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In this blog Simon Elliman considers the different levels of suspicion of skin lesions which are applied in different countries, and argues that General Practitioners (GPs) in the UK may be too complacent when making treatment decisions when melanoma is, or should be, suspected.
Melanoma is a form of skin cancer, and the NHS Choices website advises that the most common sign is either the appearance of a new mole or changes to an existing mole.
In November 2010, Zimbabwe-born England cricket coach Andy Flower was touring Australia. The team’s security advisor, an Australian named Reg Dickason, had recently had surgery for melanoma on his left arm, and mentioned to Flower that he might want to get the spot under his left eye checked out. Flower was convinced enough to see a dermatologist in Brisbane immediately. A biopsy was taken, revealing traces of malignant melanoma, and literally within days Flower was under the knife having a wide excision.
The story made headline news as Flower had to miss some of the First Test Match at the Gabba, but the part of the story which interests me as a clinical negligence lawyer practising in the UK (and as a keen amateur cricketer who spends long days in the sun) was that he had been given the all-clear by a doctor in England only a few weeks earlier.
Over the last few years I have acted for several clients with late diagnosed malignant melanoma, all with worryingly similar stories of a complacent approach by a doctor to a suspicious mole or lesion. Sadly, none of them are now alive to tell the tale. This experience has led me to wonder whether UK doctors remain unduly complacent in their approach to the diagnosis and treatment of suspected melanoma, compared to doctors in other countries.
The Office for National Statistics (ONS) has reported that the number of melanoma skin cancer registrations in the UK has increased from 4,777 in 1995 to 12,993 in 2014. Taking into account the impact of an increasing and ageing population, that represents an increase from 11.2 per 100,000 people to 25.7 per 100,000 people.
A significant factor is likely to be that the number of UK residents holidaying abroad doubled between 1980 and 1989, and as that generation ages, the effects of hot sun upon unprotected skin are being felt. Whatever the reasons, there is a quickly increasing incidence of a deadly disease.
Since 2005, guidance from the National Institute for Health and Care Excellence (NICE) has been in place to ensure that GPs refer on cases to dermatological specialists if a lesion has some of the following characteristics:
If a referral is made, the same process as Andy Flower underwent in 2005 should be followed, namely a biopsy, and thereafter, if melanoma is detected, a wide excision, with the purpose of eradicating all melanoma. If the disease is caught early, and all melanoma is removed, the prognosis is excellent. If melanoma is left in situ, it will spread via the lymph glands and usually eventually metastasise throughout the body, often with fatal secondaries in the brain and liver.
In the cases which I have conducted, there has always been an early warning sign, where a skin lesion has changed significantly, but a GP has taken too casual an approach, falsely reassuring the patient, or, on occasion, dangerously attempting to destroy the lesion in the GP surgery by cautery or cryotherapy, in the absence of any biopsy to establish whether melanoma is present. In such cases, the results of such a course of action have proved fatal within a very few years.
Had Andy Flower received such treatment in 2010, I very much doubt he would be alive today. There are of course many other lessons to be learned about melanoma. The great Australian Test cricketer and much-loved commentator Richie Benaud died from melanoma in 2015, not due to any missed diagnosis, but simply because he had spent decades in the hot sun without proper protection, as so many of his generation did. Taking care in the hot sun is the most important part of the battle for all of us. But I do continue to wonder whether UK doctors, and especially the GPs in the ‘front-line’ in terms of opportunities for early diagnosis, have a high enough index of suspicion for this devastating condition.