1. C&H Skin Cancer Referral Pathway 2013 Dr Sara Ritchie CCG GP Dermatology Lead

2. Designed to complement the 2WW form To include full pathway for MM, SCC and also BCC

3. a melanoma..

4. Melanoma + SCC As per 2WW, refer suspected melanoma or suspected SCC on 2WW Keratoacanthoma should all be referred as suspected SCC Remember rapidly growing skin lesions of unknown origin should also be referred on 2WW

5. BCC BCCs can be referred either to secondary care routinely, or to the Primary Care Minor Surgery Providers depending on the type of BCC BCCs are divided into Low-risk and High-risk

6. a nodular BCC..

7. Low-Risk BCCs are: < 1cm diameter below the clavicle Nodular BCCs Superficial BCCs

8. High-Risk BCCs are: > 1cm on face (or above clavicle) aggressive histologic forms (eg morphoeic, micronodular, multifocal, infiltrative) recurrent at same site

9. High-Risk BCCs must all be referred to secondary care for full excision (initial biopsy only may be done by GPSI or in- house if beneficial for diagnosis) Low-Risk BCCs can be referred for excision to Primary Care Minor Surgery Provider or GPSI (provider must be trained in BCC excision + attend 4 secondary care MDTs / year)

10. Skin cancer not requiring excision: Bowens disease (SCC in-situ) can be treated by Efudix or cryotherapy Superficial BCC can be treated by Aldara or cryotherapy These require biopsy for diagnosis

11. Changing Moles If a changing mole cannot be confidently diagnosed as benign it should be referred on 2ww (do not biopsy in primary care!) NB Presence of 3 colours in a mole is suspicious Pyogenic granuloma - any rapidly growing bleeding pink nodule now use 2ww Spitz naevi - consider 2ww at any age

12. Special Cases of Pigmented Naevi Giant congenital naevi (>20cm) - if history of change refer on 2WW. If stable lesions just refer routinely to secondary care for monitoring. Multiple naevi - if > 50 banal naevi, or > 5 atypical looking naevi but none currently suspicious of melanoma - consider routine secondary care referral for monitoring

13. a keratoacanthoma..

14. Suspected SCC Assume all keratoacanthoma is SCC - 2ww Cutaneous horn - 15% have SCC in base - if atypical, or induration at base, or vessels at base - consider 2WW Transplant patients / Immunosuppressant Medication - these patients are at v high risk of SCC, which may be atypical and aggressive - if new or growing skin lesion refer on 2ww

15. Non-Healing Skin Lesions Beware any non-healing lesion on a sun-exposed site - always think of BCC! Remember some non-healing lesions may be SCC eg if crusted / indurated / ulcerated / or >1cm - then consider urgent referral on 2ww NB In HIV +ve patients (even if well- controlled on ARVs) BCCs can occur at a younger age, and have a higher risk of recurrence

16. Actinic Keratoses Beware single actinic keratosis - consider assessing with dermoscopy (or actinic keratoses not responding to cryotherapy - consider referral) If multiple can treat with cryotherapy or Efudix, or refer to GPSI or secondary care Multiple AKs in a transplant patient - always treat or refer field change in these patients (high risk of SCC)