice May 2010 NICE guidance on cancer services (update)

Updated guidance This guidance updates recommendations on the management of low-risk basal cell carcinomas in the community in ‘Improving outcomes for people with skin tumours including melanoma’ (NICE guidance on cancer services, 2006).

What this presentation covers Background Recommendations Discussion Find out more

Background :1 Concerns raised about the implementation of some aspects of NICE 2006 guidance on skin cancer services in relation to: –arrangements under which GPs could remove ‘low- risk’ basal cell carcinomas (BCC) –how services for skin cancer patients were being commissioned.

Background :2 BCC is the commonest type of cancer in the UK Main risk factor for BCC is sun exposure BCC is rarely fatal, but it can metastasise in a very small number of cases Majority of BCCs can be treated in an out-patient or community setting

Background :3 - types of BCC Nodular Basosquamous © Schofield JK and Kneebone R (2006) Skin lesions: a practical guide to diagnosis management and minor surgery. Superficial PigmentedMorphoeic © dermNetNZ.org (

Recommendations Communication Training, education and accreditation Low-risk BCCs for DES/LES Model 1 practitioners Other models of care Quality assurance

Communication All healthcare professionals managing BCCs in the community should provide information, advice and support for patients and their families or carers.

Training, education and accreditation Healthcare professionals in the community need specialist training in skin lesion diagnosis and management PCTs or LHBs should ensure that all GPs and GPwSIs who diagnose, manage and excise low-risk BCCs in the community are: –fully accredited to do so –undergo CPD to maintain their accreditation Accreditation should be performed by PCTs or LHBs and will differ for GPs and GPwSIs

Criteria for removing low-risk nodular BCCs based on patient and lesion characteristics, including: –patient’s age, immunosuppression and genetic susceptibility –anatomical location and history of the lesion –size and clinical appearance of the lesion Refer to a member of the LSMDT, following discussion with the patient, if: diagnostic doubt criteria not met needed to offer full range of treatments Discuss incompletely excised BCCs with a member of the LSMDT Low-risk BCCs for DES/LES :1

Criteria for accreditation of GPs: demonstrate competency have specialist training appropriate to their role send all skin specimens to histology for analysis provide information about site of excision and provisional diagnosis on the histology request form maintain a ‘fail-safe’ log of all procedures. Low-risk BCCs for DES/LES :2

Criteria for accreditation of GPs (continued): provide quarterly feedback to their PCT or LHB on histology provide details to their PCT or LHB of all types of skin cancer removed in their practice provide evidence of an annual review of clinical compared with histological accuracy in diagnosis attend, at least annually, an educational meeting organised by the Skin Cancer Network Site Specific Group. Low-risk BCCs for DES/LES :3

Model 1 practitioners: are ‘Group 3 GPwSIs in dermatology and skin surgery’ and a new ‘GPwSI in skin lesions and skin surgery’ should be trained and accredited in the management and excision of low-risk BCCs in the community should manage an expanded range of low-risk BCCs, including some on the head and neck –exclusion criteria based on patient and lesion characteristics, including: o patient’s age, immunosuppression and genetic susceptibility o size, clinical appearance and anatomical location of the lesion Model 1 practitioners (1)

Criteria for accreditation of ‘Group 3 GPwSI in dermatology and skin surgery’ should follow the framework for the training and accreditation of Model 1 practitioners defined by the Department of Health: accreditation by PCTs or LHBs appropriate to role linked to named skin cancer LSMDT and attendance at four LSMDT meetings per year clinical governance arrangements with PCT or LHB continuing professional development requirements. Model 1 practitioners (2)

A new ‘GPwSI in skin lesions and skin surgery’ should be developed: training and accreditation to same standard as ‘Group 3 GPwSI in dermatology and skin surgery’ but for skin lesions only (excluding the inflammatory skin disorders) all other criteria to match the ‘Group 3 GPwSI in dermatology and skin surgery’ managing low-risk BCCs only within the framework for the ‘Group 3 GPwSI in dermatology and skin surgery’. Model 1 practitioners (3)

Model 2 practitioners: outreach community skin cancer services under acute trust or LHB governance linked to the LSMDT Overlap between Model 1 (‘Group 3 GPwSI in dermatology and skin surgery’) and Model 2 practitioners Hospital specialists working in the community Other models of care

Histological examination of all skin lesion samples Histology request forms to be improved to capture national skin cancer minimum dataset requirements Failsafe mechanism to ensure results are received and acted upon Specialist referral if histology result reclassifies Identification of individual practitioner as a requirement for commissioning services Quality assurance: histopathology

Quality assurance: data collection and audit A written or electronic record for suspected and actual skin cancers should be maintained All excised BCCs should be audited GPs managing low-risk BCCs in the community should: –attend at least one educational meeting annually –provide evidence of clinical compared with histological accuracy All BCC should be registered by cancer registries

Cost and savings The update to the 2006 NICE guidance on skin cancer services is unlikely to have significant incremental costs above those associated with the original guidance. A move towards increased activity in the community may result in a slight decrease in costs. Conversely, a move towards more referrals to secondary care may result in a cost increase, although overall the costs associated with these changes are not thought to be significant at a national level.

Discussion What are the current local arrangements for managing patients with low-risk BCC in general practice? How can we improve patient access to services? How can we build the capacity of general practice to manage patients with low-risk BCC? What training needs are there to deliver the recommendations and how can these be met?

Find out more Visit for: the guidance ‘Understanding NICE guidance’ costing statement commissioning factsheet baseline assessment.