Transcript NICE Guidelines Updates, Dr Victoria Brown, Consultant

BCCs & GPs
Dr Victoria Brown
Consultant Dermatologist
West Hertfordshire Hospitals
NHS Trust
Which are BCCs?
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Basal Cell Carcinoma
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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
Which BCCs are GPs “allowed” to
manage according to NICE guidelines?
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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
NICE Skin Tumours (IOG) Improving
Outcomes Guidance: Updated May 2010
Low risk BCCs may be managed in the community by:
1. GPs performing skin surgery within LES/DES
framework
2. Model 1 practitioners:
Group 3 GPwSI in dermatology & skin surgery*
GPwSI in skin lesions & skin sugery
3. 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
Criteria for accreditation of DES/LES
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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
Additional Criteria for Accreditation
of Model 1 Practitioners
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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
Criteria for accreditation of Model 2
Practitioners
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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
High vs Low Risk BCCs
Low Risk
High Risk
Patient age
>25 yrs
<25 yrs
Immunosuppressed
N
Y
BCC above clavicle
N
Y
BCC diameter
<1cm
>1cm
“high risk” histological type
N
Y
Recurrent/previously incompletely excised
N
Y
Anatomically difficult/cosmetically imp site
N
Y
Ill defined margins
N
Y
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 siteY/N
Ill defined margins
Y/N
BCC Histological Subtypes
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Nodular
Cystic
Superficial
Pigmented
Morphoeic
Micronodular
Infiltrative
Basosquamous
Which BCCs are GPs “allowed” to
manage according to NICE guidelines?
49 yr old man: <1cm BCC on forearm
Treatment options for low risk BCCs:
observe
Treatment Options for low risk BCCs:
Surgery
68 yr old man: 8cm BCC on back
Treatment options for superficial
BCCs: Surgery
Non- surgical treatment options for
superficial BCCs
Non- surgical treatment options for
superficial BCCs
Efudix cream
Treatment options for superficial
BCCs: photodynamic therapy
High Risk BCCs
Treatment Options for High Risk BCCs
MOHs Surgery
Take Home Points
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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
Primary Prevention of BCCs
Low Risk BCCs for DES/LES GP
Low Risk BCCs for Model 1 or 2
practitioners