BCCs & GPs

Dr Victoria Brown

Consultant DermatologistWest Hertfordshire Hospitals NHS Trust

Which are BCCs?

12 3

4

765

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

12 3

4

765

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 BCCsLow Risk High Risk

Patient age >25 yrs <25 yrs

Immunosuppressed N Y

BCC above clavicle N Y

BCC diameter <1cm >1cm

“high risk” histological type N Y

Recurrent/previously incompletely excised N Y

Anatomically difficult/cosmetically imp site N Y

Ill defined margins N Y

BCC Referral Form

Is patient:under 25 Y/Nimmunosuppressed Y/N

Is the lesion:Above the clavicle Y/N>1cm diameter Y/N

Recurrent/previously incompletely excised Y/NIn an anatomically difficult/cosmetically imp site Y/NIll 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

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

1st time: dermatology, plastic surgery

Often >1 BCC at initial consultation - full skin examination

Don’t forget patient education after 1st BCC

Primary Prevention of BCCs

Low Risk BCCs for DES/LES GP

Low Risk BCCs for Model 1 or 2 practitioners