Industrializing skin cancer care: better and cheaper?

Abstract

Skin cancer is the commonest cancer in European populations, with incidence rates in the UK for non-melanoma skin cancer (NMSC) and melanoma of 115 and 16 per 100,000 respectively (figures for NMSC are likely underestimates as registration is known to be incomplete). 1Despite the high frequency, overall UK skin cancer-related mortality is low with absolute rates of 0.5 for NMSC and 2.6 per 100,000 for melanoma. 2 The purpose of skin cancer treatment is to reduce case-fatality by removal of cancers before they have metastasized, and to minimize morbidity and disfigurement from the direct effects of the primary tumour.The current management of skin cancer in the UK and many countries is based on what might be termed a 'corner shop' model. Patients present to their GP or to a single-handed dermatologist in office practice and either (i) are diagnosed as not needing further treatment because the suspect lesion is benign, (ii) undergo excision of the suspect lesion by their physician or (iii) are referred to an expert (often hospital based) for further diagnosis and surgery if needed. All these consultations are likely very typical traditional 'medical' consultations, with a single doctor and patient operating in isolation with, to coin a phrase, the patient walking into the consultations room and then 'shaking hands with their physician'. I suggest that this traditional model is unnecessarily expensive and likely inferior in quality to a more industrialized model. To understand why change is necessary, we need to start with the changing epidemiology of skin cancer, and highlight changes in the skill mix of physicians.Standardized rates of skin cancer have risen 3-5-fold over the last 30 years in many European populations.1 Allowing for changes in age structure, such increases imply a seven-fold increase in the number of cases of the most common skin cancer, basal cell carcinoma. Today, referrals for diagnosis and management of skin cancer account for 50% of referrals to most dermatology units. Modelling suggests that skin cancer case numbers will double over the next 23 years.

Skin cancer: prevention is better than cure

“…I agree with Dr Rees 1 that skin cancer is an important health issue due to its raising incidence. Although the article focuses on the management of skin cancer by surgery, there are preventive programmes and treatments to reduce the risk of developing skin cancer.…”

Skin cancer, and some limitations on how we innovate and practice medicine

“…For some areas of medicine that may make sense . For skin cancer, I and others have argued, it does not . Skin cancer ‘factories’ in which a large number of nonphysicians work under the guidance of experienced physicians is surely worth moving towards in larger cities.…”