Early detection of melanoma is key, so let’s teach it
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.a3138 (Published 06 January 2009) Cite this as: BMJ 2009;338:a3138All rapid responses
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Melanoma detection is complicated, even for those with specialist
training (1). Moreover, the consequences of diagnostic delay and
misdiagnosis are potentially life threatening. Therefore evidence-based
strategies which improve the detection rates of early, thin, melanomas,
and improve the overall care of patients with melanoma, are needed.
Whilst the suggestions of Hayes (2) for the introduction of community
dermoscopists to facilitate earlier melanoma diagnosis and to help screen
out benign lesions are novel, there are untried, untested and lacking a
sound evidence base. Surely patients with suspicious lesions deserve to
see the appropriately trained health care profession first, who can most
accurately diagnose and treat their lesion, and provide adequate follow-up
surveillance, based on evidence based guidelines. Isn’t this a consultant
dermatologist, based at the centre of a multi-disciplinary team?
1. Thirlwell C, Nathan P. Melanoma – Part 2 : management. BMJ 2008;
337:a2488, doi:10.1136/bmj.a2488
2. Hayes SF. Early detection of melanoma is key, so let’s teach it. BMJ
2009; 338;a3138
Competing interests:
None declared
Competing interests: No competing interests
The melanoma affects a reasonably big proportion of the
population.People with skin type I or II or those who live in areas with
increased sun exposure are particularly susceptible.
Variation in color and/or an increase in diameter, height, or
asymmetry of borders of a pigmented lesion are noted by more than 80% of
patients with melanoma at the time of diagnosis. Symptoms such as
bleeding, itching, ulceration, and pain in a pigmented lesion are less
common but warrant an evaluation.
The disease has been proven to affect 38/100000 males and 29.5/100000
females in 2002. 160000 new cases of melanoma have been reported worldwide
in 2002 and 41000 deaths have been reported worldwide in 2002 due to
melanoma-related conditions.
Due to the wide range of presentations of the lesions the doctors
should be extremelly cautious as the results can even be fatal.
The BAD recommendations for follow up of melanoma are:
3-monthly for 3 years and
6-monthly for further 2 years.
It is very important not only to recognise the suspicious lesions in
a primary practice setting but also to take into account the severity of
the possible complications and follow up the patients even when the
'official' follow up by the dermatology team has come to an end.
Competing interests:
None declared
Competing interests: No competing interests
Dr Hayes article is to be applauded both for highlighting the
difficulties confronting GPs in diagnosing or screening for skin cancers
and for its wider implications.
Given that about fifteen percent of GP consultations relate to skin
disorders and that dermatology is a uniquely complex specialty, the
paucity of dermatology training given to trainee GPs and in GPs' CPD does
patients a great disservice and is a national disgrace.
There is a growing cohort of GPs with a Special Interest in
Dermatology, and the Primary Care Dermatology Society is to be
congratulated for the excellent work it does in encouraging and helping to
train them. But all GPs need a proper grounding in dermatology if they are
to provide patients with acceptable services. That will best be achieved
by giving practices a financial incentive by incorporating points for the
treatment of skin diseases (perhaps skin cancer, eczema, psoriasis and
acne vulgaris) into the Quality Outcomes Framework of the GMS contract,
which includes none at present. (The only mention of dermatology in the
Framework is the exclusion of non-melanotic skin cancer from the record of
cancer patients a practice is expected to maintain!)
Competing interests:
The writer is a Trustee of the Primary Care Dermatology Society and was until March 2007 chief executive of the Skin Care Campain.
Competing interests: No competing interests
Re: Diagnosing melanoma; Novel attempts to facilitate earlier detection must be evidence-based.
Depends on what you call evidence. The call for 'evidence' can be a
progress stopper when a straightforward observation from the front line is
dismissed as worthless until backed by a randomised multi centre placebo
controlled trial. For which there are no time, funds or backing.
Britain has 400 consultant dermatologists. Spain has 2,300, Italy
3,000, France 8,000, for similar populations. Patients are shocked when I
tell them this (in answer to their complaints about long hospital waiting
times). Our low numbers of dermatologists are not due to a lack of keen,
bright young doctors who wish to enter the speciality, but due to
centrally controlled trainee numbers set at an internationally low level
for reasons which I do not understand.
Certainly in France, from which originates the excellent skin lesion
diagnostic resource www.dermoscopic.blogspot.com, there is a lesser need
to teach GPs better skin lesion diagnostic skills, since any patient
worried about a mole simply presents themselves directly to a
dermatologist, their brass plates can be seen in every town. However, in
Britain with vastly fewer dermatologists than the European average, and GP
gatekeeper system, we rely on GPs limiting specialist referrals due to
limited secondary care capacity, and so GPs certainly do need good
recognition skills. I will not bore readers with a long list of my
anecdotes about trivial benign lesions refered as suspected skin cancers,
or serious malignancies misdiagnosed as benign.
Good enough skin lesion recognition skills are not routinely taught
to most GPs. Do we need a randomised controlled trial to prove that
teaching GP registrars the whole of dermatology in half a day is not
enough?
It is a counsel of perfection that every patient with a skin lesion
should be seen by a fully trained consultant dermatologist. The system
would crash. Does anyone suggest that with 400 dermatologists for a
population of 60,000,000 that this is realistic? Might as well suggest
that every meal is cooked by a 3 star Michelin chef.
Dermoscopy is not a magic bullet, but there is enough published
evidence to show that it works in trained hands. The real issue is that
GPs are not routinely taught enough general dermatology (including skin
lesion recognition) to be fit for purpose and that the system needs to
change.
Whatever, the bottom line remains the same. 1,850 British patients
died from malignant melanoma in 2006. twice as many as died from cancer of
the cervix, for which we have universal, community based, screening. This
number could have been reduced, as far as we can reasonably deduce from
the available evidence, by earlier diagnosis. What are we, primary and
secondary care doctors and healthcare planners, going to do about this?
Competing interests:
SH is a GPSI and teaches dermoscopy
Competing interests: No competing interests