BCCs & GPs

1. BCCs & GPs Dr Victoria Brown Consultant DermatologistWest Hertfordshire Hospitals NHS Trust

2. Which are BCCs? 4 2 3 1 6 5 7

3. 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

4. Which BCCs are GPs “allowed” to manage according to NICE guidelines? 4 2 3 1 6 5 7

9. 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

10. NICE Skin Tumours (IOG) Improving Outcomes Guidance: Updated May 2010 Low risk BCCs may be managed in the community by: • GPs performing skin surgery within LES/DES framework • Model 1 practitioners: Group 3 GPwSI in dermatology & skin surgery* GPwSI in skin lesions & skin sugery • 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

12. 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

13. 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

14. 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

15. High vs Low Risk BCCs

16. BCC Referral Form Is patient: under 25 Y/N immunosuppressed Y/N Is the lesion: Above the clavicle Y/N >1cm diameter Y/N Recurrent/previously incompletely excised Y/N In an anatomically difficult/cosmetically imp site Y/N Ill defined margins Y/N

17. BCC Histological Subtypes • Nodular • Cystic • Superficial • Pigmented • Morphoeic • Micronodular • Infiltrative • Basosquamous

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

19. 49 yr old man: <1cm BCC on forearm

20. Treatment options for low risk BCCs: observe

21. Treatment Options for low risk BCCs: Surgery

22. 68 yr old man: 8cm BCC on back

23. Treatment options for superficial BCCs: Surgery

24. Non- surgical treatment options for superficial BCCs

25. Non- surgical treatment options for superficial BCCs Efudix cream

26. Treatment options for superficial BCCs: photodynamic therapy

27. High Risk BCCs

28. MOHs Surgery Treatment Options for High Risk BCCs

29. 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

30. Primary Prevention of BCCs

31. Low Risk BCCs for DES/LES GP

32. Low Risk BCCs for Model 1 or 2 practitioners