Choosing to biopsy or refer suspicious melanocytic lesions in general practice

Abstract

BackgroundGeneral practitioners (GPs) are involved in the management of most melanocytic skin lesions in Australia. A high quality biopsy technique is a crucial first step in management, as it is recognized that poor techniques can mislead, delay, or miss a diagnosis of melanoma. There has been little published on the biopsy decisions and techniques of GPs. This study aims to describe the current management choices made by GPs for suspicious melanocytic skin lesions and to compare their choices with the best practice guidelines.MethodsAn anonymous survey of GPs presented with three clinical scenarios with increasing complexity of melanoma in which a referral or biopsy decision was specified.Results391 mailed surveys with a 76.3% response rate. Mean biopsy experience was 4.14 biopsies per GP per month. The rates of choosing to refer among the three scenarios were 31%, 52% and 81% respectively, with referral to surgery being the most common choice (81%). Most biopsy techniques (55%) were chosen according to best practice guidelines, although non-guideline biopsy techniques chosen included shave (n = 10), punch biopsy (n = 57), wide excisions (n = 65), and flaps (n = 10). The few GPs (n = 5) who identified themselves as skin specialist GPs were no more likely to adhere to guidelines than their colleagues.ConclusionA majority of referrals and biopsies were chosen by GPs according to best practice guidelines, but concern remains for the high proportion of GPs making non-guideline based choices. How GPs choose to biopsy or refer needs further training, audit, and research if Australia is to improve the outcome of melanoma management in general practice.

GPs’ involvement in diagnosing, treating, and referring patients with suspected or confirmed primary cutaneous melanoma: a qualitative study

“…These findings extend what is already known about the complexity and diversity of the clinical pathways for melanoma in Australia 14,15,31 and the overlapping roles GPs, dermatologists, and surgeons have in performing surgical procedures such as wide local excision for melanoma. 15,27 The finding that opportunities for formal and informal training affected GPs' confidence and decisions around referral broadens understanding of the relationship between training and the decision to refer, 15 making explicit the interconnectedness of interest and concern about misdiagnosis with training and confidence. The findings also highlight how GPs' involvement in cancer care can extend well beyond screening, prevention, and supportive care to include provision of definitive treatment, an area that other Australian studies have not acknowledged.…”

“…What is known is that considerable variation exists in GP practice in relation to the decision to biopsy versus the decision to refer, with up to 20% of GPs reporting that they do not perform biopsies at all. 15 However, to the authors' knowledge, there are currently no available data reporting the factors that influence a GP's decision to manage and treat patients with melanoma themselves rather than to refer them to a specialist or to a specialist centre.…”

“…Previous research has explored various aspects of melanoma care in the Australian setting, 14,[16][17][18][19][20][21][22] including compliance with clinical practice guidelines, 15,[23][24][25][26][27] but not how GPs understand their multiple potential roles within melanoma patient care. The aim of the current study was to identify factors that affect GPs' confidence in, and attitudes towards, managing patients with suspected or confirmed melanoma, and how GPs explain their decisions to biopsy, treat, or refer.…”

A Clinical Aid for Detecting Skin Cancer: The Triage Amalgamated Dermoscopic Algorithm (TADA)

“…6 The dearth of dermatologic education in medical school curricula and family medicine residencies 7,8 underscores the need for providing PCPs with better tools and training for the management of cutaneous lesions. 9 …”

Doctors’ recognition and management of melanoma patients’ risk: An Australian population-based study

“…Several studies have described aspects of melanoma care in the Australian setting (18,19,22,(29)(30)(31)(32), or have measured compliance with clinical practice guidelines (21,(33)(34)(35)(36). However, to our knowledge our study is the first to report on doctors' knowledge of patients' risk factors and its relationship with subsequent skin-related follow-up advice and recommendations for melanoma in Australia.…”