How should GPs respond to a suspected melanoma?

Melanoma is a form of skin cancer that usually starts in the skin and can originate from a mole, however around half of all melanomas start in normal-looking skin.

Research conducted by Macmillan suggests that the number of people developing melanomas is on the rise with about 14,500 people in the UK being diagnosed just in 2013. Over the last decade, the number of people diagnosed with melanoma in the UK has increased by almost half.

Who is at a risk of getting melanoma?

People with dark skin are much less likely than people with fair skin to get melanoma. This is because their skin has more natural protection and has fewer melanocyte cells than people with pale skin. In the UK, melanomas are slightly more common in women than in men.

Other risk factors include:

• skin type
• hair and eye colour
• number of moles
• family history of melanoma
• certain medical conditions, including having a weakened immune system

What can you do to minimise the risk of getting melanoma?

Recent NICE guidance outlines a number of recommendations in relation to sun exposure, including:

• when applying sun cream people should use at least factor 15 sun creams, with adults urged to use 6-8 teaspoons (35ml) per application.
• babies and children, those with fair skin or hair, people with lots of moles or freckles and those with a family history of skin cancer should take extra care in the sun
• higher factor sun creams – such as factor 30 – may offer better protection but do “not necessarily mean people can spend more time in the sun without the risk of burning”
• applying sunscreen too thinly reduces the amount of protection it gives.
• sunscreens should be re-applied after being in the water, after towel drying, sweating or when it may have rubbed off
• cream should also be applied twice – once half an hour before going out and again before going in the sun – if people are going out long enough to risk burning
• babies under six months of age should be kept out of direct strong sunlight and children need sun protection between March and October
• people should expose their arms and legs to the sun for short periods in order to build up vitamin D.

Although most of the above recommendations are likely to reduce the risk of developing skin cancer, it is important to remember that you need to stay vigilant as, unfortunately, these steps alone are unlikely to completely eliminate the risk. It is therefore important that you recognise the signs of skin cancer and seek medical attention at the earliest opportunity.

Signs of skins cancer or melanoma

There are a number of signs to look out for if you have concerns about a mole or irregularity. The NHS choices website has a useful ABCDE checklist, to assist with telling the difference between a normal mole and one that may be melanoma, detailed below:

Asymmetrical – melanomas have two very different halves and are an irregular shape;

Border – unlike a normal mole, melanomas have a notched or ragged border;

Colours – melanomas will be a mix of two or more colours;

Diameter – unlike most moles, melanomas are larger than 6mm (0.25in)

Enlargement or elevation – a mole that changes characteristics and size over time is more likely to be melanoma.

If you are concerned about a particular mole or changes in your skin after considering the above checklist, it is important that you seek advice from your GP urgently as they will be able to offer assistance and make the necessary referral for further investigations.

So, how should GPs respond?

It is well recognised that GP’s are under enormous time pressure. In June 2005 guidance from NICE put in place a seven point scoring system to ensure that GP’s refer on cases promptly to a specialist if a patient has some of the following characteristics.

• a history of change in size of the lesion (it is clear that no GP would be able to know this therefore it is important that a GP checks this with their patient);
• irregularity of shape;
• irregularity of colour;
• larger diameter 7mm or more;
• inflammation;
• oozing;
• change in sensation.

Each of the above features score one point, if a patient scores three points or more your GP must make an urgent referral within two weeks for further investigations.

Patients are usually referred to dermatology in the first instance, and an excision is made and a biopsy is then performed upon the tissue. This is then sent to the laboratory to determine whether or not the lesion is cancerous. If it is then further treatment may be required.

My colleagues and I often see cases where our clients have suffered a delayed diagnosis or misdiagnosis of melanoma due to negligent failings in their medical treatment, for example where the patient’s GP fails to consider the possibility of cancer diagnosis and does not make the required referral. Delayed diagnosis can lead to the cancer advancing, requiring more extensive treatment and a worse prognosis for the patient.

If you or a member of your family has been affected by a delayed or misdiagnosis and would like to discuss this further then please contact a member of the Clinical Negligence team.