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 ‘lowrisk’ 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
Superficial
Nodular
Basosquamous
©dermNetNZ.org
(http://dermnetnz.org)
Morphoeic
© Schofield
Pigmented
JK and Kneebone R (2006) Skin lesions: a practical guide
to diagnosis management and minor surgery.
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
Low-risk BCCs for DES/LES :1
• 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 :2
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 :3
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.
Model 1 practitioners (1)
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 (2)
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 (3)
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’.
Other models of care
• 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
Quality assurance:
histopathology
• 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:
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 www.nice.org.uk/CSGSTIM for:
•
•
•
•
•
the guidance
‘Understanding NICE guidance’
costing statement
commissioning factsheet
baseline assessment.