Surgical excision of skin cancer: the importance of training

Abstract

Background Skin cancers are the most common malignancy in New Zealand and their treatment imparts a huge burden on the healthcare system both in terms of the cost of surgical intervention and in treatment delivery (estimates are in excess of NZ$33 million per annum for the year 2000). Currently in New Zealand, skin cancers are excised by dermatologists, general practitioners (GPs), GPs with a special interest in skin surgery (GPSIs) and specialist surgeons with diverse training backgrounds including ear, nose and throat, ophthalmic and general surgeons. To date there is scant literature evaluating complete excision rates following surgical treatment of skin cancer between these vocational groups. Objectives To review retrospectively pathology reports from all skin excisions sent to one private pathology laboratory over three consecutive months. The aim was to investigate the margins of excision and completeness of skin cancer surgery performed by each vocational group. Methods A retrospective analysis of skin pathology reports was undertaken for a 3-month period between April and June 2007. Raw data obtained from the pathology reports included diagnosis, completeness of excision, size of specimens, body site and vocational group of the medical practitioner performing the surgery. Results In total, 1532 lesions were excised: 432 benign and 1100 malignant. Six hundred and seven were from the head and neck. Dermatologists excised 276 lesions of which 93% were malignant, 55% were from the head and neck, and 0% were incompletely excised. GPs excised 633 lesions: 63% malignant, 30% head and neck, 23% incomplete excision of malignant lesions. GPSIs excised 368 lesions: 71% malignant, 35% head and neck, 21.5% incomplete malignant excision. Specialist surgeons excised 255 lesions: 72% malignant, 53% head and neck, 20% incomplete malignant excision. Conclusion GPs and GPSIs excised more benign lesions and had higher incomplete excision rates of skin cancer surgery than dermatologists. Incomplete excision rates for the vocational groups ranged from 0% to 45% depending on site and pathology.

Efficacy of general practitioners with specialty interests for surgical procedures

“…A total of six studies (Table ) were identified as suitable for inclusion in the present review, as outlined in the PRISMA diagram (Fig. ).…”

“…). Three studies analysed efficacy of GPwSIs with regard to surgical excision of skin lesions. One study looked at the economic evaluation of a GPwSI‐led dermatology service in primary care and included GPwSIs carrying out skin excisions.…”

“…One study (Salmon et al . ) performed a retrospective analysis of skin pathology reports over a 3‐month period in 2007 for all skin lesions in a provincial region of New Zealand. It primarily investigated completeness of excision of malignant skin lesions by each vocational group.…”

A regional programme to improve skin cancer management

“…Standards are usually not monitored except by audit of individual doctors, with training generally being informal 'peer to peer' learning, with occasional continuing medical education activities. 2,3 and other countries [4][5][6][7] have shown that skin specialists diagnose and excise skin cancers better than GPs. GPs may unnecessarily remove benign lesions or, because of cost barriers for some patients, refer minor lesions to hospital clinics, placing a high demand on these services.…”

Patient preferences and patient‐centredness in skin cancer care: implications for clinicians and patient management

“…In Australia, GPs have long managed the majority of BCCs and SCCs . However, comparability of GP‐delivered with specialist‐delivered skin cancer management (or particular aspects of management) remains uncertain …”