High-risk basal cell carcinoma excision in primary care: a retrospective observational study of compliance with NICE guidance

Abstract

ObjectivesTo assess compliance with 2010 National Institute for Health and Care Excellence (NICE) guidance on cancer services relating to the management of basal cell carcinomas (BCC) in the community, where except in specific circumstances it is recommended that only low-risk BCCs should be excised routinely.Design and settingA retrospective observational study of the histopathology reports of BCC excisions received from primary care in two district general hospitals in the South of England. One hundred consecutive BCC excisions were analysed from each hospital.Outcome measuresThe numbers of high-risk BCCs excised in primary care according to histological subtype, anatomical site and age and if these excisions were compliant with NICE 2010 guidance. Completeness of excision and mention of BCC on histology request were secondary outcomes.ResultsHistologically high-risk subtypes were present in 32% (64/200) of BCCs excised in the community. Only 17/64 were excised by general practitioners (GPs) who were accredited to do so. Non-compliance regarding anatomical site occurred in 16% of samples; only one was non-compliant regarding patient age. There was a high overall rate of complete excision (94.5%) with variation in presence of the term BCC on histology request forms.ConclusionsNICE 2010 guidance relating to BCC excision in primary care was not followed in a considerable number of cases. Compliance with NICE 2010 guidance depends on the ability to recognise high-risk BCCs clinically and manage appropriately. It also shows that despite close supervision by secondary care, there are still failures of compliance.GP training in identification of subtypes of BCC might be improved, as well as an increase in numbers of GPs accredited to carry out high-risk BCC excisions. Difficulty in diagnosing high-risk histological subtypes of BCC preoperatively should be considered in any future revision of NICE guidance.

Measuring the quality of skin cancer management in primary care: A scoping review

“…71,81,[88][89][90][91] Treatment processes Thirty-two articles examined treatment processes of care. Evaluations of excision performance and adequacy of GPs (88%) usually measured the proportion of skin cancers exc ised 17,28,34,62,76,[78][79][80][81][82][83][85][86][87][88][91][92][93] or the proportion of complete (vs. partial) excisions. 23,28,34,37,71,76,82,83,86,87,[91][92][93][94] Other surgical treatment procedures, such as curettage, were also examined, 46,66,69,71,73,87 as well as non-surgical treatment such as cryotherapy.…”

“…Community screening [65][66][67][68] Full-body skin examination (FBSE) for community members by dermatologically trained physicians 67 13 (28) Diagnosing suspect lesions [58][59][60][61][62][63][64]69,70 Use of checklists for meeting dermoscopy standards of use for patients with suspected basal cell carcinoma diagnosis 60 Treatment protocols and documentation Surgical and procedural safety 58,[69][70][71][72][73] Surgical wound management protocol for standardised excision management 72…”

“…Pathology delays 71,81,88 Time interval (delays) from primary excision until registration of histopathological diagnosis in patients with melanoma 81 Referral delays 81,88 Referral lead time between primary care and university level care 88 Treatment delays 71,81,[88][89][90][91] Surgical delay of 1.5 months from biopsy to excision in patients with melanoma 89 Treatment process Excision performance and adequacy 17,23,25,28,34,37,46,62,66,68,69,[71][72][73]76,[78][79][80][81][82][83]85,87,88,[91][92][93][94] Proportion of excisions performed on skin lesions suspected of malignancy 17…”

“…22,23 Research has drawn attention to GPs' capabilities in managing skin cancer but also to concerns around variation in the quality of care. [22][23][24][25] High levels of variability in diagnostic accuracy have been found between individual GPs, 26,27 and high variability in GPs familiarity with best practice guidance on high-risk excisions 28 and use of sentinel lymph node biopsy. 29 Skin cancer focused protocols and guidelines have been developed by dermatological and oncological societies (e.g.…”

Excision margin of T3 basal cell carcinoma in maxillofacial area: A retrospective cohort study of Asians

“…Although rarely fatal, BCC will diminish the quality of life by devastating aesthetic and psychosocial sequelae, and functional impairment especially in maxillofacial area. In addition, being located in maxillofacial area, BCC is more likely to be classified as "high risk" for the difficult anatomical site (so-called H zone; Cole et al, 2019). However, the treatment of BCC, particularly in advanced stage of high risk, is an area where high-level evidence guiding management is lacking, and the standard surgical margin has not yet been completely determined.…”