BCCs & GPs Dr Victoria Brown Consultant Dermatologist West Hertfordshire Hospitals NHS Trust

Which are BCCs?

Basal Cell Carcinoma Commonest cancer in UK 60% of all skin cancers in UK 80% head & neck Slow growing Locally invasive Rarely metastasize Do NOT refer as 2 week wait

Which BCCs are GPs “allowed” to manage according to NICE guidelines?

NICE Skin Tumours (IOG) Improving Outcomes Guidance: Updated May 2010 Lesions suspicious of SCC/MM – 2 WW referral to dermatology Pre-cancerous lesions (e.g. Bowen’s, AKs) can be treated by GP or referred to GPwSI or dermatologist

NICE Skin Tumours (IOG) Improving Outcomes Guidance: Updated May 2010 Low risk BCCs may be managed in the community by: 1.GPs performing skin surgery within LES/DES framework 2.Model 1 practitioners: Group 3 GPwSI in dermatology & skin surgery* GPwSI in skin lesions & skin sugery 3.Model 2 practitioners: skin surgery only: nurse or GP** * Guidance and competencies for the provision of services using GPwSIs : Dermatology and skin surgery 2007 ** National Cancer Peer Review Programme: Manual for skin cancer services 2008: skin measures

Criteria for accreditation of DES/LES Demonstrate competency in skin surgery (DOPS) Training in recognition & diagnosis of skin lesions All specimens  histology Log book – inform patients of diagnosis/plan Quarterly feedback to PCT on histology Annual review of clinical cf histological diagnosis for all low risk BCCs managed Annual attendance at skin cancer network meeting: CPD

Additional Criteria for Accreditation of Model 1 Practitioners Accredited by PCT according to national guidance for GPwSI Linked to named LSMDT Attends 4 LSMDT meetings/year Skin cancer clinical practice audited annually Clinical governance/appraisal from PCT New “GPwSI in skin lesions & skin surgery”: training & accreditation to the same standard as Group 3 GPwSI but for skin lesions only

Criteria for accreditation of Model 2 Practitioners Demonstrate competency in skin surgery (DOPS) Associated with a named LSMDT Perform skin surgery on pre-diagnosed skin cancers receiving referrals from LSMDT member with agreed treatment plan If GP: annual review of clinical vs histological diagnosis annual attendance at Skin Cancer Network meeting

High vs Low Risk BCCs Low RiskHigh Risk Patient age>25 yrs<25 yrs ImmunosuppressedNY BCC above clavicleNY BCC diameter<1cm>1cm “high risk” histological typeNY Recurrent/previously incompletely excisedNY Anatomically difficult/cosmetically imp siteNY Ill defined marginsNY

BCC Referral Form Is patient: under 25Y/N immunosuppressedY/N Is the lesion: Above the clavicleY/N >1cm diameterY/N Recurrent/previously incompletely excisedY/N In an anatomically difficult/cosmetically imp siteY/N Ill defined margins Y/N

BCC Histological Subtypes Nodular Cystic Superficial Pigmented Morphoeic Micronodular Infiltrative Basosquamous

Which BCCs are GPs “allowed” to manage according to NICE guidelines?

49 yr old man: <1cm BCC on forearm

Treatment options for low risk BCCs: observe

Treatment Options for low risk BCCs: Surgery

68 yr old man: 8cm BCC on back

Treatment options for superficial BCCs: Surgery

Non- surgical treatment options for superficial BCCs

Efudix cream

Treatment options for superficial BCCs: photodynamic therapy

High Risk BCCs

Treatment Options for High Risk BCCs MOHs Surgery

Take Home Points Determine if low or high risk BCC Low risk BCCs can be managed in primary care NICE Guidelines 2010: accreditation = hoops! High risk BCC or unsure of diagnosis: Refer correctly 1 st time: dermatology, plastic surgery Often >1 BCC at initial consultation - full skin examination Don’t forget patient education after 1 st BCC

Primary Prevention of BCCs

Low Risk BCCs for DES/LES GP

Low Risk BCCs for Model 1 or 2 practitioners